Disruption of the murine mdr2 (multidrug-resistance) disease, characterized by a portal inflammation and a gene, which encodes a phosphatidylcholine flippase, ductular proliferation, is probably the consequence of leads to a hepatic disorder because of loss of biliary a toxic effect of bile acids on the biliary epithelium in phospholipid secretion. Among the hereditary human the absence of biliary phospholipids. 13,22 Because hucholestasis, a subtype of progressive familial intrahe-man bile acids are more hydrophobic than those of ropatic cholestasis with high g-glutamyltranspeptidase dents, it is expected that the absence of MDR3 P-glyco-(GGT) serum activity shares histological, biochemical, protein (the human homolog of mdr2 P-glycoprotein) and genetic features with mice lacking mdr2 gene ex-would result in severe liver disease manifest in child- suggest at least three subcategories.27-30 However, no associated genetic defect has been identified. It has The mouse mdr2 gene (standard gene symbol Pgy-been suggested that one subtype of PFIC may be attrib-3) and its human homolog MDR3 (also called MDR2, utable to a defect in primary bile acid secretion, 29 and it standard gene symbol PGY3) are members of the multi-has been established that children affected by another drug gene family 1-7 that do not confer multidrug resis-subtype have a defect in primary bile acid synthesis. 30 tance 8-11 but encode P-glycoproteins, which act as phos-In both of these subtypes, cholestasis is associated with phatidylcholine flippases.12-17 These P-glycoproteins normal serum g-glutamyltranspeptidase (GGT) activare, in liver, exclusively found in the canalicular mem-ity, and there is no ductular proliferation as assessed brane of hepatocytes.18-21 Disruption of the mdr2 gene by liver histology. [29][30] By contrast, the pathological in mice has led to evidence for a physiological role of mechanism is unknown for the third subtype characthe mdr2 P-glycoprotein in biliary excretion. 13 In homo-terized by high serum GGT activity and ductular prolifzygous mdr2 0/0 mice, phospholipids are absent from eration and inflammatory infiltrate in portal areas bile and the animals suffer from liver disease. 13,22 This with patency of intrahepatic and extrahepatic bile ducts. This pattern of nonsuppurative cholangitis is very similar to the hepatic injury observed in mdr2 0/ Received November 27, 1995; accepted January 16, 1996. liver of a patient, and we analyzed the bile phospholipid Supported in part by a grant from Mutuelle Générale de l'Education Natiocontent of another patient, both with high serum GGT