Her younger sister (III.16) developed liver disease in her early teens and died of cirrhosis at age 19 (Fig. 1). A first cousin (III.1) died of liver disease at age 6 and her sister, a 32-year-old reportedly healthy Ibrutinib in vitro woman (III.5), had self-limited jaundice and abdominal swelling as a child that fully resolved by age 9. On physical examination the proband had jaundice, multiple echymoses, splenomegaly, and mild pedal edema. Laboratory evaluation revealed mildly elevated levels of aspartate aminotransferase (AST) (67 IU/L, normal range: 13-40 IU/L),

alanine aminotransferase (ALT) (50 IU/L, normal range: 10-40 IU/L), alkaline phosphatase (ALKP) (153 IU/L, normal range: 38-126 IU/L), and a normal GGT level (14 IU/L, normal range: 4-63 IU/L). Her serum bilirubin was 1.8 mg/dL (normal range: 0.2-1.3 mg/dL) with a direct bilirubin of 1.3 mg/dL (normal range: 0.0-0.3 mg/dL). Her prothrombin time and international normalized ratio (INR) was increased (2.0, normal range: 0.8-1.2) and serum albumin level was reduced (3 g/dL, normal range: 3.4-5.4 g/dL). Abdominal computerized tomography (CT) showed a small nodular liver, numerous splenic and gastroesophageal varices, and marked splenomegaly (spleen span of 24 cm). Liver biopsy revealed extensive bridging fibrosis with abnormal ducts encircling parenchymal nodules. Laboratory evaluation was negative for Wilson’s disease, hemochromatosis, and α1 anti-trypsin deficiency as well as for viral or autoimmune

hepatitis. She denied any history of alcohol abuse. Blood samples were collected from the 13 family members who were available for study (Fig. JNK inhibitor molecular weight 1). The proband’s parents (II.10 and II.11) were first cousins and two of her paternal uncles (II.2 and II.4) married first cousins. Two brothers (II.4 and II.10) had married two sisters (II.5 and II.11). The

32-year-old offspring of a paternal uncle (III.5) had been diagnosed with liver disease in childhood but was subsequently asymptomatic and had normal serum levels of hepatic enzymes (AST = 21 IU/L, ALT = 30 IU/L, ALKP = 67 IU/L) and bilirubin (total, 0.9 mg/dL; direct, 0.3 mg/dL) at the time of this study. The inheritance pattern of liver disease in the family was most consistent with an autosomal recessive disorder. Given the high level of consanguinity Nintedanib (BIBF 1120) in the family, we hypothesized that the affected family members were homozygous for a mutation inherited identical-by-descent from a common ancestor. Genotype analysis revealed extensive homozygosity in all three family members, including single regions encompassing 63% and 78% of chromosomes 10 and 19, respectively, in the affected first cousin (III.5). We focused on those runs of homozygosity (ROH) that were >3 Mb because regions of this length are uncommon in the general population22 (Fig. 2). Candidate regions were further refined by identifying those ROHs that were shared by both affected patients but not by the unaffected family member. The resulting candidate regions totaled 36.5 Mb or 1.