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Günendi T, Kocaman OH, Dörterler ME, Kaya V, Efe C, Boleken ME. Non-operative management of iatrogenic esophageal perforation in a 6-year-old child. Acta Chir Belg 2023; 123:682-686. [PMID: 35838032 DOI: 10.1080/00015458.2022.2101748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/11/2022] [Indexed: 11/01/2022] [Imported: 09/26/2023]
Abstract
BACKGROUND Esophageal perforations are rare, the most common encountered esophageal perforation is iatrogenic in origin. It can be life-threatening if not diagnosed and treated early. Medical treatment has been recommended primarily in hemodynamically stable children. Drainage of intrathoracic or periesophageal fluid formation should be reserved to patients with hemodynamic instability. Surgical intervention may seldomly be required, depending on the localization and size of the defect. CASE REPORT A 6-year-old male patient was referred to our clinic due to an esophageal perforation whilst removing the foreign body from upper esophagus under direct vision of a rigid esophagoscope. A radiologic appearance similar to esophageal duplication was detected along the esophagus in the esophagogram. A secondary esophagoscopy was carried out by our clinic, laceration at the esophagopharyngeal junction and dissection along the esophagus were observed and the foreign body was propelled into the stomach. The patient, whose clinical condition was stable, was managed medically without the need for a surgical intervention. CONCLUSIONS Esophageal perforation is rare, yet perilous if not handled properly. We do not encounter this clinical entity frequently. Despite its rarity it can arise either iatrogenically or while managing a previous complication such as a simple nasogastric tube insertion in an infant or during an endoscopy for an esophageal foreign body. Its management is challenging, and we believe that non-operative treatment is still an important option in childhood esophageal perforations.
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Gatselis NK, Zachou K, Loza AJM, Cançado ELR, Arinaga-Hino T, Muratori P, Efe C, Floreani A, Invernizzi P, Takahashi A, Takaki A, Beretta-Piccoli BT, van Hoek B, Lytvyak E, Guedes LV, Purnak T, Cazzagon N, Lygoura V, Arvaniti P, Rigopoulou EI, Muratori L, Dalekos GN. Prevalence and significance of antimitochondrial antibodies in autoimmune hepatitis (AIH): Results from a large multicentre study of the International AIH Group. Eur J Intern Med 2023; 116:43-50. [PMID: 37302951 DOI: 10.1016/j.ejim.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023] [Imported: 09/26/2023]
Abstract
BACKGROUND & AIMS Antimitochondrial antibodies (AMA) are specific markers for the diagnosis of primary biliary cholangitis (PBC) but can also be found occasionally in patients with autoimmune hepatitis (AIH). The present large multicentre cohort study assessed the prevalence and significance of AMA in AIH-patients. METHODS 123 AMA-positive AIH-patients were investigated and compared with 711 age-matched AMA-negative AIH-patients and 69 patients with AIH/PBC variant. RESULTS AMA prevalence in AIH-patients was 5.1% (range: 1.2%-11.8%). AMA-positivity was associated with female sex (p = 0.031) in AMA-positive AIH-patients but not with liver biochemistry, bile duct injury on liver biopsy, disease severity at baseline and response to treatment compared to AMA-negative AIH-patients. Comparing AMA-positive AIH-patients to those with AIH/PBC variant, there was no difference in disease severity. Regarding liver histology, AIH/PBC variant patients were characterized by the presence of at least one feature of bile duct damage (p<0.001). Response to immunosuppressive treatment was similar among groups. From AMA-positive AIH patients only those with evidence of non-specific bile duct injury had higher risk to progress to cirrhosis (HR=4.314, 95%CI: 2.348-7.928; p<0.001). During follow-up, AMA-positive AIH-patients had higher risk to develop histological bile duct injury (HR 4.654, 95%CI 1.829-11.840; p = 0.001). CONCLUSIONS AMA presence is relatively common among AIH-patients, but their clinical significance seems important only when they co-exist with non-specific bile duct injury at the histological level. Therefore, a careful evaluation of liver biopsy seems of utmost importance in these patients.
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Kulkarni AV, Anders M, Nazal L, Ridruejo E, Efe C. Cases of severe acute liver injury following inactivated SARS-CoV-2 vaccination. J Hepatol 2023; 78:e60-e61. [PMID: 36351480 PMCID: PMC9639389 DOI: 10.1016/j.jhep.2022.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022] [Imported: 09/26/2023]
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Efe C, Kulkarni AV, Terziroli Beretta-Piccoli B, Magro B, Stättermayer A, Cengiz M, Clayton-Chubb D, Lammert C, Bernsmeier C, Gül Ö, la Tijera FHD, Anders M, Lytvyak E, Akın M, Purnak T, Liberal R, Peralta M, Ebik B, Duman S, Demir N, Balaban Y, Urzua Á, Contreras F, Venturelli MG, Bilgiç Y, Medina A, Girala M, Günşar F, Londoño MC, Androutsakos T, Kisch A, Yurci A, Güzelbulut F, Çağın YF, Avcı E, Akyıldız M, Dindar-Demiray EK, Harputluoğlu M, Kumar R, Satapathy SK, Mendizabal M, Silva M, Fagiuoli S, Roberts SK, Soylu NK, Idilman R, Yoshida EM, Montano-Loza AJ, Dalekos GN, Ridruejo E, Schiano TD, Wahlin S. Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome. Hepatology 2022; 76:1576-1586. [PMID: 35567545 PMCID: PMC9348326 DOI: 10.1002/hep.32572] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022] [Imported: 09/26/2023]
Abstract
BACKGROUND AND AIMS A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series. APPROACH AND RESULTS We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up. CONCLUSIONS SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.
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Codoni G, Kirchner T, Engel B, Villamil AM, Efe C, Stättermayer AF, Weltzsch JP, Sebode M, Bernsmeier C, Lleo A, Gevers TJG, Kupčinskas L, Castiella A, Pinazo J, De Martin E, Bobis I, Sandahl TD, Pedica F, Invernizzi F, Del Poggio P, Bruns T, Kolev M, Semmo N, Bessone F, Giguet B, Poggi G, Ueno M, Jang H, Elpek GÖ, Soylu NK, Cerny A, Wedemeyer H, Vergani D, Mieli-Vergani G, Lucena MI, Andrade RJ, Zen Y, Taubert R, Beretta-Piccoli BT. Histological and serological features of acute liver injury after SARS-CoV-2 vaccination. JHEP Rep 2022; 5:100605. [DOI: 10.1016/j.jhepr.2022.100605] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/22/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] [Imported: 09/26/2023] Open
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Efe C, Taşçılar K, Gerussi A, Bolis F, Lammert C, Ebik B, Stättermayer AF, Cengiz M, Gökçe DT, Cristoferi L, Peralta M, Massoumi H, Montes P, Cerda E, Rigamonti C, Yapalı S, Adali G, Çalışkan AR, Balaban Y, Eren F, Eşkazan T, Barutçu S, Lytvyak E, Zazueta GM, Kayhan MA, Heurgue-Berlot A, De Martin E, Yavuz A, Bıyık M, Narro GC, Duman S, Hernandez N, Gatselis NK, Aguirre J, Idilman R, Silva M, Mendizabal M, Atay K, Güzelbulut F, Dhanasekaran R, Montano-Loza AJ, Dalekos GN, Ridruejo E, Invernizzi P, Wahlin S. SARS-CoV-2 vaccination and risk of severe COVID-19 outcomes in patients with autoimmune hepatitis. J Autoimmun 2022; 132:102906. [PMID: 36088883 PMCID: PMC9448709 DOI: 10.1016/j.jaut.2022.102906] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 02/06/2023] [Imported: 09/26/2023]
Abstract
Background Data regarding outcome of Coronavirus disease 2019 (COVID-19) in vaccinated patients with autoimmune hepatitis (AIH) are lacking. We evaluated the outcome of COVID-19 in AIH patients who received at least one dose of Pfizer- BioNTech (BNT162b2), Moderna (mRNA-1273) or AstraZeneca (ChAdOx1-S) vaccine. Patients and methods We performed a retrospective study on AIH patients with COVID-19. The outcomes of AIH patients who had acute respiratory syndrome coronavirus 2 (SARS-CoV-2) breakthrough infection after at least one dose of COVID-19 vaccine were compared to unvaccinated patients with AIH. COVID-19 outcome was classified according to clinical state during the disease course as: (i) no hospitalization, (ii) hospitalization without oxygen supplementation, (iii) hospitalization with oxygen supplementation by nasal cannula or mask, (iv) intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v) ICU admission with invasive mechanical ventilation or (vi) death, and data was analyzed using ordinal logistic regression. Results We included 413 (258 unvaccinated and 155 vaccinated) patients (81%, female) with a median age of 52 (range: 17–85) years at COVID-19 diagnosis. The rates of hospitalization were (36.4% vs. 14.2%), need for any supplemental oxygen (29.5% vs. 9%) and mortality (7% vs. 0.6%) in unvaccinated and vaccinated AIH patients with COVID-19. Having received at least one dose of SARS-CoV-2 vaccine was associated with a significantly lower risk of worse COVID-19 severity, after adjusting for age, sex, comorbidities and presence of cirrhosis (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI], 0.10–0.31). Overall, vaccination against SARS-CoV-2 was associated with a significantly lower risk of mortality from COVID-19 (aOR 0.20, 95% CI 0.11–0.35). Conclusions SARS-CoV-2 vaccination significantly reduced the risk of COVID-19 severity and mortality in patients with AIH.
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Efe C, Purnak T. Letter to the editor: Medical therapy of autoimmune hepatitis in pregnancy. Hepatology 2022; 76:E65-E66. [PMID: 35586891 DOI: 10.1002/hep.32576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 12/08/2022] [Imported: 09/26/2023]
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Risk factors and outcomes associated with recurrent autoimmune hepatitis following liver transplantation. J Hepatol 2022; 77:84-97. [PMID: 35143897 DOI: 10.1016/j.jhep.2022.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 12/19/2022] [Imported: 09/26/2023]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis can recur after liver transplantation (LT), though the impact of recurrence on patient and graft survival has not been well characterized. We evaluated a large, international, multicenter cohort to identify the probability and risk factors associated with recurrent AIH and the association between recurrent disease and patient and graft survival. METHODS We included 736 patients (77% female, mean age 42±1 years) with AIH who underwent LT from January 1987 through June 2020, among 33 centers in North America, South America, Europe and Asia. Clinical data before and after LT, biochemical data within the first 12 months after LT, and immunosuppression after LT were analyzed to identify patients at higher risk of AIH recurrence based on histological diagnosis. RESULTS AIH recurred in 20% of patients after 5 years and 31% after 10 years. Age at LT ≤42 years (hazard ratio [HR] 3.15; 95% CI 1.22-8.16; p = 0.02), use of mycophenolate mofetil post-LT (HR 3.06; 95% CI 1.39-6.73; p = 0.005), donor and recipient sex mismatch (HR 2.57; 95% CI 1.39-4.76; p = 0.003) and high IgG pre-LT (HR 1.04; 95% CI 1.01-1.06; p = 0.004) were associated with higher risk of AIH recurrence after adjusting for other confounders. In multivariate Cox regression, recurrent AIH (as a time-dependent covariate) was significantly associated with graft loss (HR 10.79, 95% CI 5.37-21.66, p <0.001) and death (HR 2.53, 95% CI 1.48-4.33, p = 0.001). CONCLUSION Recurrence of AIH following transplant is frequent and is associated with younger age at LT, use of mycophenolate mofetil post-LT, sex mismatch and high IgG pre-LT. We demonstrate an association between disease recurrence and impaired graft and overall survival in patients with AIH, highlighting the importance of ongoing efforts to better characterize, prevent and treat recurrent AIH. LAY SUMMARY Recurrent autoimmune hepatitis following liver transplant is frequent and is associated with some recipient features and the type of immunosuppressive medications use. Recurrent autoimmune hepatitis negatively affects outcomes after liver transplantation. Thus, improved measures are required to prevent and treat this condition.
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Bayhan I, Wahlin S, Efe C. Editorial: acute severe autoimmune hepatitis-a diagnostic and therapeutic dilemma. Aliment Pharmacol Ther 2022; 56:170-171. [PMID: 35689316 DOI: 10.1111/apt.16981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] [Imported: 09/26/2023]
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Efe C, Harputluoğlu M, Soylu NK, Yilmaz S. Letter to the editor: Liver transplantation following severe acute respiratory syndrome-coronavirus-2 vaccination-induced liver failure. Hepatology 2022; 75:1669-1671. [PMID: 35175635 PMCID: PMC9087410 DOI: 10.1002/hep.32409] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 01/05/2023] [Imported: 08/29/2023]
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Pape S, Snijders RJALM, Gevers TJG, Chazouilleres O, Dalekos GN, Hirschfield GM, Lenzi M, Trauner M, Manns MP, Vierling JM, Montano-Loza AJ, Lohse AW, Schramm C, Drenth JPH, Heneghan MA, Alvarez F, Andrade R, Arikan C, Assis D, Bardou-Jacquet E, Biewenga M, Cancado E, Cazzagon N, Chazouillères O, Colloredo G, Cuarterolo M, Dalekos G, Debray D, Robles-Díaz M, Drenth J, Dyson J, Efe C, Engel B, Ferri S, Fontana R, Gatselis N, Gerussi A, Halilbasic E, Halliday N, Heneghan M, Hirschfield G, van Hoek B, Hørby Jørgensen M, Indolfini G, Iorio R, Jeong S, Jones D, Kelly D, Kerkar N, Lacaille F, Lammert C, Leggett B, Lenzi M, Levy C, Liberal R, Lleo A, Lohse A, Ines Lopez S, de Martin E, McLin V, Mieli-Vergani G, Milkiewicz P, Mohan N, Muratori L, Nebbia G, van Nieuwkerk C, Oo Y, Ortega A, Páres A, Pop T, Pratt D, Purnak T, Ranucci G, Rushbrook S, Schramm C, Stättermayer A, Swain M, Tanaka A, Taubert R, Terrabuio D, Terziroli B, Trauner M, Valentino P, van den Brand F, Villamil A, Wahlin S, Ytting H, Zachou K, Zeniya M. Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group. J Hepatol 2022; 76:841-849. [PMID: 35066089 DOI: 10.1016/j.jhep.2021.12.041] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/18/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022] [Imported: 09/26/2023]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment. METHODS A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis. RESULTS The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'. CONCLUSIONS These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints. LAY SUMMARY Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.
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Efe C, Lammert C, Taşçılar K, Dhanasekaran R, Ebik B, Higuera-de la Tijera F, Calışkan AR, Peralta M, Gerussi A, Massoumi H, Catana AM, Purnak T, Rigamonti C, Aldana AJG, Khakoo N, Nazal L, Frager S, Demir N, Irak K, Melekoğlu-Ellik Z, Kacmaz H, Balaban Y, Atay K, Eren F, Alvares-da-Silva MR, Cristoferi L, Urzua Á, Eşkazan T, Magro B, Snijders R, Barutçu S, Lytvyak E, Zazueta GM, Demirezer-Bolat A, Aydın M, Heurgue-Berlot A, De Martin E, Ekin N, Yıldırım S, Yavuz A, Bıyık M, Narro GC, Kıyıcı M, Akyıldız M, Kahramanoğlu-Aksoy E, Vincent M, Carr RM, Günşar F, Reyes EC, Harputluoğlu M, Aloman C, Gatselis NK, Üstündağ Y, Brahm J, Vargas NCE, Güzelbulut F, Garcia SR, Aguirre J, Anders M, Ratusnu N, Hatemi I, Mendizabal M, Floreani A, Fagiuoli S, Silva M, Idilman R, Satapathy SK, Silveira M, Drenth JPH, Dalekos GN, N Assis D, Björnsson E, Boyer JL, Yoshida EM, Invernizzi P, Levy C, Montano-Loza AJ, Schiano TD, Ridruejo E, Wahlin S. Effects of immunosuppressive drugs on COVID-19 severity in patients with autoimmune hepatitis. Liver Int 2022; 42:607-614. [PMID: 34846800 DOI: 10.1111/liv.15121] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] [Imported: 09/26/2023]
Abstract
BACKGROUND We investigated associations between baseline use of immunosuppressive drugs and severity of Coronavirus Disease 2019 (COVID-19) in autoimmune hepatitis (AIH). PATIENTS AND METHODS Data of AIH patients with laboratory confirmed COVID-19 were retrospectively collected from 15 countries. The outcomes of AIH patients who were on immunosuppression at the time of COVID-19 were compared to patients who were not on AIH medication. The clinical courses of COVID-19 were classified as (i)-no hospitalization, (ii)-hospitalization without oxygen supplementation, (iii)-hospitalization with oxygen supplementation by nasal cannula or mask, (iv)-intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v)-ICU admission with invasive mechanical ventilation or (vi)-death and analysed using ordinal logistic regression. RESULTS We included 254 AIH patients (79.5%, female) with a median age of 50 (range, 17-85) years. At the onset of COVID-19, 234 patients (92.1%) were on treatment with glucocorticoids (n = 156), thiopurines (n = 151), mycophenolate mofetil (n = 22) or tacrolimus (n = 16), alone or in combinations. Overall, 94 (37%) patients were hospitalized and 18 (7.1%) patients died. Use of systemic glucocorticoids (adjusted odds ratio [aOR] 4.73, 95% CI 1.12-25.89) and thiopurines (aOR 4.78, 95% CI 1.33-23.50) for AIH was associated with worse COVID-19 severity, after adjusting for age-sex, comorbidities and presence of cirrhosis. Baseline treatment with mycophenolate mofetil (aOR 3.56, 95% CI 0.76-20.56) and tacrolimus (aOR 4.09, 95% CI 0.69-27.00) were also associated with more severe COVID-19 courses in a smaller subset of treated patients. CONCLUSION Baseline treatment with systemic glucocorticoids or thiopurines prior to the onset of COVID-19 was significantly associated with COVID-19 severity in patients with AIH.
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You H, Ma X, Efe C, Wang G, Jeong SH, Abe K, Duan W, Chen S, Kong Y, Zhang D, Wei L, Wang FS, Lin HC, Yang JM, Tanwandee T, Gani RA, Payawal DA, Sharma BC, Hou J, Yokosuka O, Dokmeci AK, Crawford D, Kao JH, Piratvisuth T, Suh DJ, Lesmana LA, Sollano J, Lau G, Sarin SK, Omata M, Tanaka A, Jia J. APASL clinical practice guidance: the diagnosis and management of patients with primary biliary cholangitis. Hepatol Int 2022; 16:1-23. [PMID: 35119627 PMCID: PMC8843914 DOI: 10.1007/s12072-021-10276-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022] [Imported: 09/26/2023]
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Coronavirus disease 2019 (COVID-19) in Autoimmune Hepatitis. HEPATOLOGY FORUM 2022; 3:68-70. [PMID: 35783480 PMCID: PMC9243756 DOI: 10.14744/hf.2022.2022.0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/20/2022] [Imported: 09/26/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 is a highly transmissible and pathogenic virus that leads to coronavirus disease 2019 (COVID-19). The preexisting liver diseases alter the course of COVID-19. Therefore, specific management strategies must be considered in individuals with chronic liver diseases (CLDs) and COVID-19. Autoimmune hepatitis (AIH) is a rare immune-mediated liver disease. Patients with AIH require life-long treatment with immunosuppressive drugs that may increase the risk of poor COVID-19 outcomes. The stage of underlying liver disease is another factor that can affect the clinical outcomes of COVID-19 in patients with AIH. In this review, we aim to provide relevant issues that will be helpful to clinicians in understanding and improving the clinical care for patients with AIH during the pandemic.
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Demir N, Ekin N, Torgutalp M, Wahlin S, Efe C. Two decades of research on autoimmune liver disease in Turkey. TURKISH JOURNAL OF GASTROENTEROLOGY 2021; 31:877-882. [PMID: 33626000 DOI: 10.5152/tjg.2020.19866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] [Imported: 08/29/2023]
Abstract
BACKGROUND/AIMS Autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) are the 3 main autoimmune liver diseases (AILDs). The epidemiology of AILD in Turkey is not known. To determine the scientific status, we performed a scientometric analysis of AILD-related original articles that originated from Turkey. MATERIALS AND METHODS We searched the Web of Science database, the Science Citation Index Expanded (SCI-E), and the Social Sciences Citation Index (SSCI) by using the keywords "autoimmune hepatitis," "primary biliary cholangitis/primary biliary cirrhosis," and "primary sclerosing cholangitis" in conjunction with "Turkey." A scientometric analysis was done on the search results. RESULTS We identified 117 AILD-related papers that were published in Turkey from 1997 to 2019. Among these, 70 case reports, letters, and reviews and 2 original articles that were not cited in SCI-E/SSCI were excluded. The remaining 45 original articles were further analyzed. These studies were related to AIH (n=22), PBC (n=7), PSC (n=9), PBC-AIH overlap (n=5), and others (n=2). Four of the publications originated in pediatric settings; 9 of 45 papers were published from 1997 to 2008 and 36 papers were published from 2009 to 2019. Most papers (75%) were reported from 5 centers; 9 papers (20%) were published in journals with an impact factor of 3 or higher. CONCLUSION The overall number and quality of AILD-related papers in Turkey are unexpectedly low, although a number of papers have received considerable international recognition. More epidemiologic, prospective, and multicenter research projects are warranted to advance AILD knowledge and to produce high-quality research from Turkey.
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Kabaçam G, Wahlin S, Efe C. Autoimmune hepatitis triggered by COVID-19: A report of two cases. Liver Int 2021; 41:2527-2528. [PMID: 34478591 PMCID: PMC8662284 DOI: 10.1111/liv.15044] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 12/14/2022] [Imported: 08/29/2023]
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Efe C, Wahlin S. Letter to the Editor: Reply to Autoimmune Hepatitis and Coronavirus Disease 2019: Disease Outcomes and Tacrolimus Use. Hepatol Commun 2021; 6:3272. [PMID: 34558846 PMCID: PMC8653226 DOI: 10.1002/hep4.1798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] [Imported: 09/26/2023] Open
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Efe C, Dhanasekaran R, Lammert C, Ebik B, Higuera‐de la Tijera F, Aloman C, Rıza Calışkan A, Peralta M, Gerussi A, Massoumi H, Catana AM, Torgutalp M, Purnak T, Rigamonti C, Gomez Aldana AJ, Khakoo N, Kacmaz H, Nazal L, Frager S, Demir N, Irak K, Ellik ZM, Balaban Y, Atay K, Eren F, Cristoferi L, Batıbay E, Urzua Á, Snijders R, Kıyıcı M, Akyıldız M, Ekin N, Carr RM, Harputluoğlu M, Hatemi I, Mendizabal M, Silva M, Idilman R, Silveira M, Drenth JP, Assis DN, Björnsson E, Boyer JL, Invernizzi P, Levy C, Schiano TD, Ridruejo E, Wahlin S. Outcome of COVID-19 in Patients With Autoimmune Hepatitis: An International Multicenter Study. Hepatology 2021; 73:2099-2109. [PMID: 33713486 PMCID: PMC8250536 DOI: 10.1002/hep.31797] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] [Imported: 08/29/2023]
Abstract
BACKGROUND AND AIMS Data regarding outcome of COVID-19 in patients with autoimmune hepatitis (AIH) are lacking. APPROACH AND RESULTS We performed a retrospective study on patients with AIH and COVID-19 from 34 centers in Europe and the Americas. We analyzed factors associated with severe COVID-19 outcomes, defined as the need for mechanical ventilation, intensive care admission, and/or death. The outcomes of patients with AIH were compared to a propensity score-matched cohort of patients without AIH but with chronic liver diseases (CLD) and COVID-19. The frequency and clinical significance of new-onset liver injury (alanine aminotransferase > 2 × the upper limit of normal) during COVID-19 was also evaluated. We included 110 patients with AIH (80% female) with a median age of 49 (range, 18-85) years at COVID-19 diagnosis. New-onset liver injury was observed in 37.1% (33/89) of the patients. Use of antivirals was associated with liver injury (P = 0.041; OR, 3.36; 95% CI, 1.05-10.78), while continued immunosuppression during COVID-19 was associated with a lower rate of liver injury (P = 0.009; OR, 0.26; 95% CI, 0.09-0.71). The rates of severe COVID-19 (15.5% versus 20.2%, P = 0.231) and all-cause mortality (10% versus 11.5%, P = 0.852) were not different between AIH and non-AIH CLD. Cirrhosis was an independent predictor of severe COVID-19 in patients with AIH (P < 0.001; OR, 17.46; 95% CI, 4.22-72.13). Continuation of immunosuppression or presence of liver injury during COVID-19 was not associated with severe COVID-19. CONCLUSIONS This international, multicenter study reveals that patients with AIH were not at risk for worse outcomes with COVID-19 than other causes of CLD. Cirrhosis was the strongest predictor for severe COVID-19 in patients with AIH. Maintenance of immunosuppression during COVID-19 was not associated with increased risk for severe COVID-19 but did lower the risk for new-onset liver injury during COVID-19.
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Wang G, Tanaka A, Zhao H, Jia J, Ma X, Harada K, Wang FS, Wei L, Wang Q, Sun Y, Hong Y, Rao H, Efe C, Lau G, Payawal D, Gani R, Lindor K, Jafri W, Omata M, Sarin SK. The Asian Pacific Association for the Study of the Liver clinical practice guidance: the diagnosis and management of patients with autoimmune hepatitis. Hepatol Int 2021; 15:223-257. [PMID: 33942203 PMCID: PMC8144150 DOI: 10.1007/s12072-021-10170-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/27/2021] [Indexed: 02/06/2023] [Imported: 09/26/2023]
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Efe C, Torgutalp M, Henriksson I, Alalkim F, Lytvyak E, Trivedi H, Eren F, Fischer J, Chayanupatkul M, Coppo C, Purnak T, Muratori L, Werner M, Muratori P, Rorsman F, Onnerhag K, Nilsson E, Heurgué-Berlot A, Demir N, Semela D, Kıyıcı M, Schiano TD, Montano-Loza AJ, Berg T, Ozaslan E, Yoshida EM, Bonder A, Marschall HU, Beretta-Piccoli BT, Wahlin S. Extrahepatic autoimmune diseases in primary biliary cholangitis: Prevalence and significance for clinical presentation and disease outcome. J Gastroenterol Hepatol 2021; 36:936-942. [PMID: 32790935 DOI: 10.1111/jgh.15214] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/28/2020] [Accepted: 08/09/2020] [Indexed: 12/14/2022] [Imported: 08/29/2023]
Abstract
BACKGROUND AND AIM The prevalence and clinical significance of extrahepatic autoimmune diseases (EHAIDs) have not been evaluated in a large cohort of primary biliary cholangitis (PBC). METHODS The medical records of 1554 patients with PBC from 20 international centers were retrospectively reviewed. Development of decompensated cirrhosis (ascites, variceal bleeding, and/or hepatic encephalopathy) and hepatocellular carcinoma were considered clinical endpoints. RESULTS A total of 35 different EHAIDs were diagnosed in 440 (28.3%) patients with PBC. Patients with EHAIDs were more often female (92.5% vs 86.1%, P < 0.001) and seropositive for anti-mitochondrial antibodies (88% vs 84%, P = 0.05) and antinuclear antibodies and/or smooth muscle antibodies (53.8% vs 43.6%, P = 0.005). At presentation, patients with EHAIDs had significantly lower levels of alkaline phosphatase (1.76 vs 1.98 × upper limit of normal [ULN], P = 0.006), aspartate aminotransferase (1.29 vs 1.50 × ULN, P < 0.001), and total bilirubin (0.53 vs 0.58 × ULN, P = 0.002). Patients with EHAIDs and without EHAIDs had similar rates of GLOBE high-risk status (12.3% vs 16.1%, P = 0.07) and Paris II response (71.4% vs 69.4%, P = 0.59). Overall, event-free survival was not different in patients with and without EHAIDs (90.8% vs 90.7%, P = 0.53, log rank). Coexistence of each autoimmune thyroid diseases (10.6%), Sjögren disease (8.3%), systemic sclerosis (2.9%), rheumatoid arthritis (2.7%), systemic lupus erythematosus (1.7%), celiac disease (1.7%), psoriasis (1.5%), and inflammatory bowel diseases (1.3%) did not influence the outcome. CONCLUSIONS Our study confirms that EHAIDs are frequently diagnosed in patients with PBC. The presence of EHAIDs may influence the clinical phenotype of PBC at presentation but has no impact on PBC outcome.
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Efe C, Umay A, Purnak T. Fasciola As An Unusual Cause of Cholangitis. Clin Gastroenterol Hepatol 2021; 19:e33. [PMID: 32147590 DOI: 10.1016/j.cgh.2020.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023] [Imported: 09/26/2023]
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Efe C. Tacrolimus as second-line therapy in acute severe autoimmune hepatitis. Scand J Gastroenterol 2021; 56:298. [PMID: 33369499 DOI: 10.1080/00365521.2020.1867890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] [Imported: 08/29/2023]
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Wahlin S, Efe C. Both tacrolimus and mycophenylate mophetil should be considered second-line therapy for autoimmune hepatitis. J Hepatol 2021; 74:753-755. [PMID: 33309114 DOI: 10.1016/j.jhep.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022] [Imported: 09/26/2023]
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Efe C, Simşek C, Batıbay E, Calışkan AR, Wahlin S. Feasibility of telehealth in the management of autoimmune hepatitis before and during the COVID-19 pandemic. Expert Rev Gastroenterol Hepatol 2020; 14:1215-1219. [PMID: 32909852 DOI: 10.1080/17474124.2020.1822734] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] [Imported: 08/29/2023]
Abstract
OBJECTIVES We aimed to evaluate the feasibility of telehealth in the management of patients with autoimmune hepatitis (AIH). The COVID-19 outbreak during the study period provided an opportunity to evaluate any pandemic influence on how telehealth was perceived by patients and physicians. METHODS We included patients with AIH who were followed in the Harran University hospital, Turkey. Patients were managed by either remote telehealth or standard care. RESULTS A total of 46 (telehealth, n=19 and standard care, n= 27) patients (40 female) with a median age of 32 (range 17-74) years at diagnosis were included in the study. Until the start of the COVID-19 pandemic, the rates of biochemical remission and relapse after remission were similar in the telehealth and standard care groups (89.5% vs. 89.1% and 15.8% vs. 25.9%, p=ns, for both). The telehealth group maintained remission significantly better than the standard care group (100% vs. 77.3%, p=0.035) during the COVID-19 period. All relapses were due to non-adherence to therapy. Psychiatric problems, pregnancy-related issues and drug side-effects could all be managed remotely by telehealth. CONCLUSIONS In this study, we show for the first time that telehealth is a feasible alternative for managing AIH, both under normal circumstances and during the COVID-19 pandemic. EXPERT OPINION Autoimmune hepatitis (AIH) requires long-life lifelong immunosuppression and follow-up for most patients. The use of telehealth may be an alternative way to evaluate these patients remotely. We show for the first time that telehealth is effective and useful in the management of AIH in regular time as well during COVID-19. We hope that our study can extend use of telehealth in the evaluation of patients with other causes of chronic liver disease.
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Pape S, Gevers TJG, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Taubert R, Jaeckel E, Manns MP, Papp M, Sipeki N, Stickel F, Efe C, Ozaslan E, Purnak T, Nevens F, Kessener DJN, Kahraman A, Wedemeyer H, Hartl J, Schramm C, Lohse AW, Heneghan MA, Drenth JPH. High discontinuation rate of azathioprine in autoimmune hepatitis, independent of time of treatment initiation. Liver Int 2020; 40:2164-2171. [PMID: 32410363 PMCID: PMC7496382 DOI: 10.1111/liv.14513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023] [Imported: 09/26/2023]
Abstract
BACKGROUND Guidelines regarding treatment for autoimmune hepatitis (AIH) favour two strategies for azathioprine (AZA) introduction: concurrent with steroids at induction or delayed by 2-4 weeks. The safety and efficacy of both strategies have been unexplored. METHODS We established a cohort of 900 AIH patients from 12 centres in 7 European countries. There were 631 patients who used AZA as part of the therapeutic regimen. We distinguished two groups: patients with early AZA (<2 weeks) or delayed AZA initiation (≥2 weeks). Primary outcome was discontinuation of AZA in the first year of treatment. Cox regression and propensity score matching was performed to determine difference in outcomes between groups. RESULTS Patients with early AZA initiation had significantly lower transaminases and bilirubin at baseline. Discontinuation rates of AZA did not differ between early and delayed starters (16.6% vs 14.2%), which did not reach statistical significance (hazard ratio 0.97, 95% confidence interval 0.61-1.55, P = .90). Stratification according to baseline disease activity or propensity score matching did not alter the results. Main reason for AZA discontinuation was intolerance to treatment (14.0% vs 13.2%, P = .78) with nausea and vomiting as main side effects. AIH remission rates were comparable among groups. CONCLUSION The discontinuation rate of AZA in AIH treatment is ~15% in the first year of treatment. Early or delayed AZA initiation does not differ in remission and discontinuation rates in AIH induction therapy. Our data suggest that either strategy may be used as part of AIH treatment.
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