Is a Candidate Modifier of Liver Disease Severity in Alagille Syndrome

Background & Aims: Alagille syndrome is an autosomal-dominant, multisystem disorder caused primarily by mutations in , resulting in bile duct paucity, cholestasis, cardiac disease, and other features. Liver disease severity in Alagille syndrome is highly variable, however, factors influencing the hepatic phenotype are unknown. We hypothesized that genetic modifiers may contribute to the variable expressivity of this disorder.

Methods: We performed a genome-wide association study in a cohort of Caucasian subjects with known pathogenic mutations, comparing patients with mild vs severe liver disease, followed by functional characterization of a candidate locus.

Results: We identified a locus that reached suggestive genome-level significance upstream of the thrombospondin 2 () gene. codes for a secreted matricellular protein that regulates cell proliferation, apoptosis, and angiogenesis, and has been shown to affect Notch signaling. By using a reporter mouse line, we detected thrombospondin 2 expression in bile ducts and periportal regions of the mouse liver. Examination of -null mouse livers showed increased microvessels in the portal regions of adult mice. We also showed that thrombospondin 2 interacts with NOTCH1 and NOTCH2 and can inhibit JAG1-NOTCH2 interactions.

Conclusions: Based on the genome-wide association study results, thrombospondin 2 localization within bile ducts, and demonstration of interactions of thrombospondin 2 with JAG1 and NOTCH2, we propose that changes in thrombospondin 2 expression may further perturb JAG1-NOTCH2 signaling in patients harboring a mutation and lead to a more severe liver phenotype. These results implicate as a plausible candidate genetic modifier of liver disease severity in Alagille syndrome.