. 2024 Feb 20;83(7):726-738.

doi: 10.1016/j.jacc.2023.12.005.

Intrahepatic Transcriptomics Differentiate Advanced Fibrosis and Clinical Outcomes in Adults With Fontan Circulation

Katia Bravo-Jaimes¹, Xiuju Wu², Leigh C Reardon³, Gentian Lluri⁴, Jeannette P Lin⁴, Jeremy P Moore³, Glen van Arsdell⁵, Reshma Biniwale⁵, Ming-Sing Si⁵, Bita V Naini⁶, Robert Venick⁷, Sammy Saab⁸, Christopher L Wray⁹, Reid Ponder¹⁰, Carl Rosenthal¹¹, Alexandra Klomhaus¹², Kristina I Böstrom², Jamil A Aboulhosn⁴, Fady M Kaldas¹³

Affiliations

¹ Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA; Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA.
² Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA.
³ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Department of Pediatric Cardiology, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA.
⁴ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA.
⁵ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Division of Congenital Cardiovascular Surgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California USA; Department of Surgery, University of California-Los Angeles, Los Angeles, California, USA.
⁶ Department of Pathology and Lab Services, University of California, Los Angeles, California, USA.
⁷ Department of Gastroenterology, Hepatology, and Nutrition, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA.
⁸ Pfleger Liver Institute, University of California, Los Angeles, California, USA.
⁹ Department of Anesthesiology, University of California, Los Angeles, California, USA.
¹⁰ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA.
¹¹ Dumont-UCLA Liver Transplant Center, Department of Surgery, University of California, Los Angeles, California, USA.
¹² Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
¹³ Dumont-UCLA Liver Transplant Center, Department of Surgery, University of California, Los Angeles, California, USA. Electronic address: FKaldas@mednet.ucla.edu.

PMID: 38355242
PMCID: PMC11627240
DOI: 10.1016/j.jacc.2023.12.005

Intrahepatic Transcriptomics Differentiate Advanced Fibrosis and Clinical Outcomes in Adults With Fontan Circulation

Katia Bravo-Jaimes et al. J Am Coll Cardiol. 2024.

. 2024 Feb 20;83(7):726-738.

doi: 10.1016/j.jacc.2023.12.005.

Authors

Affiliations

¹ Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA; Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA.
² Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA.
³ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Department of Pediatric Cardiology, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA.
⁴ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA.
⁵ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA; Division of Congenital Cardiovascular Surgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California USA; Department of Surgery, University of California-Los Angeles, Los Angeles, California, USA.
⁶ Department of Pathology and Lab Services, University of California, Los Angeles, California, USA.
⁷ Department of Gastroenterology, Hepatology, and Nutrition, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA.
⁸ Pfleger Liver Institute, University of California, Los Angeles, California, USA.
⁹ Department of Anesthesiology, University of California, Los Angeles, California, USA.
¹⁰ Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California, USA.
¹¹ Dumont-UCLA Liver Transplant Center, Department of Surgery, University of California, Los Angeles, California, USA.
¹² Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
¹³ Dumont-UCLA Liver Transplant Center, Department of Surgery, University of California, Los Angeles, California, USA. Electronic address: FKaldas@mednet.ucla.edu.

PMID: 38355242
PMCID: PMC11627240
DOI: 10.1016/j.jacc.2023.12.005

Abstract

Background: The molecular mechanisms underlying Fontan-associated liver disease (FALD) remain largely unknown.

Objectives: This study aimed to assess intrahepatic transcriptomic differences among patients with FALD according to the degree of liver fibrosis and clinical outcomes.

Methods: This retrospective cohort study included adults with the Fontan circulation. Baseline clinical, laboratory, imaging, and hemodynamic data as well as a composite clinical outcome (CCO) were extracted from medical records. Patients were classified into early or advanced fibrosis. RNA was isolated from formalin-fixed paraffin-embedded liver biopsy samples; RNA libraries were constructed with the use of an rRNA depletion method and sequenced on an Illumina Novaseq 6000. Differential gene expression and gene ontology analyses were performed with the use of DESeq2 and Metascape.

Results: A total of 106 patients (48% male, median age 31 years [IQR: 11.3 years]) were included. Those with advanced fibrosis had higher B-type natriuretic peptide levels and Fontan, mean pulmonary artery, and capillary wedge pressures. The CCO was present in 23 patients (22%) and was not predicted by advanced liver fibrosis, right ventricular morphology, presence of aortopulmonary collaterals, or Fontan pressures on multivariable analysis. Samples with advanced fibrosis had 228 upregulated genes compared with early fibrosis. Samples with the CCO had 894 upregulated genes compared with those without the CCO. A total of 136 upregulated genes were identified in both comparisons and were enriched in cellular response to cytokine stimulus or oxidative stress, VEGFA-VEGFR2 signaling pathway, TGF-β signaling pathway, and vasculature development.

Conclusions: Patients with FALD and advanced fibrosis or the CCO exhibited upregulated genes related to inflammation, congestion, and angiogenesis.

Keywords: Fontan outcomes; Fontan-associated liver disease; liver fibrosis; single ventricle; transcriptomics.

PubMed Disclaimer

Conflict of interest statement

Funding Support and Author Disclosures Dr Bravo-Jaimes was supported by the Adult Congenital Heart Association Research Grant 2021. Dr Klomhaus was supported by the National Institutes of Health (NIH)/National Center for Advancing Translational Science UCLA CTSI grant no. UL1TR001881. Dr Böstrom was supported by NIH/National Heart, Lung, and Blood Institute grant nos. HL81397 and HL154548. Dr Aboulhosn was supported by the Streisand/American Heart Association Endowed Chair in Cardiology. Dr Kaldas was supported by the Kelly Lee Tarantello Endowed Chair in Integrative Liver Transplantation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

**FIGURE 1. Survival Analysis**
Kaplan-Meier curve comparing time to the composite clinical outcome, relative to the date of Fontan palliation, between patients with early vs advanced fibrosis.

**FIGURE 2. DEGs in Advanced Fibrosis and the Composite Clinical Outcome**
(A) Volcano plot of 231 differentially expressed genes (DEGs) (228 upregulated) in patients with FALD and advanced fibrosis vs early fibrosis. Highlighted genes were among the top upregulated genes in advanced fibrosis. (B) Volcano plot of 906 DEGs (894 upregulated) in patients with Fontan-associated liver disease (FALD) and the composite clinical outcome vs those without it. Highlighted genes were among the top upregulated genes in FALD patients with the composite clinical outcomes. The likelihood ratio test with negative binomial generalized linear model was used for fitting and DEGs analysis with the use of R package DESeq2. DEG cutoffs: Log₂ fold change (FC) ≥1 and adjusted P value (Padj) <0.05 with the use of the Benjamini-Hochberg method. NS = not significant; Sig = significant.

**FIGURE 3. Upregulated Gene Enrichment Analyses in Advanced Fibrosis and the Composite Clinical Outcome**
(A) Representative terms of gene ontology and pathway enrichment analysis using 136 upregulated genes both in advanced liver fibrosis and in patients with the composite clinical outcomes. (B) Top associated human diseases of gene disease association analysis (DisGeNet) using these 136 upregulated genes.

**FIGURE 4. Selected DEGs in FALD According to the Degree of Fibrosis**
(A) Genes associated with liver fibrosis from etiologies other than FALD. (B) Representative top upregulated genes associated with tissue fibrosis in other organs. Expression of each gene was plotted with the use of violin in combination with box plots among patients with FALD according to the degree of liver fibrosis. Expression levels were plotted using normalized gene counts in log10 scale. Adjusted P value calculated with the use of the Benjamini-Hochberg method for multiple comparison testing. ns = not significant; other abbreviations as in Figure 2.

**FIGURE 5. Selected DEGs in FALD According to the Composite Clinical Outcomes**
(A) Genes associated with liver fibrosis from etiologies other than FALD. (B) Representative top upregulated genes associated with tissue fibrosis in other organs. Combined violin and box plots of gene expression among FALD patients according to the composite clinical outcome. The likelihood ratio test with negative binomial generalized linear model was used for DEG analysis. Expression levels were plotted using normalized gene counts in log10 scale. Adjusted P value calculated with the use of the Benjamini-Hochberg method for multiple comparison testing. Abbreviations as in Figure 2.

**CENTRAL ILLUSTRATION. Intrahepatic Transcriptomics, Advanced Fibrosis, and Clinical Outcomes in Fontan-Associated Liver Disease**
In this study we identified differentially expressed genes (DEGs) related to inflammation, congestion, and angiogenesis among those with advanced vs early liver fibrosis as well as those who experienced the composite clinical outcome (CCO) vs those who did not.

See this image and copyright information in PMC

Update of

Intrahepatic transcriptomics differentiate advanced fibrosis and clinical outcomes in adults with the Fontan circulation.
Bravo-Jaimes K, Wu X, Reardon LC, Lluri G, Lin JP, Moore JP, Arsdell GV, Biniwale R, Si MS, Naini BV, Venick R, Saab S, Wray CL, Ponder R, Rosenthal C, Klomhaus A, Böstrom KI, Aboulhosn JA, Kaldas FM. Bravo-Jaimes K, et al. medRxiv [Preprint]. 2023 Jun 7:2023.06.05.23290997. doi: 10.1101/2023.06.05.23290997. medRxiv. 2023. Update in: J Am Coll Cardiol. 2024 Feb 20;83(7):726-738. doi: 10.1016/j.jacc.2023.12.005. PMID: 37333414 Free PMC article. Updated. Preprint.

Comment in

Turning to "Omics" in Understanding Fontan-Associated Liver Disease.
Kim YY, Hoteit MA. Kim YY, et al. J Am Coll Cardiol. 2024 Feb 20;83(7):739-740. doi: 10.1016/j.jacc.2023.12.025. J Am Coll Cardiol. 2024. PMID: 38355243 No abstract available.

References

1. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971;26:240–248. 10.1136/thx.26.3.240 - DOI - PMC - PubMed
1. Emamaullee J, Zaidi AN, Schiano T, et al. Fontan-associated liver disease: screening, management, and transplant considerations. Circulation. 2020;142:591–604. 10.1161/circulationaha.120.045597 - DOI - PMC - PubMed
1. Agnoletti G, Ferraro G, Bordese R, et al. Fontan circulation causes early, severe liver damage. Should we offer patients a tailored strategy? Int J Cardiol. 2016;209:60–65. 10.1016/j.ijcard.2016.02.041 - DOI - PubMed
1. Goldberg DJ, Surrey LF, Glatz AC, et al. Hepatic fibrosis is universal following Fontan operation, and severity is associated with time from surgery: a liver biopsy and hemodynamic study. J Am Heart Assoc. 2017;6. 10.1161/jaha.116.004809 - DOI - PMC - PubMed
1. Khan S, Aziz H, Emamaullee J. Research priorities in Fontan-associated liver disease. Curr Opin Organ Transplant. 2020;25:489–495. 10.1097/mot.0000000000000803 - DOI - PubMed

Publication types

Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Intrahepatic Transcriptomics Differentiate Advanced Fibrosis and Clinical Outcomes in Adults With Fontan Circulation

Affiliations

Intrahepatic Transcriptomics Differentiate Advanced Fibrosis and Clinical Outcomes in Adults With Fontan Circulation

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Update of

Comment in

References

Publication types

MeSH terms

Substances

Grants and funding

LinkOut - more resources

Full Text Sources

Medical