201
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Lohse AW, Wiegard C. Diagnostic criteria for autoimmune hepatitis. Best Pract Res Clin Gastroenterol 2011; 25:665-71. [PMID: 22117633 DOI: 10.1016/j.bpg.2011.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/25/2011] [Indexed: 01/31/2023]
Abstract
The clinical spectrum of autoimmune hepatitis is very wide. In addition, autoimmune hepatitis can present in any age group. Diagnosis is usually made by a combination of clinical, laboratory and histological features. Diagnostic scores can help both in the daily diagnostic work-up of patients, and in allowing comparability of clinical scientific studies. However, all diagnostic scores have limitations in individual cases, which are discussed in this review.
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Affiliation(s)
- Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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202
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Mieli-Vergani G, Vergani D. Autoimmune liver diseases in children - what is different from adulthood? Best Pract Res Clin Gastroenterol 2011; 25:783-95. [PMID: 22117642 DOI: 10.1016/j.bpg.2011.10.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 10/25/2011] [Indexed: 01/31/2023]
Abstract
Autoimmune liver disorders in childhood include autoimmune hepatitis, autoimmune sclerosing cholangitis and de novo autoimmune hepatitis after liver transplant. These inflammatory liver disorders are characterised histologically by interface hepatitis, biochemically by elevated transaminase levels and serologically by autoantibodies and increased levels of immunoglobulin G. Autoimmune hepatitis is particularly aggressive in children and progresses rapidly unless immunosuppressive treatment is started promptly. With appropriate treatment 80% of patients achieve remission and long-term survival. Autoimmune sclerosing cholangitis responds to the same treatment used for autoimmune hepatitis in regards to parenchymal inflammation, but bile duct disease progresses in about 50% of cases, leading to a worse prognosis and higher transplantation requirement; it has a high recurrence rate post-liver transplant. De novo autoimmune hepatitis after liver transplant affects children transplanted for non-autoimmune conditions and responds well to the same treatment schedule used for autoimmune hepatitis, but not to the schedule used for acute rejection.
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Affiliation(s)
- Giorgina Mieli-Vergani
- King's College London School of Medicine at King's College Hospital, Paediatric Liver, GI and Nutrition Centre, Denmark Hill, London SE5 9RS, UK
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203
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Cavazzana I, Ceribelli A, Taraborelli M, Fredi M, Norman G, Tincani A, Satoh M, Franceschini F. Primary biliary cirrhosis-related autoantibodies in a large cohort of italian patients with systemic sclerosis. J Rheumatol 2011; 38:2180-5. [PMID: 21921093 DOI: 10.3899/jrheum.110167] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To analyze the prevalence, associations, and fine specificity of autoantibodies to primary biliary cirrhosis (PBC)-associated antigens (MIT3, Sp100, and gp210) in a cohort of Italian patients with systemic sclerosis (SSc). METHODS Sera samples from 201 patients with SSc were tested for antibodies to MIT3, gp210, and Sp100 by ELISA (the PBC screen). Anti-MIT3-positive sera were studied for IgG or IgA isotypes. All sera were analyzed by indirect immunofluorescence on HEp-2 cells and on rodent kidney/stomach/liver tissue sections in order to detect antinuclear and antimitochondrial antibodies (AMA). SSc was selected by American College of Rheumatology criteria and classified based on LeRoy's criteria. RESULTS Forty-three (21.4%) sera samples were positive for PBC screen antibodies. Anti-MIT3 antibodies were detected in 36 samples, anti-Sp100 in 5, and anti-gp210 in 1 sample. The other 3 PBC screen-positive samples showed no specificity for the single antigens. PBC screen-positive patients more frequently showed a limited cutaneous SSc subtype (p = 0.04), anticentromere antibodies (ACA; p = 0.0013), elevated alkaline phosphatase (ALP) (p < 0.0001), PBC (p = 0.002), and AMA (p = 0.008). Teleangiectasia and calcinosis were less frequent in this group of patients. IgG+IgA anti-MIT3-positive patients had higher prevalence of AMA (p = 0.0035), diagnosis of PBC (p = 0.014), and increased ALP (p = 0.039), all considered biochemical markers of severe liver disease. CONCLUSION PBC screen antibodies were detected in 20% of patients with SSc, strongly associated with ACA. ACA+/PBC screen+ patients had higher risk of developing PBC or elevation of ALP.
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Affiliation(s)
- Ilaria Cavazzana
- Rheumatology Unit, Spedali Civili, Piazzale Spedali Civili 1, 25100 Brescia, Italy.
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204
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Characteristics of autoimmune hepatitis in the Asia-Pacific Region: historical review. Hepatol Int 2011; 6:342-9. [PMID: 22020829 DOI: 10.1007/s12072-011-9313-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/27/2011] [Indexed: 01/20/2023]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) has been considered a relatively rare disease in Asia, including Japan, where there is a high frequency of infection with hepatitis viruses. METHOD We reviewd the ethnic differences of clinical features of autoimmume hepatitis by reported paper. RESULT Immunogenetic predisposition, especially differences in human leukocyte antigens (HLAs), has been pointed out as one of the factors for the occurrence of AIH. In other words, HLA-DR3, which is the first disease-susceptibility gene for AIH discovered in UK and the USA, is extremely rare in Asia including Japan. Moreover, HLA-DR4, which is more frequent than HLA-DR3 in Asia, is associated with a favorable response to treatment and improved prognosis. This also explains why diagnosis and treatment of AIH have not drawn as much attention as viral hepatitis. However, as a survey conducted in Japan shows, the number of patients diagnosed with AIH is increasing. However, the number of elderly patients positive for HLA-DR4 is also increasing in UK and the USA. CONCLUSION In the era of genome-wide association studies, further progress of studies on AIH, a typical disease model for immunological liver cell damage, is expected.
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205
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Yang Z, Liang Y, Qin B, Li C, Zhong R. Clinical significance of conventional serum autoantibodies for various liver diseases in a Chinese population. Clin Biochem 2011; 45:203-6. [PMID: 21933666 DOI: 10.1016/j.clinbiochem.2011.08.1146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Revised: 08/23/2011] [Accepted: 08/24/2011] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the prevalence of autoantibodies in various liver diseases and evaluate the performance parameters of AMA, ANA and their combinations for PBC. DESIGN AND METHODS This study enrolled 115 PBC patients, 695 patients with other liver diseases and 105 healthy subjects. RESULTS AMA were detected mainly in PBC patients, while ANA were detected in all categories. The high titer and multiple nuclear dot, rim-like and centromere (MRC) patterns of ANA were found in the majority of PBC patients, in contrast to moderate titers and other patterns. All the liver diseases but HAV and NAFLD had significantly independent association with ANA. The combination of MRC patterns and AMA showed superior performance parameters for PBC. CONCLUSIONS Although ANA can occur in various liver diseases, high titer and MRC patterns of ANA are more specific for PBC. The combination of MRC patterns and AMA has superior performance for PBC.
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Affiliation(s)
- Zaixing Yang
- Department of Laboratory Diagnostics, Changzheng Hospital, Second Military Medical University, Shanghai, China
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206
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Abstract
Autoimmune hepatitis (AIH) is an inflammatory liver disease that mainly affects females. It is characterized histologically by interface hepatitis, biochemically by increased aspartate and alanine aminotransferase levels, and serologically by the presence of autoantibodies and increased levels of immunoglobulin G. AIH affects both adults and children, and is particularly aggressive in the latter group. It is a relatively rare but devastating disease, which progresses rapidly unless immunosuppressive treatment is started promptly. With appropriate treatment 80% of patients achieve remission and long-term survival. Those patients who progress to end-stage liver disease because they are unresponsive or nonadherent to treatment, and those with fulminant liver failure (encephalopathy grade II-IV) at diagnosis, require liver transplantation. Seropositivity for smooth muscle and/or antinuclear antibodies defines type 1 AIH, while positivity for liver kidney microsomal type 1 antibodies defines type 2 AIH. The primary cause of AIH is unknown; however, considerable knowledge about the mechanisms of liver damage involved has been gathered over the past 30 years, which is likely to provide the basis for specific modes of treatment and a possible cure.
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207
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Białkowska J, Zygmunt A, Lewiński A, Stankiewicz W, Knopik-Dąbrowicz A, Szubert W, Jabłkowski M. Hepatitis and the polyglandular autoimmune syndrome, type 1. Arch Med Sci 2011; 7:536-9. [PMID: 22312376 PMCID: PMC3258753 DOI: 10.5114/aoms.2011.23427] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 08/25/2010] [Accepted: 10/14/2010] [Indexed: 11/28/2022] Open
Abstract
Autoimmune polyglandular syndrome, type 1 (APS-1) is a rare syndrome. Here we present a case report of a 24-year-old female patient who complained of progressive weakness. While autoimmune hepatitis was diagnosed, no improvement of biochemical parameters was obtained after immunosuppressive treatment. Hypoparathyroidism and adrenocortical failure were identified. Her health status clearly improved once proper control of the calcium-phosphate metabolism was obtained and after the administration of substitution hydrocortisone doses, leading to full normalization of biochemical liver tests. The reported case illustrates a rare form of APS-1 failure, in which the diagnosed autoimmune hepatitis was only the first symptom.
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Affiliation(s)
- Jolanta Białkowska
- Department of Infectious and Liver Diseases, Medical University of Lodz, Poland
| | - Arkadiusz Zygmunt
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Poland
| | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Poland
| | - Wanda Stankiewicz
- Microwave Safety Department, Military Institute of Hygiene and Epidemiology, Warsaw, Poland
| | | | | | - Maciej Jabłkowski
- Department of Infectious and Liver Diseases, Medical University of Lodz, Poland
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208
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Smyk D, Cholongitas E, Kriese S, Rigopoulou EI, Bogdanos DP. Primary biliary cirrhosis: family stories. Autoimmune Dis 2011; 2011:189585. [PMID: 21687641 PMCID: PMC3112499 DOI: 10.4061/2011/189585] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 02/09/2011] [Accepted: 03/07/2011] [Indexed: 01/03/2023] Open
Abstract
Primary biliary cirrhosis (PBC) is a chronic immune-mediated cholestatic liver disease of unknown aetiology which affects mostly women in middle age. Familial PBC is when PBC affects more than one member of the same family, and data suggest that first-degree relatives of PBC patients have an increased risk of developing the disease. Most often, these familial clusters involve mother-daughter pairs, which is consistent with the female preponderance of the disease. These clusters provide evidence towards a genetic basis underlying PBC. However, clusters of nonrelated individuals have also been reported, giving strength to an environmental component. Twin studies have demonstrated a high concordance for PBC in monozygotic twins and a low concordance among dizygotic twins. In conclusion, studies of PBC in families clearly demonstrate that genetic, epigenetic, and environmental factors play a role in the development of the disease.
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Affiliation(s)
- Daniel Smyk
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RS, UK
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209
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210
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Qiu D, Wang Q, Wang H, Xie Q, Zang G, Jiang H, Tu C, Guo J, Zhang S, Wang J, Lu Y, Han Y, Shen L, Chen X, Hu X, Wang X, Chen C, Fu Q, Ma X. Validation of the simplified criteria for diagnosis of autoimmune hepatitis in Chinese patients. J Hepatol 2011; 54:340-7. [PMID: 21056494 DOI: 10.1016/j.jhep.2010.06.032] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 06/10/2010] [Accepted: 06/22/2010] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS In 1999, the International Autoimmune Hepatitis Group (IAIHG) revised the diagnostic criteria for autoimmune hepatitis (AIH). It subsequently developed the simplified criteria in 2008 to enhance clinical applicability and practicability. In this study, we validated the simplified diagnostic criteria in Chinese patients with AIH or other chronic liver diseases in comparison with the revised original criteria. METHODS Diagnostic scores were determined using the revised original criteria and the simplified criteria in 405 patients with diverse liver diseases. The sample included 127 patients with AIH type I diagnosed by the descriptive criteria, 77 patients with primary biliary cirrhosis (PBC), 6 patients with AIH-PBC overlap syndrome, 47 patients with drug-induced liver injury (DILI), 36 patients with non-alcoholic steatohepatitis (NASH), 82 patients with chronic hepatitis B (CHB), and 30 patients with chronic hepatitis C (CHC). The simplified criteria were compared to the revised original criteria based on sensitivity, specificity, and predictability for the pre-treatment diagnosis of AIH. RESULTS The simplified criteria had sensitivity and specificity of 90% and 95%, respectively, for the diagnosis of probable AIH in the Chinese patients. This compares well with the more rigorous revised original criteria, which had sensitivity and specificity of 100% and 93%, respectively, for probable AIH. On definite AIH, the simplified criteria had sensitivity and specificity of 62% and 99%, respectively, compared to 64% and 100% for definite AIH by the revised original criteria. In addition, the predictabilities of the revised original criteria and simplified criteria were 96% and 94% for probable AIH, and 88% and 87% for definite AIH, respectively, in our groups. Using the revised original criteria, 84 patients were diagnosed with definite AIH. On the other hand, among these 84 patients, the simplified criteria diagnosed only 61 patients with definite AIH (accordant diagnosis) and provided the 23 other patients with downgraded diagnosis. Comparison of the clinical and laboratory features of these two groups (accordant diagnosis vs. downgraded/excluded diagnosis) showed that the patients with downgraded diagnosis had significantly higher histological scores than the patients with accordant diagnosis. CONCLUSIONS The simplified criteria are comparable to the revised original criteria and have high sensitivity and specificity for the diagnosis of AIH in Chinese patients. Liver histology is critical for the diagnosis of AIH especially when using the simplified criteria. Further study or prospective evaluation is needed to confirm these observations, however, due to the small group of CHC patients as well as the absence of primary sclerosing cholangitis (PSC) patients in our study.
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Affiliation(s)
- Dekai Qiu
- Department of Gastroenterology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Institute of Digestive Disease, Shanghai, China
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211
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Performance parameters of the conventional serological markers for autoimmune hepatitis. Dig Dis Sci 2011; 56:545-54. [PMID: 21127976 DOI: 10.1007/s10620-010-1501-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 11/15/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autoimmune hepatitis is defined by a conventional battery of autoantibodies that may also be present in other liver diseases. AIMS To define the performance parameters of the conventional autoantibodies for autoimmune hepatitis, determine the diagnostic implications of simultaneous autoantibody production, and assess the performances of serological assays based on indirect immunofluorescence and enzyme immunoassay. METHODS In this study, 265 adults satisfying codified criteria for autoimmune hepatitis and 342 adults who satisfied conventional diagnostic criteria for another chronic liver disease were each assessed for the conventional autoantibodies. RESULTS Antinuclear antibodies, smooth muscle antibodies, and antibodies to liver kidney type 1 had sensitivities of only 32, 16, and 1%, respectively, for the diagnosis of autoimmune hepatitis, and their diagnostic accuracy ranged from 56 to 61%. The combination of antinuclear antibodies and smooth muscle antibodies at presentation had superior sensitivity (43%), specificity (99%), positive (97%) and negative (69%) predictabilities, and diagnostic accuracy (74%) than each marker alone. The occurrence of multiple autoantibodies was lower in other chronic liver diseases than in autoimmune hepatitis (8% versus 51%, p < 0.000001). The enzyme immunoassay for antinuclear antibodies had an accuracy that was not discriminative for autoimmune hepatitis (p = 0.06). CONCLUSIONS Isolated autoantibodies have a low diagnostic accuracy for autoimmune hepatitis. Concurrent antinuclear antibodies and smooth muscle antibodies have superior performance parameters. The enzyme immunoassay for antinuclear antibodies performs less well than the assay based on indirect immunofluorescence.
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212
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Stinton LM, Swain M, Myers RP, Shaheen AA, Fritzler MJ. Autoantibodies to GW bodies and other autoantigens in primary biliary cirrhosis. Clin Exp Immunol 2011; 163:147-56. [PMID: 21091667 PMCID: PMC3043305 DOI: 10.1111/j.1365-2249.2010.04288.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2010] [Indexed: 12/13/2022] Open
Abstract
Autoantibodies to intracellular targets in mitochondria and nuclei are serological hallmarks of primary biliary cirrhosis (PBC). One of the most recently identified cellular targets of PBC autoantibodies is a novel cytoplasmic structure referred to as GW bodies [GWB, G (glycine) W (tryptophan)-containing bodies (GWB)]. GWB are indentified as discrete cytoplasmic domains that are involved in mRNA processing via the RNA interference (RNAi) pathway. Key components of GWB include the proteins GW182, Ago2, RNA-associated protein 55 (RAP55) and Ge-1/Hedls. The primary objective was to study the frequency and clinical association of antibodies directed to GWB components, in 109 PBC patients. Autoantibodies to mitochondrial antigen-pyruvate dehydrogenase complex (M2), branched-chain 2-oxo-acid dehydrogenase complex and 2-oxo glutarate dehydrogenase complex (3E-BPO), gp210, sp100, promyelocytic leukaemia cell antigen (PML) and liver kidney microsomal-1 antigen (LKM-1) were detected by a line immunoassay and antibodies to GWB (GW182, RAP55, Ge-1, GW2, GW3) and glutamate receptor interacting protein (GRIP)-associated protein-1 (GRASP-1), by an addressable laser bead immunoassay (ALBIA). The most common GWB autoantigen targets were: RAP55-28%, GW182-12%, GW2-2% and antibodies to GRASP-1-17%. By comparison, the frequency of reactivity to established PBC autoantigens was: gp210, 27%; sp100, 27% and PML, 17%. None of the autoantibodies were associated with differences in Mayo risk score or liver decompensation. This study is the first study to show that antibodies to RAP55, GW182 and GRASP-1 are the most common GWB targets in PBC.
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Affiliation(s)
- L M Stinton
- Department of Medicine, University of Calgary, AB, Canada
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213
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Overlap syndromes: the International Autoimmune Hepatitis Group (IAIHG) position statement on a controversial issue. J Hepatol 2011; 54:374-85. [PMID: 21067838 DOI: 10.1016/j.jhep.2010.09.002] [Citation(s) in RCA: 324] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 08/30/2010] [Accepted: 09/02/2010] [Indexed: 12/12/2022]
Abstract
Some patients present with overlapping features between disorders within the spectrum of autoimmune liver diseases (i.e. autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC)) and are commonly classified as having an "overlap syndrome". Standardized definitions of "overlap syndromes" are lacking. The aim of this report by the International Autoimmune Hepatitis Group (IAIHG) is to evaluate if there are important reasons to classify conditions with overlapping features between autoimmune liver diseases as separate diagnostic entities. Definition of diagnostic criteria for overlap conditions can only be arbitrary. The IAIHG scoring system for diagnosis of AIH has been widely used to diagnose "overlap syndromes", but was not intended for such use and has not proven to be an efficient tool for this purpose. Some patients with overlapping features between a cholestatic and hepatitic disorder appear to benefit from treatment with a combination of ursodeoxycholic acid and immunosuppressants, but this strategy is not evidence-based, and it seems unjustified to define new diagnostic groups in this regard. The IAIHG suggests that patients with autoimmune liver disease should be categorized according to the predominating feature(s) as AIH, PBC, and PSC/small duct PSC, respectively, and that those with overlapping features are not considered as being distinct diagnostic entities. The IAIHG scoring system should not be used to establish subgroups of patients. Patients with PBC and PSC with features of AIH should be considered for immunosuppressive treatment. Due to the low prevalence of such "overlap syndromes", prospective interventional therapeutic trials cannot be expected in the foreseeable future.
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214
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Mackay IR. A 50-year experience with autoimmune hepatitis: and where are we now? J Gastroenterol 2011; 46 Suppl 1:17-28. [PMID: 21072544 DOI: 10.1007/s00535-010-0325-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 08/23/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) as chronic active hepatitis became recognized in the 1940s as a progressive hyperglobulinemic disease affecting younger women attributed to persisting virus infection of the liver: autoimmunity then was barely on the horizon. EARLY OBSERVATIONS The lupus erythematosus (LE) cell reported in 1948 signified the presence of antinuclear autoantibodies, promoting perceptions of autoimmunity in certain chronic diseases. Recognition of LE cells in chronic hepatitis led to the designation of 'lupoid hepatitis', with autoimmunity further substantiated by anti-cytoplasmic autoantibodies detected by complement fixation. Next a serum reactant with smooth muscle of rodent stomach was found to have a wider distribution and became identified as an autoantibody to filamentous (F) actin. Therapy with corticosteroids proved effective, particularly combined with azathioprine. Various trials showed greatly improved survival and established modern therapy of AIH. An HLA-based predisposition (B8, DR3) was the first pointer to a genetic etiology. RECENT ADVANCES Recombinant or purified autoantigenic substrates have led to automated assays, which, together with improved immunofluorescence procedures, allow serological confidence in diagnosis and institution of effective immunosuppressive therapies. The liver-kidney 'microsomal' autoantigen reactive with cytochrome P450 2D6 distinguishes two serological types of AIH that appear pathogenetically distinct. Molecular characterization of antigens and epitopes remains wanting in type 1 AIH. FUTURE PROSPECTS The challenge remains with both types of AIH to elucidate in molecular terms the genetic and environmental basis of pathogenesis from initiation to ultimate progression and cirrhosis (when inadequately treated). Advancing technologies are bringing this goal closer to being attainable.
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Affiliation(s)
- Ian R Mackay
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, 3800, Australia.
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215
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Liu H, Norman GL, Shums Z, Worman HJ, Krawitt EL, Bizzaro N, Vergani D, Bogdanos DP, Dalekos GN, Milkiewicz P, Czaja AJ, Heathcote EJ, Hirschfield GM, Tan EM, Miyachi K, Bignotto M, Battezzati PM, Lleo A, Leung PS, Podda M, Gershwin ME, Invernizzi P. PBC screen: an IgG/IgA dual isotype ELISA detecting multiple mitochondrial and nuclear autoantibodies specific for primary biliary cirrhosis. J Autoimmun 2010; 35:436-42. [PMID: 20932720 DOI: 10.1016/j.jaut.2010.09.005] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 09/14/2010] [Accepted: 09/14/2010] [Indexed: 01/14/2023]
Abstract
A dual isotype (IgG, IgA) enzyme-linked immunosorbent assay (ELISA) designed to provide enhanced detection of primary biliary cirrhosis (PBC)-specific autoantibodies against both major mitochondrial and nuclear antigens has been developed and recently become commercially available. The assay (PBC Screen) simultaneously detects IgG and IgA autoantibodies to the immunodominant portions of the 3 major mitochondrial (MIT3) and nuclear (gp210, and sp100) antigens. The aim of this study was to compare the performance of the PBC Screen to the combined performance obtained with individual IgG ELISAs to MIT3, gp210, and sp100 on a large group of selected patients from multiple centers. A total of 1175 patients with PBC and 1232 subjects without PBC were evaluated. Non-PBC groups included healthy controls (624) as well as individuals with autoimmune hepatitis (281), primary sclerosing cholangitis (77), viral hepatitis (91 hepatitis B and 98 hepatitis C), other liver diseases (31), and other infectious or autoimmune diseases (30). The PBC Screen at the receiver operator characteristic optimized cutoff of 27.8 units, had an overall sensitivity of 83.8%, specificity of 94.7% and area under curve of 0.9212. This was similar to the specificity of 96.1% obtained by the combined results of individual MIT3, sp100, and gp210 IgG ELISAs (kappa index at 0.898). Of the 253 PBC patients without AMA detectable by immunofluorescence, 113 (44.7%) were interpreted as positive for PBC-specific autoantibodies. In conclusion, the PBC Screen is an appropriate first-line test for the diagnosis of PBC, including for patients negative for markers assessed using conventional methods.
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Affiliation(s)
- Haiying Liu
- Division of Internal Medicine and Center for Autoimmune Liver Diseases, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
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216
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Abstract
Autoimmune hepatitis (AIH) is a form of chronic hepatitis of unknown etiology. It was first described in the 1950s as a form of chronic hepatitis noted in younger women. It was later termed lupoid hepatitis due to its association with autoantibodies before being named AIH in 1965. Corticosteroids and azathioprine have been the standard therapy for AIH, but due to treatment failures and toxicities from these medications, new medications are being investigated as possible treatment options. Rituximab has been used in various autoimmune disorders with good success. We report the case of a 34-year-old Caucasian woman with a history of B cell lymphoma and concurrent AIH treated with rituximab. The diagnosis of AIH was made by classic serological and histological features. The patient was initially treated with steroids but had a progression of her disease as well as suffering toxicities from the steroids. She was then given eight weeks of rituximab with good improvement in both laboratory and histological findings.
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Affiliation(s)
- E Barth
- United States Air Force, Lackland AFB, San Antonio, Tex., USA
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217
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Comparison of simplified score with the revised original score for the diagnosis of autoimmune hepatitis: a new or a complementary diagnostic score? Dig Liver Dis 2010; 42:807-12. [PMID: 20399157 DOI: 10.1016/j.dld.2010.03.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 12/24/2009] [Accepted: 03/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The International Autoimmune Hepatitis Group developed a simplified score for autoimmune hepatitis. We assessed this "new scoring system" and compared it with the International Autoimmune Hepatitis Group original revised score. METHODS 502 patients were evaluated namely, 428 had liver diseases of various etiology [hepatitis B (n=109), hepatitis C (n=100), hepatitis D (n=4), alcoholic liver disease (n=28), non-alcoholic fatty liver disease (n=55), autoimmune cholestatic diseases (n=77), liver disorders of undefined origin (n=32) and miscellaneous hepatic disorders (n=23)], 13 had autoimmune hepatitis/overlap syndromes, 18 had autoimmune hepatitis/concurrent with other liver diseases and 43 had autoimmune hepatitis. RESULTS The specificity of the simplified score was similar to that of the revised score (97% vs. 97.9%). The sensitivity in unmasking autoimmune hepatitis in autoimmune hepatitis/overlap syndromes was also similar in both systems (53.8% and 61.5%). However, the sensitivity for autoimmune hepatitis diagnosis in autoimmune hepatitis patients with concurrent liver disorders was lower by the new score (p=0.001). Liver biopsy proved to be the only independent factor for unmasking autoimmune hepatitis component among patients (p=0.003). CONCLUSION The simplified score is a reliable and simple tool for excluding autoimmune hepatitis. However, both systems cannot unmask autoimmune hepatitis component efficiently in autoimmune hepatitis patients with concurrent autoimmune or non-autoimmune liver diseases. This study also strongly reiterates the importance of liver biopsy in the work-up of patients.
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218
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Muratori L, Muratori P, Granito A, Pappas G, Cassani F, Lenzi M. Current topics in autoimmune hepatitis. Dig Liver Dis 2010; 42:757-64. [PMID: 20615766 DOI: 10.1016/j.dld.2010.05.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 05/23/2010] [Accepted: 05/31/2010] [Indexed: 12/11/2022]
Abstract
Autoimmune hepatitis is a chronic liver disease of unknown aetiology characterized by interface hepatitis, hypergammaglobulinaemia and circulating autoantibodies. In the last decade a number of advancements have been made in the field of clinical and basic research: the simplified diagnostic criteria, the complete response defined as normalization of transaminase levels, the molecular identification of the antigenic targets of anti-liver cytosol antibody type 1 and anti-soluble liver antigen, the detection of anti-actin antibodies, the description of de novo autoimmune hepatitis after liver transplantation for non-autoimmune liver diseases, the characterization of autoimmune hepatitis with overlapping features of primary biliary cirrhosis or primary sclerosing cholangitis, the preliminary experience with novel treatment strategies based on cyclosporine, mycophenolate mofetil and budesonide, the role played by "impaired" regulatory T cells and the development of novel animal models of autoimmune hepatitis.
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Affiliation(s)
- Luigi Muratori
- Department of Clinical Medicine, Alma Mater Studiorum - University of Bologna, Policlinico Sant'Orsola-Malpighi, Padiglione 11, Bologna, Italy.
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219
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Rodrigues CEM, Caleiro MTC, de Carvalho JF. Anti-liver and antiendomysial autoantibodies in primary antiphospholipid (Hughes’) syndrome. Lupus 2010; 19:1579-1580. [DOI: 10.1177/0961203310376638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- CEM Rodrigues
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - MTC Caleiro
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - JF de Carvalho
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil,
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220
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Liu H, Liu Y, Wang L, Xu D, Lin B, Zhong R, Gong S, Podda M, Invernizzi P. Prevalence of primary biliary cirrhosis in adults referring hospital for annual health check-up in Southern China. BMC Gastroenterol 2010; 10:100. [PMID: 20815889 PMCID: PMC2944334 DOI: 10.1186/1471-230x-10-100] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 09/03/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primary biliary cirrhosis (PBC) is an autoimmune liver disease characterized by the presence of anti-mitocondrial autoantibodies (AMA) which has an essential role also for diagnosis. In addition, also some anti-nuclear antibodies (ANA) have been shown to be highly specific PBC. The purpose of this study was to assess the prevalence of PBC among the adults referring hospital for annual health check-up in Southern China by screening sera for PBC-specific autoantibodies. METHODS AMA and ANA were screened in 8,126 adults (mean age 44 ± 15 years, 48% females) by indirect immunofluorenscence (IIF). Positive sera were tested by ELISA/immunoblotting for AMA-M2, anti-sp100 and anti-gp210. A diagnosis of PBC was re-assessed six months after the initial testing. RESULTS Out of 8,126 individuals 35 were positive for AMA and 79 positive for ANA. Nineteen, 4, and 3 of the subjects positive for AMA and/or ANA showed reactivity for AMA-M2, anti-sp100 or gp210, respectively, further tested with ELISA/immunoblotting. Fourteen in the 39 individuals positive for AMA at IIF, AMA-M2, anti-gp210, or anti-sp100 had abnormal cholestatic liver functional indices. One definite and 3 probable PBC diagnosis could be made in 4 cases including 3 females and 1 male after half a year. CONCLUSIONS We found a point prevalence rate of PBC among Southern Chinese adults attending for yearly health check-up of 492 cases per million (95% CI, 128 to 1,093) and 1,558 cases per million (95% CI, 294 to 3,815) for women over 40, a finding similar to prevalence reported in other geographical areas.
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Affiliation(s)
- Haiying Liu
- Clinical Laboratory, Guangzhou Women and Children’s Medical Center, 9 Jinsui Road, Guangzhou 510623, China
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221
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Czaja AJ. Autoantibodies as prognostic markers in autoimmune liver disease. Dig Dis Sci 2010; 55:2144-61. [PMID: 20464491 DOI: 10.1007/s10620-010-1268-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 04/23/2010] [Indexed: 01/25/2023]
Abstract
Certain autoantibodies in autoimmune liver disease have prognostic implications that are under-utilized and under-developed. The goals of this review are to indicate progress in characterizing the autoantibodies with prognostic connotations and to indicate the feasibility and importance of discovering other markers. Prime source and review articles in English were selected by a Medline search through 2010. Antibodies to soluble liver antigen, actin, liver cytosol type 1, asialoglycoprotein receptor, chromatin, cyclic citrullinated peptide, and uridine glucuronosyltransferases have been associated with the occurrence, severity, and progression of autoimmune hepatitis, and antibodies to Sp100, gp210, and centromere have had similar implications in primary biliary cirrhosis. Antibodies to soluble liver antigen have shown the most promise in autoimmune hepatitis as they have been associated with severe histological changes, long durations of treatment, relapse after drug withdrawal, and high frequency of liver failure. Antibodies to the nuclear rim pore protein, gp210, have shown the most promise in primary biliary cirrhosis as they have been associated with severe interface hepatitis, lobular inflammation, and progression to liver failure. The major limitations of the autoantibodies have been their lack of standardized assays, low negative predictabilities, and fluctuating levels. Performance parameters will improve as critical pathogenic pathways, comprehensive testing batteries, and standardized assays through international exchange workshops are developed. Progress has been made in identifying the serological markers of prognosis in autoimmune liver disease, and they promise to reflect critical disease mechanisms and enhance patient management.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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222
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Toh BH, Taylor R, Pollock W, Dearden S, Gill CC, Buchner C, Burlingame RW. ‘Actin-reactive’ discriminated from ‘non-actin-reactive’ smooth muscle autoantibody by immunofluorescence reactivity with rat epithelial cell line. Pathology 2010; 42:463-9. [DOI: 10.3109/00313025.2010.493867] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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223
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Autoantibodies and liver disease: uses and abuses. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 24:225-31. [PMID: 20431809 DOI: 10.1155/2010/431913] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Confirming whether a patient has autoimmune liver disease is challenging, given its varied presentation and complex definitions. In the continued absence of pathognomonic serum markers, diagnosis requires evaluation of laboratory investigations and, frequently, a liver biopsy - all of which need to be interpreted in the correct clinical context, with an emphasis on exclusion of viral infections, drug toxicity and metabolic disease. However, clear diagnosis is important for appropriate and timely therapy. Autoantibodies remain important tools for clinicians, and were the first proposed serological markers to aid in differentiating viral from chronic autoimmune hepatitis. Their presence is occasionally considered to be synonymous with autoimmune liver disease - a misinterpretation of their clinical significance. The present article summarizes the serum autoantibodies currently investigated in clinical and research practice, along with a description of their value in adult chronic liver diseases, with an emphasis on their appropriate use in the diagnosis and management of patients with autoimmune liver disease.
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224
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Koyabu M, Uchida K, Miyoshi H, Sakaguchi Y, Fukui T, Ikeda H, Takaoka M, Hirohara J, Nishio A, Uemura Y, Uemoto S, Okazaki K. Analysis of regulatory T cells and IgG4-positive plasma cells among patients of IgG4-related sclerosing cholangitis and autoimmune liver diseases. J Gastroenterol 2010; 45:732-41. [PMID: 20087609 DOI: 10.1007/s00535-010-0199-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Accepted: 12/23/2009] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Patients with autoimmune pancreatitis (AIP) characteristically show elevated serum levels of immunoglobulin G4 (IgG4) and abundant infiltration of IgG4-positive plasmacytes in the involved organs. The most common involved organ showing extrapancreatic lesions is the bile duct, which exhibits sclerosing cholangitis (SC). However, the role of IgG4 in the development of IgG4-related SC (IgG4-SC) remains unclear. To clarify the role of IgG4 in IgG4-SC, we have performed an immunohistochemical analysis of the bile duct. METHODS Laboratory and immunohistochemical findings of liver biopsy specimens obtained from patients with IgG4-SC, primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and primary biliary cirrhosis (PBC) were compared. The biopsy specimens were first stained with anti-IgG1, anti-IgG4, and anti-Foxp3 (forkhead box P3) antibodies, and the ratio of IgG4-, IgG1-, and Foxp3-positive cells, respectively, to infiltrated mononuclear cells (IgG4/Mono, IgG1/Mono, Foxp3/Mono) was assessed. RESULTS The ratio of IgG4/IgG1-positive plasma cells was significantly higher in specimens obtained from patients with IgG4-SC than in those from patients with PSC, AIH, and PBC. The Foxp3/Mono ratio in patients with PBC was significantly higher than that in patients with IgG4-SC and PSC. In patients with IgG4-SC, the number of Foxp3-positive cells was significantly correlated with the number of IgG4-positive cells; in the other patient groups, there was no correlation. CONCLUSIONS The IgG4/IgG1 ratio in the liver may be a useful marker for differential diagnosis of IgG4-SC and PSC. In IgG4-SC, abundant infiltration of regulatory T cells (Tregs) may affect the switching of B cells to IgG4-producing plasmacytes, and there is a possibility that the function of Tregs is different in IgG4-SC and other liver diseases (PSC, AIH, and PBC).
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Affiliation(s)
- Masanori Koyabu
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, 10-15 Fumizono, Moriguchi, Osaka, 570-8507, Japan
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225
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Czaja AJ. The role of autoantibodies as diagnostic markers of autoimmune hepatitis. Expert Rev Clin Immunol 2010; 2:33-48. [PMID: 20477086 DOI: 10.1586/1744666x.2.1.33] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Autoantibody testing is the first step towards the diagnosis of autoimmune hepatitis, and it is essential in the evaluation of acute and chronic hepatitis of undetermined cause and allograft dysfunction following liver transplantation. A standard diagnostic repertoire has been promulgated, and other autoantibodies are emerging that may have prognostic value. Supplemental autoantibodies may prove useful in assessing patients who lack the standard markers or who are distinctive among those with conventional markers. Serologic testing will improve as assays are standardized by serum exchange workshops, core diagnostic batteries are codified and promulgated, and markers emerge that are tightly associated with pathogenic mechanisms, and closely reflect disease activity and outcome.
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Affiliation(s)
- Albert J Czaja
- Mayo Clinic, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA.
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226
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Abstract
OBJECTIVES Some patients with primary biliary cirrhosis (PBC) have antinuclear antibodies (ANAs). These ANAs include the "multiple nuclear dots" (MND) staining pattern, targeting promyelocytic leukemia protein (PML) nuclear body (NB) components, such as "speckled 100-kD" protein (Sp100) and PML. A new PML NB protein, designated as Sp140, was identified using serum from a PBC patient. The aim of this study was to analyze the immune response against Sp140 protein in PBC patients. METHODS We studied 135 PBC patients and 157 pathological controls with type 1 autoimmune hepatitis, primary sclerosing cholangitis, and systemic lupus erythematosus. We used indirect immunofluorescence and a neuroblastoma cell line expressing Sp140 for detecting anti-Sp140 antibodies, and a commercially available immunoblot for detecting anti-Sp100 and anti-PML antibodies. RESULTS Anti-Sp140 antibodies were present in 20 (15%) PBC patients but not in control samples, with a higher frequency in antimitochondrial antibody (AMA)-negative cases (53 vs. 9%, P<0.0001). Anti-Sp140 antibodies were found together with anti-Sp100 antibodies in all but one case (19 of 20, 90%) and with anti-PML antibodies in 12 (60%) cases. Anti-Sp140 positivity was not associated with a specific clinical feature of PBC. CONCLUSIONS Our study identifies Sp140 as a new, highly specific autoantigen in PBC for the first time. The very frequent coexistence of anti-Sp140, anti-Sp100 and anti-PML antibodies suggests that the NB is a multiantigenic complex in PBC and enhances the diagnostic significance of these reactivities, which are particularly useful in AMA-negative cases.
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MESH Headings
- Adult
- Child
- Cholangitis/diagnosis
- Cholangitis/immunology
- Cholangitis/therapy
- Cholangitis, Sclerosing/diagnosis
- Cholangitis, Sclerosing/therapy
- Cholestasis, Intrahepatic/diagnosis
- Cholestasis, Intrahepatic/etiology
- Cholestasis, Intrahepatic/prevention & control
- Cholestasis, Intrahepatic/therapy
- Cystic Fibrosis/complications
- Female
- Hepatitis, Autoimmune/diagnosis
- Hepatitis, Autoimmune/therapy
- Humans
- Immunoglobulin G/metabolism
- Infant
- Liver Cirrhosis, Biliary/diagnosis
- Liver Cirrhosis, Biliary/therapy
- Male
- Osteoporosis/etiology
- Osteoporosis/therapy
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/therapy
- Syndrome
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228
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Mieli-Vergani G, Heller S, Jara P, Vergani D, Chang MH, Fujisawa T, González-Peralta RP, Kelly D, Mohan N, Shah U, Murray KF. Autoimmune hepatitis. J Pediatr Gastroenterol Nutr 2009; 49:158-64. [PMID: 19561543 DOI: 10.1097/mpg.0b013e3181a1c265] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune hepatitis is characterized by inflammatory liver histology, circulating nonorgan-specific autoantibodies, and increased levels of immunoglobulin G, in the absence of a known etiology. Two types of juvenile autoimmune hepatitis (AIH) are recognized according to seropositivity for smooth muscle and/or anti-nuclear antibody (AIH type 1) or liver kidney microsomal antibody (AIH type 2). There is a female predominance in both. AIH type 2 presents more acutely, at a younger age and commonly with immunoglobulin A deficiency, whereas duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in the 2 groups. Immunosuppressive treatment with steroids and azathioprine, which should be instituted promptly to avoid progression to cirrhosis, induces remission in 80% of cases. Relapses are common, often due to nonadherence. Drugs effective in refractory cases include cyclosporine and mycophenolate mofetil. Long-term treatment is usually required, with only some 20% of AIH type 1 patients able to discontinue therapy successfully. In childhood, sclerosing cholangitis with strong autoimmune features, including interface hepatitis and serological features identical to AIH type 1, is as prevalent as AIH, but it affects boys and girls equally. Differential diagnosis relies on cholangiographic studies. In autoimmune sclerosing cholangitis liver parenchymal damage responds satisfactorily to immunosuppressive treatment, whereas bile duct disease tends to progress. In this article we review the state of the art of diagnosis, monitoring, and treatment for children with AIH.
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229
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Eyraud V, Chazouilleres O, Ballot E, Corpechot C, Poupon R, Johanet C. Significance of antibodies to soluble liver antigen/liver pancreas: a large French study. Liver Int 2009; 29:857-64. [PMID: 19302185 DOI: 10.1111/j.1478-3231.2009.01986.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antibodies to soluble liver antigen (SLA)/liver pancreas (LP) are generally considered as highly specific diagnostic markers of type 1 auto-immune hepatitis (AIH-1), and are particularly useful in patients without conventional antibodies. However, the presence of anti-SLA/LP in type 2 auto-immune hepatitis (AIH-2), primary sclerosing cholangitis (PSC) and hepatitis C has recently been reported. The aim was thus to describe the characteristics of anti-SLA/LP-positive patients in the largest series reported to date. METHODS Sera were selected from the period between 1998 and 2005, based on the presence of antibodies to SLA/LP detected by two methods. The clinical status of patients was determined from their medical records. RESULTS Eighty-one anti-SLA/LP-positive patients with available clinical data were included: 89% (72/81) had a diagnosis of AIH-1, including 10 (12%) associated with cholestatic diseases (primary biliary cirrhosis in seven cases and PSC in three cases). Six patients (7%) suffered from another liver disease: hepatitis C (n=3) and drug-induced hepatitis (n=3). No specific diagnosis was made in three patients. CONCLUSIONS Antibodies to SLA/LP are of a major diagnostic value for AIH-1, including paediatric forms and overlap syndromes with cholestatic diseases, but are not found in association with anti-liver/kidney/microsome type 1 or antibodies to liver cytosol type 1. They are rarely present in other liver diseases such as hepatitis C and drug-induced hepatitis.
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Affiliation(s)
- Violaine Eyraud
- AP-HP Hôpital Saint-Antoine, Unité d'Immunologie, Paris, France
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230
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Vergani D, Longhi MS, Bogdanos DP, Ma Y, Mieli-Vergani G. Autoimmune hepatitis. Semin Immunopathol 2009; 31:421-35. [PMID: 19533129 DOI: 10.1007/s00281-009-0170-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Accepted: 06/01/2009] [Indexed: 12/17/2022]
Abstract
Autoimmune hepatitis (AIH) is an inflammatory liver disease affecting mainly females and characterised histologically by interface hepatitis, biochemically by elevated transaminase levels and serologically by the presence of autoantibodies and increased levels of immunoglobulin G. AIH responds to immunosuppressive treatment, which should be instituted as soon as diagnosis is made. Seropositivity for smooth muscle and/or anti-nuclear antibody defines type 1 AIH, while positivity for liver kidney microsomal type 1 antibody defines type 2 AIH. The aetiology of AIH is unknown, though both genetic and environmental factors are involved in its expression. Immune reactions against host liver antigens are believed to be the major mechanism of liver damage.
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Affiliation(s)
- Diego Vergani
- Institute of Liver Studies, Paediatric Liver Centre, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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231
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Muratori P, Granito A, Quarneti C, Ferri S, Menichella R, Cassani F, Pappas G, Bianchi FB, Lenzi M, Muratori L. Autoimmune hepatitis in Italy: the Bologna experience. J Hepatol 2009; 50:1210-8. [PMID: 19395113 DOI: 10.1016/j.jhep.2009.01.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 12/13/2008] [Accepted: 01/12/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS Autoimmune hepatitis affects mainly women. It is subdivided into type 1 and type 2 according to the autoantibody profile and without immunosuppression usually evolves to cirrhosis and end-stage liver failure. METHODS We evaluated clinical, biochemical, immunological and genetic features and treatment response of 163 consecutive Italian patients with autoimmune hepatitis. RESULTS At diagnosis, type 1 autoimmune hepatitis showed more inflamed liver histology and more pronounced cholestasis, whereas type 2 was more common in children. Male and female patients shared similar clinical, biochemical and immunological features. Of 89 patients with 5-year follow-up or longer, 23 patients irrespective of presenting clinical, biochemical and immunological features achieved complete remission (normal transaminases and gammaglobulin levels) which was maintained with minimal steroid dosage; attempt at treatment withdrawal led to disease exacerbation. Complete responders had more often HLA DRB1*0401 (p = 0.011) and their risk of disease progression was lower (p < 0.0001). CONCLUSIONS Type 1 and type 2 autoimmune hepatitis is one and the same disease. Autoimmune hepatitis has similar features in male and female patients. HLA DRB1*0401 positive patients are more likely to achieve complete remission. Continuous low-dose steroids are necessary to maintain remission, significantly reducing the risk of disease progression.
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Affiliation(s)
- Paolo Muratori
- Department of Clinical Medicine, Alma Mater Studiorum, University of Bologna, Policlinico Sant'Orsola-Malpighi, Via Massarenti, 9, 40138 Bologna, Italy
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232
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Barrio J, Piqueras B, Rodrigo G, Rivero M. Epistaxis como forma de inicio de enfermedad hepática. An Pediatr (Barc) 2009; 70:599-601. [DOI: 10.1016/j.anpedi.2009.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 03/15/2009] [Accepted: 03/16/2009] [Indexed: 01/12/2023] Open
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233
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Muratori P, Granito A, Pappas G, Pendino GM, Quarneti C, Cicola R, Menichella R, Ferri S, Cassani F, Bianchi FB, Lenzi M, Muratori L. The serological profile of the autoimmune hepatitis/primary biliary cirrhosis overlap syndrome. Am J Gastroenterol 2009; 104:1420-5. [PMID: 19491855 DOI: 10.1038/ajg.2009.126] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES During the last decade patients with concomitant clinical, biochemical, immunoserological, and histological features of both autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) were sporadically described, but definite diagnostic criteria and specific serological markers to support the diagnosis of AIH/PBC overlap syndrome (AIH/PBC OS) are still lacking. METHODS Clinical, biochemical, and histological features, autoantibody profile, and treatment response of 15 patients with coexistent hepatitic and cholestatic liver damage, all fulfilling strict diagnostic criteria for both AIH and PBC, were compared with those of 120 patients with pure PBC and 120 patients with pure AIH. RESULTS At diagnosis, the AIH/PBC OS patients' median age was 51 years, similar to that of the PBC patients (52 years, P=NS), but significantly higher than that of the AIH patients (40 years, P=0.04). Anti-dsDNA antibodies were detected in 60% of AIH/PBC OS patients, but only in 4% of PBC patients and 26% of AIH patients (P<0.0001 and 0.01, respectively). Double positivity for antimitochondrial antibodies (AMA) and anti-dsDNA was present in 47% of those with AIH/PBC OS, but only in 2% of the pathological controls (P<0.0001; specificity: 98; 95% confidence interval (CI): 97-99.2; positive likelihood ratio: 28; 95% CI: 9.8-79.4). Combined therapy (ursodeoxycholic acid (UDCA) plus steroids) achieved biochemical response in 77% of AIH/PBC OS patients. CONCLUSIONS Concomitant AMA/anti-dsDNA seropositivity can be considered the serological profile of AIH/PBC OS. The combination of UDCA and steroids is effective in achieving persistent biochemical amelioration in most AIH/PBC OS patients.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Antinuclear/immunology
- Biopsy
- Child
- Child, Preschool
- Female
- Fluorescent Antibody Technique, Indirect
- Hepatitis, Autoimmune/complications
- Hepatitis, Autoimmune/diagnosis
- Hepatitis, Autoimmune/immunology
- Humans
- Liver/pathology
- Liver Cirrhosis, Biliary/complications
- Liver Cirrhosis, Biliary/diagnosis
- Liver Cirrhosis, Biliary/immunology
- Male
- Middle Aged
- Mitochondria, Liver/immunology
- Prognosis
- Radiography, Abdominal
- Retrospective Studies
- Syndrome
- Young Adult
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Affiliation(s)
- Paolo Muratori
- Department of Clinical Medicine, Alma Mater Studiorum, University of Bologna, Policlinico Sant'Orsola-Malpighi, via Massarenti, 9, Bologna, Italy.
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234
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Chrétien P, Chousterman M, Alsamad IA, Ozenne V, Rosa I, Barrault C, Lons T, Hagège H. Non-organ-specific autoantibodies in chronic hepatitis C patients: Association with histological activity and fibrosis. J Autoimmun 2009; 32:201-5. [DOI: 10.1016/j.jaut.2009.02.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 02/11/2009] [Indexed: 12/15/2022]
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235
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Dähnrich C, Pares A, Caballeria L, Rosemann A, Schlumberger W, Probst C, Mytilinaiou M, Bogdanos D, Vergani D, Stöcker W, Komorowski L. New ELISA for detecting primary biliary cirrhosis-specific antimitochondrial antibodies. Clin Chem 2009; 55:978-85. [PMID: 19264849 DOI: 10.1373/clinchem.2008.118299] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antimitochondrial antibodies specific for primary biliary cirrhosis (PBC) target the E2 subunits of 2-oxo acid dehydrogenase complexes, in particular the pyruvate dehydrogenase complex (PDC)-E2. Their antigen-specific detection relies on conventional ELISA using purified PDC. More recent assays have employed a hybrid containing the 3 E2-subunits (MIT3). Some PBC sera react with one or the other preparation, suggesting the presence of nonoverlapping epitopes. METHODS We have developed an ELISA (anti-M2-3E) using a mixture of purified PDC and MIT3 as antigenic targets. We compared this assay to anti-MIT3 alone, conventional anti-PDC, and indirect immunofluorescence using 173 PBC and 247 disease controls. RESULTS The anti-M2-3E ELISA showed a 93.6% diagnostic sensitivity compared with 91.3%, 83.8%, and 87.3% for MIT3, purified PDC, or indirect immunofluorescence, respectively, when all specificities are set to 98.8%. By immunoblotting, anti-M2-3E-positive sera unreactive to purified PDC recognized recombinant E2-subunits of the other 2 complexes, whereas those with no reactivity to MIT3 immunofixed PDC subunits E1alpha or E1beta. CONCLUSIONS The diagnostic accuracy of the anti-M2-3E ELISA for detection of antibodies to 2-oxo acid dehydrogenase complexes exceeds that of conventional ELISA and IFL; its novelty derives from the combination of the MIT3 hybrid and purified PDC.
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236
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Soares A, Cunha R, Rodrigues F, Ribeiro H. Smooth muscle autoantibodies with F-actin specificity. Autoimmun Rev 2009; 8:713-6. [PMID: 19232552 DOI: 10.1016/j.autrev.2009.02.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Accepted: 02/10/2009] [Indexed: 01/14/2023]
Abstract
Autoimmune hepatitis is a rare condition characterized by the presence of autoantibodies, among other features. Anti-smooth muscle autoantibodies with F-actin reactivity have long been considered specific markers of this disease, representing a valuable diagnostic element because they are distinctive of a subtype of autoimmune hepatitis: type 1. Indirect immunofluorescence is considered the best available method for detection of these autoantibodies, mainly because of its elevated sensibility, but it has some flaws: it is highly operator-dependent, and the standardization of the technique has not been achieved until now. We compared ELISA and Immunodot methods for confirming indirect immunofluorescence results in what concerns smooth-muscle autoantibodies' F-actin reactivity and concluded that ELISA is the most useful one. A new substrate is available for indirect immunofluorescence detection of anti-F-actin specificity, and seems to be a promising one, but further evaluation is needed.
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Affiliation(s)
- A Soares
- Serviço de Patologia Clínica, Hospitais da Universidade de Coimbra, Coimbra, Portugal.
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Mehendiratta V, Mitroo P, Bombonati A, Navarro VJ, Rossi S, Rubin R, Herrine SK. Serologic markers do not predict histologic severity or response to treatment in patients with autoimmune hepatitis. Clin Gastroenterol Hepatol 2009; 7:98-103. [PMID: 18955163 DOI: 10.1016/j.cgh.2008.08.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 08/19/2008] [Accepted: 08/28/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) is characterized by the presence of circulating autoantibodies, hypergammaglobulinemia, necroinflammatory histology, and a response to immunosuppressive drugs. The goal of this retrospective study was to determine whether the presence of antinuclear antibodies (ANAs) or anti-smooth muscle antibodies (ASMAs) in patients with AIH correlated with clinical presentation, histologic findings, or response to immunosuppressive therapy. METHODS Fifty-two patients diagnosed with AIH, on the basis of the revised scoring system of International Autoimmune Hepatitis group, were reviewed. Data on age, gender, aminotransferase levels, autoantibody titers, treatment regimens, and response to treatment were recorded. Seropositivity was defined as ANA >1:40 or ASMA >1:40. Percutaneous liver biopsies obtained at the initial presentation were reviewed. RESULTS Forty-two patients with AIH (81%) were seropositive, and 10 (19%) were seronegative. Both groups were similar with respect to demographics, treatment regimens, and response to therapy. Histologic parameters were similar among the 2 groups, including portal and lobular inflammation, piecemeal necrosis, and centrilobular necrosis. There were no significant differences in aminotransferase levels at diagnosis or after treatment. CONCLUSIONS The prevalence of ANAs or ASMAs did not correlate with the clinical or histologic severity of AIH at diagnosis. Furthermore, there was no correlation between antibody status and response to immunosuppressive therapy. Therefore, patients who meet the diagnosis of AIH on the basis of the revised scoring system of International Autoimmune Hepatitis Group should be given immunosuppressive therapy, regardless of antibody status.
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Affiliation(s)
- Vaibhav Mehendiratta
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Makaritsis KP, Gatselis NK, Ioannou M, Petinaki E, Dalekos GN. Polyclonal hypergammaglobulinemia and high smooth-muscle autoantibody titers with specificity against filamentous actin: consider visceral leishmaniasis, not just autoimmune hepatitis. Int J Infect Dis 2008; 13:e157-60. [PMID: 19008139 DOI: 10.1016/j.ijid.2008.08.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 08/08/2008] [Accepted: 08/15/2008] [Indexed: 12/16/2022] Open
Abstract
Visceral leishmaniasis (VL) remains a public health problem in most countries bordering the Mediterranean basin. Its diagnosis is challenging and often delayed, as the main clinical picture is often indistinguishable from that of other infectious and non-infectious diseases. Herein, we report two unusual cases of VL that presented with several characteristics of autoimmune hepatitis (AIH). Neither patient had a history of fever, only generalized symptoms accompanied by polyclonal hypergammaglobulinemia, cytopenias, signs of portal hypertension, elevated transaminases, and high titers of antinuclear and smooth-muscle autoantibodies (SMA) with reactivity against filamentous actin (F-actin), which has been recognized as specific to AIH. A clinical diagnosis of AIH was considered, but a bone marrow biopsy was performed before a liver biopsy to exclude a primary bone marrow disease. The biopsy led to the diagnosis of VL. The diagnosis was further confirmed by IgG antibodies against Leishmania spp. using ELISA and PCR-based assays. Treatment with amphotericin in the first case and pentamidine in the second (because of a severe reaction to amphotericin) was effective. From the clinical point of view, it should be emphasized that, in cases with high titers of anti-F-actin AIH-specific SMA accompanied by polyclonal hypergammaglobulinemia, the possibility of AIH should be cautiously differentiated from VL; this distinction is of paramount importance because initiation of immunosuppression for AIH treatment would be detrimental to a patient with underlying leishmaniasis. Therefore, in such cases and in areas where the disease is still present, it seems rational to exclude VL before starting any immunosuppressive therapy.
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239
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Bogdanos D, Pusl T, Rust C, Vergani D, Beuers U. Primary biliary cirrhosis following Lactobacillus vaccination for recurrent vaginitis. J Hepatol 2008; 49:466-73. [PMID: 18644655 DOI: 10.1016/j.jhep.2008.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2007] [Revised: 04/06/2008] [Accepted: 05/12/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND/AIMS Antimitochondrial antibodies directed against the E2 subunit of the pyruvate dehydrogenase complex, PDC-E2, and other mitochondrial 2-oxoacid dehydrogenases (AMA-M2) are the hallmark for diagnosis of primary biliary cirrhosis (PBC). AMA-M2 formation as an early step in the pathogenesis of PBC has recently been assumed to be triggered by bacterial mimics of the E2 subunit and certain reactant xenobiotics. We report a case of symptomatic PBC diagnosed after sequential immunization with a lactobacillus vaccine for recurrent vaginitis over years. METHODS Serum AMA-M2 specificity of the patient was evaluated by indirect immunofluorescence, immunoblotting and ELISA. Serum antibody responses against pyruvate dehydrogenase complex-E2 subunit (PDC-E2(212-226)), the major PBC-specific mitochondrial autoepitope, and microbial mimics revealed cross-reactivity with beta-galactosidase of Lactobacillus delbrueckii (LACDE BGAL(266-280)) which shows a high local homology with that of Lactobacillus species administered via the vaccine. The relative affinity of antibody reactivity to LACDE BGAL(266-280) was significantly higher than that against human PDC-E2(212-226). CONCLUSIONS We conclude that lactobacillus vaccination therapy may be another culprit for the development of PBC in genetically susceptible women.
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Affiliation(s)
- Dimitrios Bogdanos
- Institute of Liver Studies, King's College, London School of Medicine at King's College Hospital, London, United Kingdom
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An actin-myosin functional assay for analysis of smooth muscle (anti-microfilament) autoantibodies in human plasma. J Immunol Methods 2008; 338:63-6. [PMID: 18691595 DOI: 10.1016/j.jim.2008.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 05/15/2008] [Accepted: 07/14/2008] [Indexed: 11/23/2022]
Abstract
The detection of serum autoantibodies to smooth muscle (SMA) on rodent gastric mucosa by indirect immunofluorescence (IIF) has long been an immunodiagnostic marker for autoimmune hepatitis type 1 (AIH-1). The reactive antigenic moieties are cytoskeletal proteins which include polymeric F-actin as judged by the staining of microfilaments of tissue by IIF. However, their specificity for actin in AIH-1 can be and usually is uncertain. Using an in vitro functional assay, we compared the effects of Fab fragments of immunoglobulin (IgG) prepared from SMA-positive plasma from two patients with the effects of Fabs from 10 healthy subjects. Fabs are incorporated into an assay where actin (the putative antigen) activates skeletal muscle heavy meromyosin (HMM) ATPase activity. The data from these functional assays provide new insights into the significance of anti-microfilament assays in the diagnosis, and perhaps also pathogenesis, of AIH-1.
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Tsikrikoni A, Rigopoulou EI, Zachou K, Liaskos C, Kyriakou D, Dalekos GN. Bone marrow findings in patients with autoimmune liver diseases. J Gastroenterol Hepatol 2008; 23:e416-21. [PMID: 18205770 DOI: 10.1111/j.1440-1746.2008.05309.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS We have recently reported quantitative and qualitative differences of the bone marrow (BM) hematopoietic progenitor cells in autoimmune hepatitis type-1 (AIH-1) and primary biliary cirrhosis (PBC). In order to better investigate the possible involvement of BM in these diseases, we studied the morphological abnormalities of BM aspirates in the same patients with AIH-1 and PBC. METHODS BM smears from 13 AIH-1 and 13 PBC patients were investigated. BM from 12 patients with cirrhosis of non-autoimmune etiology and eight healthy individuals served as pathological (PC) and healthy controls (HC). RESULTS Erythroid, granulocyte and platelet precursors were variably altered. Polychromatic normoblasts and immature megakayocytes were higher in AIH-1 (11.9 +/- 2.9 and 16.2 +/- 16.9, respectively) and PBC (10.2 +/- 3.6 and 17.3 +/- 20.2, respectively) compared to PC (7 +/- 2 and 2.3 +/- 6.0, respectively) and HC (7.9 +/- 1.6 and 0 +/- 0, respectively) (P = 0.0001 and P = 0.006). In AIH-1, immature megakaryocytes were significantly higher in patients receiving immunosuppression (25.71 +/- 17.66 vs 5.00 +/- 5.48; P < 0.02) and were associated negatively with laboratory markers of disease activity. BM plasmacytosis was observed more frequently in AIH-1 compared to PBC and PC. BM monocytosis was found in all patients with AIH-1, PBC and PC whereas approximately half of the patients with autoimmune liver diseases and all PC had BM lymphocytosis. CONCLUSIONS BM monocytosis and lymphocytosis are commonly found in AIH-1 and PBC patients irrespective of the presence of cirrhosis or the use of immunosuppression. BM plasmacytosis appears to be a distinct finding in some AIH-1 patients, as similar findings were observed in only one PBC and one PC, whereas BM immature megakaryocytes characterize both AIH-1 and PBC. Whether BM is a target organ in AIH-1 and PBC needs further investigation.
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Affiliation(s)
- Aikaterini Tsikrikoni
- Department of Medicine, Academic Liver Unit, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Thessaly, Greece
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Umemura T, Ota M, Yoshizawa K, Katsuyama Y, Ichijo T, Tanaka E, Kiyosawa K. Association of cytotoxic T-lymphocyte antigen 4 gene polymorphisms with type 1 autoimmune hepatitis in Japanese. Hepatol Res 2008; 38:689-95. [PMID: 18371160 DOI: 10.1111/j.1872-034x.2008.00337.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM Autoimmune hepatitis (AIH) is an organ-specific autoimmune disease characterized by chronic inflammation of the liver. Although the HLA DR4 allele is associated with type 1 AIH in Japanese, the exact genetic etiology of AIH remains undefined. The cytotoxic T-lymphocyte antigen 4 (CTLA4) is an inhibitory receptor expressed by T-cells that acts largely as a negative regulator of T-cell responses, and polymorphisms of CTLA4 have been reported to be associated with susceptibility to various autoimmune diseases. Therefore, we sought to clarify whether CTLA4 single-nucleotide polymorphisms are associated with disease susceptibility in Japanese patients with type 1 AIH. METHODS We genotyped 76 patients with AIH and 100 ethically matched controls for allelic determinants using TaqMan genotyping assays at four polymorphism sites: -1722 and -318 in the promoter; +49 in exon 1 and +6230 in the 3' untranslated region. RESULTS We observed no difference in the distribution of the alleles, genotypes, or haplotypes between patients and controls. Compared with -1722 C/C patients, -1722 T/T patients were younger (56 vs. 63 years; P = 0.01) and had significantly lower serum levels of aspartate aminotransferase (313 vs. 763 IU/L; P = 0.031) and bilirubin (1.1 vs. 8.6 mg/dL; P = 0.027). Analysis of allelic frequencies revealed no significant difference between patients with and without the HLA DR4 allele. CONCLUSION These data suggest that the CTLA4 polymorphism is not associated with susceptibility to type 1 AIH in the Japanese population.
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Affiliation(s)
- Takeji Umemura
- Department of Internal Medicine, Divisions of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
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Herzog D, Soglio DBD, Fournet JC, Martin S, Marleau D, Alvarez F. Interface hepatitis is associated with a high incidence of late graft fibrosis in a group of tightly monitored pediatric orthotopic liver transplantation patients. Liver Transpl 2008; 14:946-55. [PMID: 18581476 DOI: 10.1002/lt.21444] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Chronic graft dysfunction, manifesting with elevated liver enzymes and histological features of interface hepatitis (IH), is being increasingly recognized as a long-term problem after liver transplantation. The aim of this study was to characterize our group of post-orthotopic liver transplantation (OLT) patients with respect to clinical, laboratory, and histological signs of IH. A retrospective study of charts and liver biopsy specimens from patients transplanted between 1986 and 1999 was used. Histological features of IH were found in 29/119 patients at a median interval of 23.9 months (95% confidence interval -28.2 to 52.6) after OLT. All patients with IH had risk factors for chronic rejection, such as steroid-resistant rejection, acute rejection later than 3 months post-OLT, female receiver of male graft, or pretransplant cytomegalovirus (CMV)-positive serology with a CMV-negative donor liver. None of the 29 had features favoring a diagnosis of de novo autoimmune hepatitis, but 4 had isolated hypergammaglobulinemia, and 4 had non-organ-specific autoantibodies without hyperimmunoglobulin G. Sixteen of 29 patients also had features of chronic rejection, such as foam cell arteriopathy, loss of bile ducts, or pericentral fibrosis. After abnormal biopsy, all but 1 patient were switched to tacrolimus. During a median follow-up of 12 years, death occurred in 5, retransplantation occurred in 7, and definite cirrhosis occurred in 4. In conclusion, IH was detected in 24.4% of our patients and was associated with a high degree of fibrosis development. Most likely, IH represents a form of chronic rejection directed against periportal hepatocytes.
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Affiliation(s)
- Denise Herzog
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Hôpital St-Luc, Université de Montréal, Montreal, Québec, Canada.
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Hennes EM, Zeniya M, Czaja AJ, Parés A, Dalekos GN, Krawitt EL, Bittencourt PL, Porta G, Boberg KM, Hofer H, Bianchi FB, Shibata M, Schramm C, Eisenmann de Torres B, Galle PR, McFarlane I, Dienes HP, Lohse AW. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology 2008; 48:169-76. [PMID: 18537184 DOI: 10.1002/hep.22322] [Citation(s) in RCA: 1198] [Impact Index Per Article: 70.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Diagnosis of autoimmune hepatitis (AIH) may be challenging. However, early diagnosis is important because immunosuppression is life-saving. Diagnostic criteria of the International Autoimmune Hepatitis Group (IAIHG) were complex and purely meant for scientific purposes. This study of the IAIHG aims to define simplified diagnostic criteria for routine clinical practice. Candidate criteria included sex, age, autoantibodies, immunoglobulins, absence of viral hepatitis, and histology. The training set included 250 AIH patients and 193 controls from 11 centers worldwide. Scores were built from variables showing predictive ability in univariate analysis. Diagnostic value of each score was assessed by the area under the receiver operating characteristic (ROC) curve. The best score was validated using data of an additional 109 AIH patients and 284 controls. This score included autoantibodies, immunoglobulin G, histology, and exclusion of viral hepatitis. The area under the curve for prediction of AIH was 0.946 in the training set and 0.91 in the validation set. Based on the ROC curves, two cutoff points were chosen. The score was found to have 88% sensitivity and 97% specificity (cutoff > or =6) and 81% sensitivity and 99% specificity (cutoff > or =7) in the validation set. CONCLUSION A reliable diagnosis of AIH can be made using a very simple diagnostic score. We propose the diagnosis of probable AIH at a cutoff point greater than 6 points and definite AIH 7 points or higher.
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Affiliation(s)
- Elke M Hennes
- Department of Medicine, University Medical Centre Hamburg Eppendorf, Germany
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Abstract
Liver disorders with a likely autoimmune pathogenesis in childhood include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is divided into two subtypes according to seropositivity for smooth muscle and/or antinuclear antibody (SMA/ANA, type 1) or liver kidney microsomal antibody (LKM1, type 2). There is a female predominance in both. LKM1 positive patients tend to present more acutely, at a younger age, and commonly have partial IgA deficiency, while duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in both groups. The most common type of paediatric sclerosing cholangitis is ASC. The clinical, biochemical, immunological, and histological presentation of ASC is often indistinguishable from that of AIH type 1. In both, there are high IgG, non-organ specific autoantibodies, and interface hepatitis. Diagnosis is made by cholangiography. Children with ASC respond to immunosuppression satisfactorily and similarly to AIH in respect to remission and relapse rates, times to normalization of biochemical parameters, and decreased inflammatory activity on follow up liver biopsies. However, the cholangiopathy can progress. There may be evolution from AIH to ASC over the years, despite treatment. De novo AIH after liver transplantation affects patients not transplanted for autoimmune disorders and is strikingly reminiscent of classical AIH, including elevated titres of serum antibodies, hypergammaglobulinaemia, and histological findings of interface hepatitis, bridging fibrosis, and collapse. Like classical AIH, it responds to treatment with prednisolone and azathioprine. De novo AIH post liver transplantation may derive from interference by calcineurin inhibitors with the intrathymic physiological mechanisms of T-cell maturation and selection. Whether this condition is a distinct entity or a form of atypical rejection in individuals susceptible to the development of autoimmune phenomena is unclear. Whatever its etiology, the recognition of this potentially life-threatening syndrome is important since its management differs from that of standard anti-rejection therapy.
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Mackay IR. Historical reflections on autoimmune hepatitis. World J Gastroenterol 2008; 14:3292-300. [PMID: 18528926 PMCID: PMC2716583 DOI: 10.3748/wjg.14.3292] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 02/29/2008] [Accepted: 03/07/2008] [Indexed: 02/06/2023] Open
Abstract
Autoimmune hepatitis (AIH), initially known as chronic active or active chronic hepatitis (and by various other names), first came under clinical notice in the late 1940s. However, quite likely, chronic active hepatitis (CAH) had been observed prior to this and was attributed to a persistently destructive virus infection of the liver. An earlier (and controversial) designation in 1956 as lupoid hepatitis was derived from associated L.E. cell test positivity and emphasized accompanying multisystem features and immunological aberrations. Young women featured prominently in early descriptions of CAH. AIH was first applied in 1965 as a descriptive term. Disease-characteristic autoantibodies were defined from the early 1960s, notably antinuclear antibody (ANA), smooth muscle antibody (SMA) and liver-kidney microsomal (LKM) antibody. These are still widely used diagnostically but their relationship to pathogenesis is still not evident. A liver and disease specific autoantigen has long been searched for but unsuccessfully. Prolonged immunosuppressive therapy with predisolone and azathioprine in the 1960s proved beneficial and remains standard therapy today. AIH like many other autoimmune diseases is associated with particular HLA alleles especially with the "ancestral" B8, DR3 haplotype, and also with DR4. Looking forwards, AIH is one of the several enigmatic autoimmune diseases that, despite being (relatively) organ specific, are marked by autoimmune reactivities with non-organ-specific autoantigens. New paradigms are needed to explain the occurrence, expressions and pathogenesis of such diseases.
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Abstract
Autoimmune hepatitis (AIH) is a chronic hepatitis of unknown etiology which can progress to cirrhosis. Its clinical manifestations are highly variable and sometimes follow a fluctuating course. Diagnosis is based on characteristic histologic, clinical, biochemical and serological findings. Anti-inflammatory/immunosuppressive treatment frequently induces remission but long-term maintenance therapy is often required. Liver transplantation is generally successful in patients with decompensated cirrhosis unresponsive to or intolerant of medical therapy.
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249
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Bogdanos DP, Invernizzi P, Mackay IR, Vergani D. Autoimmune liver serology: Current diagnostic and clinical challenges. World J Gastroenterol 2008; 14:3374-87. [PMID: 18528935 PMCID: PMC2716592 DOI: 10.3748/wjg.14.3374] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver-related autoantibodies are crucial for the correct diagnosis and classification of autoimmune liver diseases (AiLD), namely autoimmune hepatitis types 1 and 2 (AIH-1 and 2), primary biliary cirrhosis (PBC), and the sclerosing cholangitis variants in adults and children. AIH-1 is specified by anti-nuclear antibody (ANA) and smooth muscle antibody (SMA). AIH-2 is specified by antibody to liver kidney microsomal antigen type-1 (anti-LKM1) and anti-liver cytosol type 1 (anti-LC1). SMA, ANA and anti-LKM antibodies can be present in de-novo AIH following liver transplantation. PBC is specified by antimitochondrial antibodies (AMA) reacting with enzymes of the 2-oxo-acid dehydrogenase complexes (chiefly pyruvate dehydrogenase complex E2 subunit) and disease-specific ANA mainly reacting with nuclear pore gp210 and nuclear body sp100. Sclerosing cholangitis presents as at least two variants, first the classical primary sclerosing cholangitis (PSC) mostly affecting adult men wherein the only (and non-specific) reactivity is an atypical perinuclear antineutrophil cytoplasmic antibody (p-ANCA), also termed perinuclear anti-neutrophil nuclear antibodies (p-ANNA) and second the childhood disease called autoimmune sclerosing cholangitis (ASC) with serological features resembling those of type 1 AIH. Liver diagnostic serology is a fast-expanding area of investigation as new purified and recombinant autoantigens, and automated technologies such as ELISAs and bead assays, become available to complement (or even compete with) traditional immunofluorescence procedures. We survey for the first time global trends in quality assurance impacting as it does on (1) manufacturers/purveyors of kits and reagents, (2) diagnostic service laboratories that fulfill clinicians’ requirements, and (3) the end-user, the physician providing patient care, who must properly interpret test results in the overall clinical context.
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Antimitochondrial antibodies and other antibodies in primary biliary cirrhosis: diagnostic and prognostic value. Clin Liver Dis 2008; 12:261-76; vii. [PMID: 18456179 DOI: 10.1016/j.cld.2008.02.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Antimitochondrial antibodies (AMA) are the serologic cornerstone in the diagnosis of primary biliary cirrhosis (PBC), even if they are not detectable in a proportion of patients, notwithstanding the most sensitive and sophisticated technologies used. To fill in the serologic gap in AMA-negative PBC, there is sound evidence to consider antinuclear antibody (ANA) patterns, such as anti-multiple nuclear dots and anti-membranous/rim-like, as PBC-specific surrogate hallmarks of the disease, and their detection can be considered virtually diagnostic. Furthermore, particular ANA specificities, such as anti-gp210, anti-p62, anticentromere antibodies, and anti-dsDNA, may provide additional diagnostic and prognostic information.
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