Diagnosis and treatment of autoimmune hepatitis

A genomewide DNA microsatellite association study of Japanese patients with autoimmune hepatitis type 1

Genetic predisposition to type 1 autoimmune hepatitis (AIH) is linked mainly to HLA class II genes. We previously searched the whole HLA region for AIH susceptibility genes using microsatellite markers and found only HLA-DR/DQ to be a candidate region for this suspected multifactorial disease. As such, the aim of this study was to broaden our search and screen the whole genome for additional genes that might contribute to type 1 AIH susceptibility. Eighty-one patients with type 1 AIH (15 men, 66 women, average age 55.9) and 80 healthy sex- and age-matched Japanese controls were enrolled in this study. We performed a case-control association study using 400 polymorphic microsatellite markers with an average spacing of 10.8 cM distributed throughout the whole genome. Two markers, one on chromosome 11 (D11S902, Pc = 0.013) and one on chromosome 18 (D18S464, Pc = 0.008), were revealed to have statistically significant associations with AIH. An additional 7 markers (D2S367, D6S309, D9S273, D11S1320, D16S423, D17S938, and D18S68) were also found to be candidate susceptibility regions. In addition, our results showed there were 17 regions that may contain genes of resistance to AIH. No specific markers were detected in HLA-DR4-negative patients, and no differences were seen in the clinical courses of patients (severe versus mild to moderate).

CONCLUSION

This first genomewide scan of Japanese AIH patients revealed at least 26 candidate AIH susceptibility or resistance regions other than HLA class II loci. These results also suggested that the products of several genes interact to determine heritable susceptibility to AIH.

Evaluation of F-actin ELISA for the diagnosis of autoimmune hepatitis

OBJECTIVE

Antibodies to F-actin have been proposed to increase specificity in the diagnosis of autoimmune hepatitis (AIH). We compared the diagnostic value of a new F-actin enzyme-linked immunosorbent assay (ELISA) with the current gold standard of detection of smooth muscle antibodies by indirect immunofluorescence (SMA-IFT).

METHODS

Archived sera of 47 patients with SMA positive AIH were tested with the F-actin ELISA and SMA-IFT. Prospectively collected sera of 123 patients with various liver diseases, 35 of whom had AIH, were analyzed by both assays. Different cutoff limits were considered for the F-actin ELISA (increments between 20 and 60 ELISA units) and SMA-IFT (titers of 1:40, 1:80, and 1:160).

RESULTS

The F-actin ELISA had a sensitivity of 100% to detect all of 47 SMA positive AIH sera and the value of the ELISA units correlated with that of SMA titers (p < 0.0001). In prospective analysis, F-actin ELISA showed a superior sensitivity (74% vs 34%) and a similar specificity (98% vs 99%) and positive predictive value (88% vs 92%), compared with SMA-IFT. Combining both assays improved neither sensitivity nor specificity.

CONCLUSIONS

The new F-actin ELISA seems to be a useful diagnostic tool with similar specificity and superior sensitivity for the diagnosis of AIH, compared with standard SMA-IFT. Due to its simplicity and operator independency, the F-actin ELISA may become a preferred screening technique for detection of autoantibodies in patients with suspected AIH.

Clinical significance of HLA DRB103-DRB104 in type 1 autoimmune hepatitis

BACKGROUND

HLA DRB1*03-DRB1*04 combines both susceptibility factors for type-1 autoimmune hepatitis.

AIMS

Determine whether this phenotype is a risk factor for autoimmune hepatitis in white North American patients, assess its associations with clinical features and treatment outcome, and determine whether alleles within this phenotype affect prognosis.

METHODS

One hundred and ninety-eight patients with type 1 autoimmune hepatitis and 102 normal adults were evaluated. HLA typing was performed by DNA-based techniques.

RESULTS

Twenty-eight patients had HLA DRB1*03-DRB1*04, and the frequency was higher than in normal subjects (14% vs 4%, OR 4.0%, 95% CI 1.4-11.8, P = 0.01). Patients with DRB1*03-DRB1*04 relapsed less frequently than patients with DRB1*03 (1.3 +/- 0.3 vs 2.1 +/- 0.2, P = 0.04), but they otherwise had outcomes similar to patients with other phenotypes. Patients with DRB1*03-DRB1*04 who had 3-4 alleles encoding lysine at position DRbeta71 within the class II molecule of the major histocompatibility complex developed cirrhosis more commonly (75% vs 9%, P = 0.05) and had a higher frequency of hepatic-related death or liver transplantation (40% vs 0%, P = 0.04) than patients with fewer alleles.

CONCLUSIONS

HLA DRB1*03-DRB1*04 is a risk factor for type-1 autoimmune hepatitis, and its impact on outcome relates to the diversity of DRB1*04 alleles that encode a critical motif.

Persistent elevation of serum alanine aminotransferase levels leads to poor survival and hepatocellular carcinoma development in type 1 autoimmune hepatitis

BACKGROUND

Although the prognosis of type 1 autoimmune hepatitis is generally good with immunosuppressive treatment, the disease progresses in some patients despite the treatment. The prognosis may be determined by the clinical course.

AIM

To evaluate the long-term prognosis and assess the predictive factors for a serious event, including the development of hepatocellular carcinoma or death.

METHODS

Sixty-nine patients with type 1 autoimmune hepatitis were prospectively followed up regularly, with a median follow-up period of 96 months (49-201 months).

RESULTS

During the follow-up period, three patients (4%) developed hepatocellular carcinoma, and two of these three patients died. Another patient died of liver failure. The 10-year survival rate was 98%, and the 10-year hepatocellular carcinoma-free rate was 93%. The four patients experiencing a serious event received higher maintenance doses of corticosteroid during their follow-up periods than those did not. However, serum alanine aminotransferase levels during the follow-up period were higher in these four patients than in the others.

CONCLUSIONS

Persistent elevation of serum alanine amniotransferase levels during the follow-up period, rather than factors existing prior to medical treatment is considered to be an important prognostic factor, and it is indicated that poor outcomes may result from the resistance to immunosuppressive treatment.

Detection of autoantibodies for diagnosis of autoimmune hepatitis

AIM: To evaluate the clinical significance of autoantibody detection in the diagnosis of autoimmune hepatitis (AIH).

METHODS: Indirect immunofluorescence was used to detect the expression of anti-nuclear antibody (ANA), anti-smooth muscle antibody (SMA), antineutropil cytoplasmic antibody (ANCA), and anti-mitochondrial antibody (AMA) in patients with autoimmune hepatitis (AIH, n = 47), non-autoimmune hepatitis (n = 158) and healthy controls (n = 40). Enzyme linked immunosorbent assay (ELISA) was used to examine the content of anti-myeloperoxidase (MPO) antibody. The result was retrospectively analyzed.

RESULTS: Comparison between the rates of ANA, SMA and ANCA showed that SMA was found the highest in AIH patients (66.0%, 31/47), significantly higher than that in non-AIH patients (6.3%, 10/158). After chi-square test, SMA and AMA and MPO were markedly different between AIH and primary biliary cirrhosis (PBC) patients (P < 0.01). Finally, ANA, SMA and ANCA were correlated with AIH-Ⅰ, anti-liver/kidney microsomal antibody (LKM) with AIH-Ⅱ, and anti-soluble liver antigen antibody (SLA), ANCA with AIH-Ⅲ.

CONCLUSION: Detection of autoantibodies is helpful in the diagnosis and therapy of AIH.

Frequency and significance of antibodies to cyclic citrullinated peptide in type 1 autoimmune hepatitis

OBJECTIVES

Determine the frequency, clinical phenotype, and prognostic implications of antibodies against cyclic citrullinated peptides in patients with type 1 autoimmune hepatitis.

METHODS

Three hundred and ninety-five serum samples from 179 patients were tested by enzyme-linked immunosorbent assay, and findings correlated with clinical and histological features, frequency of HLA DR3 and DR4, and treatment outcome.

RESULTS

Twenty patients (11%) had antibodies against cyclic citrullinated peptides. Seropositivity was associated with a higher frequency of rheumatoid arthritis (RA) (25 vs. 0%, P < 0.001). Patients with antibodies against cyclic citrullinated peptides also had a significantly greater occurrence of histological cirrhosis at presentation (47 vs. 20%, P = 0.01) and death from hepatic failure than seronegative patients (25 vs. 9%, P = 0.04). Cirrhosis at presentation occurred more commonly in the patients with antibodies against cyclic citrullinated peptides and RA than in the other patients (100 vs. 21%, P = 0.005).

CONCLUSIONS

Antibodies against cyclic citrullinated peptides occur in a subgroup of patients with type 1 autoimmune hepatitis who have a greater occurrence of cirrhosis at presentation and death from hepatic failure. Their presence with RA at accession characterizes a subgroup with cirrhosis.

Azathioprine monotherapy for maintenance of remission in pediatric patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic disorder characterized by unresolving liver inflammation and has a fluctuating clinical course. Standard therapy has been corticosteroids given daily, alone or in combination with azathioprine (AZA). The potential for significant side effects from prolonged corticosteroid use remains high. To date, no pediatric literature describes long-term AZA monotherapy after induction of remission with corticosteroids. We conducted a retrospective chart review from 1990 to 2002, which revealed 8 patients with AIH. Three patients were excluded because of other diseases requiring continued or intermittent use of corticosteroids. The time to complete biochemical remission on corticosteroids and AZA was 230 days (range, 74-288 days). Azathioprine was introduced early following the diagnosis (range, 1-35 days). All 5 patients were successfully weaned off corticosteroids after a median of 378 days and were maintained on AZA monotherapy for a median of 37 months (range, 28-82 months). One patient had a disease exacerbation on AZA monotherapy 75 months after the discontinuation of corticosteroids. She responded quickly to a corticosteroid burst and has been on AZA monotherapy for 7 months. One patient relapsed after self-discontinuing all medications. Long-term remission of AIH was possible in our case series with the early introduction and maintenance treatment with AZA as monotherapy.

Liver biopsy interpretation for causes of late liver allograft dysfunction

Evaluation of needle biopsies and extensive clinicopathological correlation play an important role in the determination of liver allograft dysfunction occurring more than 1 year after transplantation. Interpretation of these biopsies can be quite difficult because of the high incidence of recurrent diseases that show histopathological, clinical, and serological features that overlap with each other and with rejection. Also, more than one insult can contribute to allograft injury. In an attempt to enable centers to compare and pool results, improve therapy, and better understand pathophysiological disease mechanisms, the Banff Working Group on Liver Allograft Pathology herein proposes a set of consensus criteria for the most common and problematic causes of late liver allograft dysfunction, including late-onset acute and chronic rejection, recurrent and new-onset viral and autoimmune hepatitis, biliary strictures, and recurrent primary biliary cirrhosis and primary sclerosing cholangitis. A discussion of differential diagnosis is also presented.

Clinical features of Japanese male patients with type 1 autoimmune hepatitis

BACKGROUND

Recently, unusual patients with autoimmune hepatitis, such as male patients, have increased.

AIM

To assess clinical feature of Japanese males with type 1 autoimmune hepatitis compared with females.

METHODS

We investigated consecutive 160 patients with type 1 autoimmune hepatitis, who consisted of 20 males and 140 females, with a median age of 55 (16-79) years.

RESULTS

Compared with females, males had a lower frequency of definite diagnosis according to the revised scoring system proposed by the International Autoimmune Hepatitis Group (40% vs. 85%) and lower serum levels of immunoglobulin G [1932 (1085-3850) mg/dL vs. 2624 (1354-6562) mg/dL]. However, they were similar in age, form of clinical onset, symptomatic concurrent autoimmune disease, human leucocyte antigen DR status and frequency of cirrhosis at the time of diagnosis. The normalization of serum alanine aminotransferase levels within 6 months after the introduction of corticosteroid treatment was lower in males compared with females (73% vs. 93%).

CONCLUSIONS

In male patients, a diagnosis of autoimmune hepatitis should be made carefully. In Japanese patients with a dominant frequency of human leucocyte antigen DR4, gender may affect the response to corticosteroid treatment.

The Japanese diagnostic criteria for autoimmune chronic pancreatitis: is it completely satisfactory?

OBJECTIVES

Autoimmune chronic pancreatitis (AIP) is a very attractive disease to clinicians in terms of its dramatic response to the oral steroid therapy in contrast to ordinary chronic pancreatitis. In the year 2002, the Japan Pancreas Society published the diagnostic criteria of AIP, and many clinicians around the world use these criteria for its diagnosis. The purpose of this study was to evaluate whether the Japanese criteria for the diagnosis of AIP are adequate or not.

METHODS

We retrospectively analyzed the clinical, radiologic, laboratory, and histologic features of 31 patients with AIP who have been successfully treated with oral corticosteroid. All the enrolled patients showed normalization or marked improvement in symptoms, laboratory, and imaging findings after steroid treatment.

RESULTS

The mean patients' age was 56 years (range, 32-78 years) and comprised 25 males and 6 females. Seven patients who responded to the steroid did not satisfy the Japanese imaging criterion because the extent of irregular narrowing was less than one third of the entire length of main pancreatic duct. Among these 7 patients, 1 patient did not meet the laboratory and histopathologic criteria as well. Another 2 patients fulfilled the Japanese imaging criterion only and showed normal IgG level, negative results of autoantibody measurements, and nondiagnostic pancreatic histopathology. Taken together, 9 (29%) of the 31 patients did not meet the Japanese diagnostic criteria for AIP, yet responded to the steroid.

CONCLUSIONS

Clinicians may miss a substantial portion of AIP patients who may benefit from steroid therapy when the diagnosis is confined to those who satisfy the criteria proposed by the Japan Pancreas Society. It is necessary to convene a worldwide consensus to develop an improved diagnostic criteria for AIP.

Autoimmune hepatitis: diagnosis, treatment, and prognosis

Autoimmune hepatitis (AIH) is an idiopathic hepatitis of unknown cause characterized by histologic evidence of chronic inflammation, liver autoantibodies, and increased gamma globulins in the serum. The clinical manifestations of AIH have been known since the 1950s and are essentially unchanged over the past 50 years. The cornerstone of therapy for AIH is immunosuppression using prednisone and azathioprine, with the vast majority of patients achieving clinical remission. This review provides a concise summary of the diagnostic criteria for AIH, describes its proposed pathogenic mechanisms and epidemiology, and offers an algorithmic approach to its initial treatment and follow-up.

Clinical and HLA phenotypes of type 1 autoimmune hepatitis in North American patients outside DR3 and DR4

AIMS

To determine the clinical phenotype and outcome of patients with definite type 1 autoimmune hepatitis, who lack human leukocyte antigen (HLA) DR3 and DR4, and to assess the importance of HLA DR7 and DR13.

METHODS

Two hundred and seven adult patients were typed for DR3, DR4, DR7, and DR13 by DNA-based techniques. One hundred and two blood donors constituted a normal population.

RESULTS

Twenty-six patients lacked DR3 and DR4 (13%). Treatment failure occurred more commonly in these individuals than in the 68 patients with DR4 (20% vs. 3%, P = 0.03), and relapse after drug withdrawal was less frequent than in the 84 patients with DR3 (55% vs. 87%, P = 0.03). HLA DR13 occurred more often than in those with DR3 (54% vs. 15%, P = 0.0002) or DR4 (54% vs. 12%, P = 0.00005), and it was more frequent than in normal adults (54% vs. 22%, P = 0.003), including those without DR3 or DR4 (54% vs. 27%, P = 0.03). HLA DR7 was not associated with susceptibility or outcome.

CONCLUSIONS

White North American patients who lack DR3 and DR4 respond differently to corticosteroid treatment than patients with classical HLA phenotypes. HLA DR13 is common in these adult patients, and it may affect treatment outcome.

Successful treatment of autoimmune hepatitis and idiopathic thrombocytopenic purpura with the monoclonal antibody, rituximab: case report and review of literature

Rituximab, a chimeric monoclonal anti-CD20 antibody, has shown activity in several autoimmune disorders. We describe a case of a 52 years old female who was diagnosed with idiopathic thrombocytopenic purpura and concomitant autoimmune hepatitis (AIH), both non-responsive to steroids. She was subsequently treated with rituximab, which resulted in a rapid increase in her platelet count and an unexpected normalization of her hepatic biochemical tests. Both her platelet count and her hepatic biochemical tests remained normal for over 5 months. In this case, rituximab showed an impressive clinical response for the treatment of AIH, and it may be considered as an alternative treatment in patients who do not respond to corticosteroid therapy. Prospective randomized studies in AIH are needed to validate this observation.

Antibodies to filamentous actin (F-actin) in type 1 autoimmune hepatitis

AIMS

To evaluate the diagnostic significance of anti-filamentous actin antibodies (A-FAA) assessed with a commercial ELISA in comparison with immunofluorescence reactivity and patterns of anti-smooth muscle antibodies (SMA); and to correlate A-FAA positivity with clinical, immunogenetic, laboratory, and histological features in patients with autoimmune hepatitis type 1 (AIH-1).

METHODS

We studied 78 consecutive untreated AIH-1 patients and 160 controls: 22 with autoimmune hepatitis type 2 (AIH-2), 51 with hepatitis C, 17 with coeliac disease (CD), 20 with primary biliary cirrhosis (PBC) and 50 blood donors. SMA was evaluated by indirect immunofluorescence (IIF) on frozen sections of rat tissues, and A-FAA with a modified commercial ELISA.

RESULTS

SMA was detected by IIF in 61 (78%) of 78 AIH-1 patients, of whom 47 (60%) had the SMA-T/G and 14 (18%) the SMA-V pattern. Of the pathological controls, 32 (20%) had the SMA-V pattern (25 with hepatitis C, 2 with AIH-2, 2 with PBC, 3 with CD). A-FAA were present in 55 AIH-1 patients (70.5%; 46 with SMA-T/G, 7 with SMA-V, and 2 SMA-negative), and in 10 controls (6%), of whom five had hepatitis C, two AIH-2, two PBC and one CD. The association between A-FAA and the SMA-T/G pattern was statistically significant (p<0.0001). A-FAA levels were higher in SMA-T/G positive than SMA-V positive AIH-1 patients and controls (p<0.0001). A-FAA positivity was significantly associated with higher gamma-globulin and IgG levels, but did not correlate with other considered parameters.

CONCLUSION

The modified A-FAA ELISA strictly correlates with the SMA-T/G pattern and is a reliable and operator independent assay for AIH-1. Detection of A-FAA, even if devoid of prognostic relevance, may be useful when interpretative doubts of standard IIF arise.

Centrilobular necrosis in autoimmune hepatitis: a histological feature associated with acute clinical presentation

AIMS

The characteristic histological feature of autoimmune hepatitis (AIH) is interface hepatitis with predominant portal lymphoplasmacytic necroinflammatory infiltration. Centrilobular necrosis (CN), reminiscent of toxic or circulatory liver injury, has been reported in AIH. The aim of this study was to assess the frequency of CN in patients with AIH and its correlation with laboratory and clinical data.

METHODS

Liver biopsies were obtained from 114 patients (90 women, 24 men, mean (SD) age 45.4 (19.4) years) with AIH and were evaluated under code by a single pathologist according to the modified Knodell score.

RESULTS

CN was found in 20 (17.5%) patients with virtually unaffected portal areas in four cases. Patients with AIH with CN had a higher total hepatic activity index (median (range) 11 (6 to 15) v 5 (2 to 10)) and presented less frequently with cirrhosis (10% v 38%). Patients with CN had a higher frequency of acute onset (87% v 32%), higher bilirubin (median (range) 12.0 (0.43 to 40.0) v 1.9 (0.36 to 46)) and higher ALT levels (median (range) 25.6 (2.7 to 63.9) v 7.2 (0.7 to 62.6)), than did patients with AIH without centrizonal injury.

CONCLUSION

CN with sparing of the portal areas represents a rare histological pattern in AIH. CN is associated with an acute clinical presentation and might reflect an early lesion preceding portal involvement. Recognition of this particular histological appearance enables early diagnosis of AIH and a timely initiation of immunosuppressive therapy.

Autoimmune hepatitis

Autoimmune hepatitis (AIH) is a progressive inflammatory hepatitis of unknown etiology that is responsive to immunosuppressive therapy. The diagnosis of AIH should be guided by the descriptive criteria and scoring system set forth by the International Autoimmune Hepatitis Group. Standard therapy is prednisone with or without azathioprine (AZA). Combination therapy with prednisone and AZA is preferred, as it allows treatment with lower individual doses of each drug and is thus associated with fewer side effects. Treatment goals include complete biochemical, clinical, and histologic remission. Treatment outcomes include complete remission with or without relapse, incomplete response, or treatment failure. Treatment withdrawal, once remission has been attained, may be associated with relapse of disease. Recurrent relapse may be addressed with long-term, lower dose maintenance treatment with prednisone or AZA. Incomplete response is addressed by attempting high-dose immunosuppressive regimens or by considering investigational medical regimens. Treatment failure is also addressed by considering investigational medical regimens. Medication toxicity is addressed with dose reduction or drug discontinuation. Should the patient progress to decompensated cirrhosis, liver transplantation is an effective treatment for AIH. Calcium and vitamin D supplementation, a well-balanced diet, and exercise are advocated in patients with AIH. Cyclosporine, mycophenolate mofetil, and tacrolimus are promising agents among the new therapies for autoimmune hepatitis. Unfortunately, newer therapeutic agents have been studied in small numbers. Larger, controlled treatment trials are needed to expand the repertoire of therapeutics to treat patients with fewer side effects and to provide alternatives for patients who are refractory to conventional therapy.

Clinical characteristics of fulminant-type autoimmune hepatitis: an analysis of eleven cases

BACKGROUND

Although a few adult cases of fulminant-type autoimmune hepatitis have been reported, their clinical features and prognosis have remained uncertain.

AIM

To assess the clinical features and prognosis of patients with fulminant-type autoimmune hepatitis.

METHODS

Eleven patients (10%) diagnosed with fulminant-type autoimmune hepatitis in accordance with the 1999 criteria of the International Autoimmune Hepatitis Group were analysed.

RESULTS

All 11 patients were female, with a median age of 53 years. Five patients survived without liver transplantation, one received a liver transplantation, and five died without liver transplantation. Nine patients (82%) survived for 2 weeks or more following diagnosis, without liver transplantation. Except for the patient receiving a liver transplantation, serum total bilirubin levels measured during the clinical course were significantly higher in non-survivors than in survivors, although the accompanying serum alanine aminotransferase levels measured for the two groups were similar. Most significantly, serum total bilirubin levels in non-survivors worsened during days 8-15, while levels in survivors improved during the same period.

CONCLUSIONS

The short-term prognosis for patients with fulminant-type autoimmune hepatitis may be good. However, patients whose serum total bilirubin levels worsen during days 8-15 should be considered for liver transplantation.

Thiopurine methyltransferase deficiency and azathioprine intolerance in autoimmune hepatitis

Thiopurine methyltransferase deficiency has been associated with intolerance to azathioprine. Our goals were to assess the frequency of enzyme deficiency in autoimmune hepatitis and correlate deficiency states with azathioprine intolerance. Eighty-six patients receiving azathioprine (50-150 mg daily) were evaluated for enzyme activity and azathioprine-related complications. Their findings were compared to 89 similarly treated but untested patients. Thirteen patients (15%) had low thiopurine methyltransferase levels (11.4+/- 0.9 U/ml RBC; range, 3.5-14.9 U/ml RBC). Azathioprine intolerance occurred as commonly in patients with normal or above normal enzyme levels as in patients with below normal levels (12% versus 15%, p = 0.7). Patients treated without enzyme testing had the same frequency of complications (9% versus 13%, p = 0.5) as tested patients. We conclude that routine screening of blood thiopurine methyltransferase levels has a low yield for identifying individual patients at risk for azathioprine toxicity during conventional low dose therapy for autoimmune hepatitis.

Diagnostic criteria for autoimmune chronic pancreatitis revisited

Autoimmune chronic pancreatitis (AIP) is increasingly being recognized worldwidely, as knowledge of this entity builds up. Above all, AIP is a very attractive disease to clinicians in terms of its dramatic response to the oral steroid therapy in contrast to ordinary chronic pancreatitis. Although many characteristic findings of AIP have been described, definite diagnostic criteria have not been fully established. In the year 2002, the Japan Pancreas Society published the diagnostic criteria of AIP and many clinicians around the world use these criteria for the diagnosis of AIP. The diagnostic criteria proposed by the Japan Pancreas Society, however, are not completely satisfactory and some groups use their own criteria in reporting AIP. This review discusses several potential limitations of current diagnostic criteria for this increasingly recognized condition. The manuscript is organized to emphasize the need for convening a consensus to develop improved diagnostic criteria.

[Hepatitis C-autoimmune hepatitis overlap syndrome: five new cases]

PURPOSE

The hepatitis C-Autoimmune hepatitis overlap syndrome is an uncommon condition whose management can be difficult in both diagnosis and treatment.

PATIENTS AND METHODS

Five cases of hepatitis C and autoimmune hepatitis overlap syndrome, brought by a retrospective study, are reported. Hepatitis C was proven by a positive HCV viral load and the autoimmune hepatitis was proven by characteristic immunological and/or histological features.

RESULTS

All patients were female, the mean age at diagnosis was 54.2 years (+/-6.6), only one patient had a history of autoimmune disease (autoimmune thyroiditis). Four patients had significant autoantibodies levels (over 1/320) and 4 had a high serum gammaglobulin level (over 1.5 times the upper normal limit). Liver biopsy showed characteristic features of autoimmune hepatitis in all cases and characteristic features of chronic HCV infection in 3 cases. Corticosteroid and/or immunosuppressive treatment was given as a first line therapy in 4 cases while an antiviral treatment has been tried in 4 cases with a good viral response in 2 of them. Corticosteroid and/or immunosuppressive treatment enhanced HCV viral load in all cases, however a histological improvement was observed in every case in which a control biopsy has been performed (3 cases).

CONCLUSION

This study highlights the deciding contribution of the initial histological findings in the diagnosis of such a HCV/autoimmune hepatitis overlap syndrome; it also demonstrates that histological outcome is not necessarily compromised by corticosteroid and/or immunosuppressive treatment.

Fatigue in liver disease: pathophysiology and clinical management

Fatigue is the most commonly encountered symptom in patients with liver disease, and it has a significant impact on their quality of life. However, although some progress has been made with regard to the understanding of the processes which may generate fatigue in general, the underlying cause(s) of liver disease-associated fatigue remain incompletely understood. The present review describes recent advances which have been made in our ability to measure fatigue in patients with liver disease in the clinical setting, as well as in our understanding of potential pathways which are likely important in the pathogenesis of fatigue associated with liver disease. Specifically, experimental findings suggest that fatigue associated with liver disease likely occurs as a result of changes in neurotransmission within the brain. In conclusion, a reasonable approach to help guide in the management of the fatigued patient with liver disease is presented.

Distinctive clinical phenotype and treatment outcome of type 1 autoimmune hepatitis in the elderly

Autoimmune hepatitis is classically a disease of young women. Our aims were to determine its occurrence, clinical phenotype, and outcome in elderly patients and contrast findings to young adults. Two-hundred-and-five white North American adults with definite type 1 autoimmune hepatitis were grouped according to age at presentation and the groups compared. Forty-seven patients (23%) were aged > or = 60 years (median age, 68 years), and 31 patients (15%) were aged < or = 30 years (median age, 25 years). The patients > or = 60 years had a higher frequency of cirrhosis at presentation than the patients < or = 30 years (33% versus 10%, P = .03). They also had thyroid or rheumatic diseases more commonly (42% vs. 13%, P = .006). HLA DR3 occurred more frequently in the patients < or = 30 years than in those > or = 60 years (58% vs. 23%, P = .004), and HLA DR4 occurred more often in the patients > or = 60 years (47% vs. 13%, P = .003). Patients aged > or = 60 years failed corticosteroid treatment less commonly than those aged < or = 30 years (5% vs. 24%, P = .03). Autoimmune hepatitis occurred in patients aged 18-30 years (15%), 31-39 years (15%), 40-49 years (21%), 50-59 years (25%), and > or = 60 years (23%). Differences in age distribution, HLA frequencies, and treatment outcome occurred after age > or = 40 years. In conclusion, elderly patients have a greater frequency of cirrhosis at presentation and HLA DR4 than patients < or = 30 years, and they have a lower occurrence of treatment failure. Transitions in clinical and genetic phenotypes occur after age > or = 40 years. Genetic susceptibilities may favor etiologic factors that are age-related.

Long term outcome and response to therapy of primary biliary cirrhosis-autoimmune hepatitis overlap syndrome

BACKGROUND/AIMS

Whether primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap syndrome requires immunosuppressive therapy in addition to ursodeoxycholic acid (UDCA) is a controversial issue.

METHODS

Seventeen patients with simultaneous form of strictly defined overlap were followed for 7.5 years. First-line treatment was UDCA alone (UDCA) in 11 and combination of immunosuppressors and UDCA (UDCA + IS) in 6.

RESULTS

Characteristics at presentation were not significantly different between the 2 groups. In the UDCA + IS group (f-up 7.3 years), biochemical response in terms of AIH features (ALT<2ULN and IgG < 16 g/L) was achieved in 4/6 and fibrosis did not progress. In the UDCA group, biochemical response was observed in three patients together with stable or decreased fibrosis (f-up 4.5 years) whereas the eight others were non-responders with increased fibrosis in four (f-up 1.6 years). Seven of these eight patients subsequently received combined therapy for 3 years. Biochemical response was obtained in 6/7 and no further increase of fibrosis was demonstrated. Overall, fibrosis progression in non-cirrhotic patients occurred more frequently under UDCA monotherapy (4/8) than under combined therapy (0/6) (P = 0.04).

CONCLUSIONS

Combination of UDCA and immunosuppressors appears to be the best therapeutic option for strictly defined PBC-AIH overlap syndrome.

Autoimmune hepatitis, from mechanisms to therapy

In 1950, Waldenström was the first to describe a chronic form of hepatitis in young women. Subsequently, the disease was found to be associated with other autoimmune syndromes and was later termed "lupoid hepatitis" because of the presence of antinuclear antibodies. In 1965, it became designated by Mackay et al. as "autoimmune hepatitis" at an international meeting, at which the general concept of autoimmunity was endorsed by the scientific community. In the early 1960s and 1970s, the value of immunosuppressive therapy with glucocorticoids and/or azathioprine was well documented in several studies. The original association of autoimmune hepatitis (AIH) and HLA alleles, which has remarkably stood the test of time, was published in 1972. In the 1970s and 1980s, several autoantibodies were identified in patients with autoimmune hepatitis directed against proteins of the endoplasmatic reticulum expressed in liver and kidney and against soluble liver antigens. Subsequently, the molecular targets of these antibodies were identified and more precisely characterized. In the last two decades many additional pieces of the AIH puzzle have been collected leading to the identification of additional antibodies and genes associated with AIH and to the emergence of new therapeutic agents. Meanwhile, the immunoserological and genetic heterogeneity of AIH is well established and it has become obvious that clinical manifestations, disease behavior, and treatment outcome may vary by racial groups, geographical regions and genetic predisposition. Currently, the International Autoimmune hepatitis group is endorsing multi-center collaborative studies to more precisely define the features at disease presentation and to define prognostic indices and appropriate treatment algorithms. Given the importance of serological testing, the IAHG is also working on guidelines and procedures for more reliable and standardized testing of autoantibodies.

Autoantibodies in autoimmune liver disease

Autoantibodies indicate an immune reactive state, but in liver disease they lack pathogenicity and disease specificity. Antinuclear antibodies, smooth muscle antibodies, antibodies to liver/kidney microsome type 1, antimitochondrial antibodies, and perinuclear antineutrophil cytoplasmic antibodies constitute the standard serological repertoire that should be assessed in all liver diseases of undetermined cause. Antibodies to soluble liver antigen/liver pancreas, asialoglycoprotein receptor, actin, liver cytosol type 1, nuclear antigens specific to primary biliary cirrhosis, and pore complex antigens constitute an investigational repertoire that promises to have prognostic and diagnostic value. These autoantibodies may emerge as predictors of treatment response and outcome. Antibodies to histones, doubled-stranded DNA, chromatin, and lactoferrin constitute a supplemental repertoire, and they support the immune nature of the liver disease. Final diagnoses and treatment strategies do not depend solely on serological markers. Autoantibodies are floating variables, and their behavior does not correlate closely with disease activity. There are no minimum levels of significant seropositivity, especially in children. Over-interpretation is the major pitfall in the clinical application of the serological results. New autoantibodies will emerge as the search for target antigens and key pathogenic pathways continues.

Efficacy and safety of prednisolone in patients with autoimmune hepatitis

A retrospective cohort study involving 29 Japanese patients with autoimmune hepatitis (AIH) was performed to clarify factors that predict the efficacy of prednisolone and the occurrence of various serious adverse effects. Independent predictors were identified by logistic analysis and with use of the Cox proportional hazard model. Responses to prednisolone were noted in 28 patients, who were classified into the complete remission group (52%) or the relapse group (48%). Multivariate analysis identified alanine aminotransferase, alkaline phosphatase, and immoglobulin G levels as independent predictors of relapse. The adverse effects most frequently observed were diabetes mellitus (37.9%), psychiatric/ neurologic symptoms (34.5%), and circulatory symptoms (34.5%). Predictive factors included lactate dehydrogenase, albumin, and fasting blood glucose levels for diabetes mellitus, alkaline phosphatase and C-reactive protein for psychiatric/ neurologic symptoms, and autoimmune hepatitis score and lactate dehydrogenase for circulatory symptoms. Selection of an optimal treatment method for individual patients may be possible after the risks of relapse and adverse effects have been estimated.

Investigations and management of gastrointestinal and hepatic manifestations of systemic lupus erythematosus

Gastrointestinal (GI) manifestations of systemic lupus erythematosus (SLE) are protean. Any part of the GI tract and the hepatobiliary system can be involved. Up to two-third of SLE patients develop GI symptoms at some stage of their illnesses. Clinical presentations of GI lupus are non-specific and can be difficult to differentiate from infective, thrombotic, therapy-related and non-SLE etiologies. Clinical acumen and appropriate endoscopic, biopsy and imaging procedures are essential for establishing the correct diagnosis. Acute abdominal pain in SLE patients can herald an intra-abdominal catastrophe and should be evaluated promptly. Surgical intervention should be instituted without delay if conservative management fails or when there is clinical or radiological suspicion of visceral perforation or intra-abdominal collections.

Persistent normalization of serum alanine aminotransferase levels improves the prognosis of type 1 autoimmune hepatitis

BACKGROUND/AIMS

Autoimmune hepatitis shows a good response to immunosuppressive treatment, and the prognosis may be determined by the clinical course. The present study was conducted in order to analyze the factors contributing to the outcomes of patients with type 1 autoimmune hepatitis.

METHODS

Eighty-four consecutive patients with type 1 autoimmune hepatitis were followed up regularly for a median follow-up period of 70.5 months (16.2-163 months). We analyzed the prognostic factors using time-fixed and time-dependent Cox proportional hazard models. The end point was progression of the disease to decompensated liver cirrhosis.

RESULTS

Seventy-seven patients (92%) were treated with prednisolone during the follow-up period, and 11 patients (13%) developed decompensated liver cirrhosis. Using a time-dependent multivariate model, the starting dose of corticosteroid (dose of prednisolone <20 mg/day), relapse within 3 months after the normalization of serum alanine aminotransferase levels with initial treatment, and elevated serum alanine aminotransferase levels during the follow-up period (>40 IU/L), all showed a significant association with progression of the disease.

CONCLUSIONS

The prognosis of type 1 autoimmune hepatitis on adequate immunosuppressive treatment improves when the serum alanine aminotransferase level persists at < or = 40 IU/L. Factors existing prior to medical treatment may not affect the prognosis.

Chloroquine for the maintenance of remission of autoimmune hepatitis: results of a pilot study

BACKGROUND: Due to the risks related to long-term treatment with prednisone and azathioprine, most clinicians try to withdraw these drugs when patients with autoimmune hepatitis are in remission. However, there is a high probability of relapse, and most patients end up receiving maintenance treatment. AIM: To evaluate the safety and efficacy of maintenance treatment with chloroquine in the prevention of autoimmune hepatitis relapses. METHODS: Classical treatment was stopped after achievement of biochemical and histological remission of autoimmune hepatitis. Chloroquine diphosphate, 250 mg daily, was given for at least 12 months or until the occurrence of relapses defined by levels of aminotransferases at least twice the upper normal values. RESULTS: Fourteen patients were consecutively treated and compared with 18 historical controls. There was a 6.49 (1.38-30.30) greater chance of relapse in the historical controls when compared with patients treated with chloroquine (72.2% x 23.5%; 0.031). CONCLUSIONS: The group treated with chloroquine had a lower frequency of relapses. Chloroquine was safe in patients with autoimmune hepatitis and hepatic cirrhosis without decompensation, on 250 mg daily up to 2 years. These preliminary results provide a basis for upcoming controlled studies comparing chloroquine with placebo or for maintenance treatment with prednisone and/or azathioprine for the prevention of autoimmune hepatitis relapses.

Autoimmune hepatitis

Autoimmune hepatitis (AIH) is an intermittently progressive liver disease characterized by hypergammaglobulinemia, autoantibodies, predominately periportal hepatitis, and a favorable response to corticosteroid therapy in most cases. There are no pathognomonic markers of autoimmune liver disease; rather, the diagnosis must be based on the presence of a constellation of characteristic clinical, laboratory, and histologic features in patients without other causes of such liver pathology. Although prednisone or prednisolone are the mainstays in initial therapy of AIH, azathioprine or other drugs with similar immunosuppressive mechanisms are of benefit for steroid-sparing effects or for use as monotherapy to maintain long-term remission. A fraction of patients meeting diagnostic criteria for AIH remains in long-term remission following withdrawal of immunosuppressive therapies, but in most patients, this disease represents a chronic condition requiring life-long monitoring and therapy.

Diagnostic value of anti-F-actin antibodies in a French multicenter study

According to international criteria, autoimmune hepatitis (AIH) type 1 is characterized by the presence of antinuclear or anti-smooth muscle antibodies (SMA) with F-actin specificity. SMA have been found in 85% of AIH patients, but are not specific to this disease, and anti-F-actin specificity is not always verified when SMA are detected. The objective of this study was to determine the diagnostic value of anti-F-actin antibodies in a large population. A multicenter study involving 12 clinical centers was performed. Patients were selected on the basis of the presence of F-actin SMA detected by indirect immunofluorescence (IIF) on rat liver-kidney-stomach sections and was confirmed by IIF on Hep2 cells treated with colchicine, or F-actin dot-blot. The clinical status of patients was determined from their medical records. One hundred sixty-eight patients were included: 76% women, 24% men; mean age of 45 years (range, 2-88 years), with a bimodal age distribution. Sixty percent had AIH type 1, and 40% had another disease. In the group of women younger than 25 years, 90% had AIH type 1. Other pathologies associated with antiactin were other liver diseases (19%), including viral hepatitis C (7%), and non-liver diseases (21%), including connective tissue diseases (12%). Antibody titers were higher in AIH than in other diseases. Antiactin antibodies are of major diagnostic value in AIH, especially in young women; they may be found in other disease settings, but mostly at low levels.

Empiric therapy of autoimmune hepatitis with mycophenolate mofetil: comparison with conventional treatment for refractory disease

GOAL

To assess the outcomes of empiric therapy with mycophenolate mofetil in patients with autoimmune hepatitis.

BACKGROUND

Mycophenolate mofetil is a purine antagonist that selectively inhibits immunocyte proliferation, and its empiric use in autoimmune hepatitis has been stimulated by small clinical experiences.

STUDY

Eight patients received mycophenolate mofetil (0.5-3 g daily) for 19 +/- 7 months as frontline therapy or after adverse responses to conventional corticosteroid treatment. Seventeen patients who had been treated with high-dose corticosteroid regimens after treatment failure constituted a historical comparison population.

RESULTS

Five of the 8 patients receiving mycophenolate mofetil and all 17 patients who had been treated with the conventional corticosteroid regimens for treatment failure responded to therapy. The frequency of response (62% vs. 100%, P = 0.02) was lower during longer intervals of treatment (19 +/- 7 months vs. 6 +/- 1 months, P = 0.02) in the patients receiving mycophenolate mofetil. None receiving mycophenolate mofetil resolved their laboratory abnormalities, whereas 6 patients in the comparison group improved to normal tests (0% vs. 35%, P = 0.1). Histologic resolution did not occur in 4 patients sampled during treatment, and successive specimens in 2 patients showed progressive fibrosis. Corticosteroids could not be withdrawn in the patients treated with mycophenolate mofetil, whereas discontinuation was possible in 7 patients in the comparison group (0% vs. 41%, P = 0.06).

CONCLUSIONS

Mycophenolate mofetil did not induce laboratory resolution, prevent progressive fibrosis, or allow corticosteroid withdrawal. Clinical trials are needed to evaluate its role and target population.

MR Imaging Findings in Autoimmune Hepatitis: Correlation with Clinical Staging

PURPOSE

To retrospectively evaluate the morphologic and enhancement features of the liver on magnetic resonance (MR) images obtained in patients with autoimmune hepatitis (AIH) and to determine if there is a correlation between MR imaging findings and severity of clinical disease as measured with the Mayo end-stage liver disease (MELD) score.

MATERIALS AND METHODS

This study was compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board. The need for informed consent was waived. Thirty-two patients (29 female and three male patients; mean age, 44 years; age range, 14-69 years) undergoing treatment for AIH underwent unenhanced and gadolinium-enhanced MR imaging. Two radiologists reviewed all cases independently to determine the presence of patchy or heterogeneous liver enhancement, biliary duct changes, lymphadenopathy, and findings of portal hypertension. Fibrosis was graded as mild, moderate, or severe reticular (corresponding to a grading scale of 1-3) or as confluent. Agreement between radiologists was assessed by using kappa coefficients. Mean MELD scores were compared across fibrosis categories by using the Kruskal-Wallis analysis of variance.

RESULTS

Of the 32 patients, two (6%) had no imaging findings of cirrhosis. Thirty patients (94%) had reticular fibrosis with a mean grade of 1.8. Six patients had confluent fibrosis, and all six had associated reticular fibrosis. Mild intrahepatic biliary duct dilatation involving the right and left lobes was observed in four patients (12%). Lymphadenopathy was observed in 12% of patients. None of the patients had hepatocellular carcinoma. There was no significant overall association between fibrosis grade and MELD score (P = .36).

CONCLUSION

Although fibrosis is a common feature in AIH and is often moderate to severe, no significant correlation between fibrosis grade and MELD score was found.

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Early treatment response predicts the need for liver transplantation in autoimmune hepatitis

BACKGROUND

The need for immunosuppression in autoimmune hepatitis is established. Previous studies have investigated short-term outcomes in patients who respond to treatment. This study assesses long-term prognosis of patients who fail to respond to standard immunosuppression.

METHODS

163 charts were reviewed, composed of 108 non-transplant patients and 55 patients who required liver transplantation (LT). Clinical endpoints were based on aminotransaminases: early treatment response (ER) was a 50% improvement at 6 months of therapy, Complete remission (CR) was an improvement to <2X normal, Relapse was worsening to >3X normal, Incomplete response (IR) was some response but no CR in 3 years, and No response (NR) was no improvement after 3 years.

RESULTS

85% of non-LT and 25% of LT patients achieved ER, 91% of non-LT and 26% of LT patients achieved CR. 41% of non-LT patients relapsed on maintenance treatment, and 41% of non-LT patients relapsed when withdrawn from treatment. 9% of non-LT and 58% of LT patients had IR. 16% in LT group showed NR, while all non-LT patients showed some response. All paired comparisons were statistically different (P<0.05). Multiple regression analysis revealed that lack of ER predicts need for LT (P=0.0005). 87% of patients who achieved ER did not require LT, whereas 16% of patients who failed ER showed NR and all required LT. Odds ratio of a patient who failed ER proceeding to LT, compared to a patient who achieved ER, was 16.8 (7.5 to 37.7, 95% CI).

CONCLUSION

Patients who fail to show a 50% improvement in transaminases at 6 months of standard immunosuppression should be considered for alternate treatment modalities or be referred earlier for LT.

A murine model of acute liver injury induced by human monoclonal autoantibody

We have previously reported an immunoglobulin (Ig) M autoantibody to hepatocyte-related 190-kd molecules in patients with type 1 autoimmune hepatitis (AIH). This molecule was first isolated by hepatocyte-specific human monoclonal antibody (MoAb). To elucidate the role of this IgM autoantibody in hepatocyte injury, we examined the reactivity of this MoAb to murine hepatocytes and then questioned whether acute hepatic injury could be induced in mice via injection of this MoAb. The reactivity of MoAb was examined via both FACS analysis using murine hepatocytes and immunostaining of liver tissues. We then identified the murine hepatocyte membrane molecule recognized by this MoAb. The role of this MoAb in the immunopathogenesis of AIH was assessed by testing whether its injection into mice could increase serum aminotransferase levels as well as cause changes in liver histology. The present results demonstrate that this MoAb cross-reacted with murine hepatocytes and recognized a 190-kd molecule on the murine hepatocyte membrane just as in human hepatocytes. One hour after the injection of MoAb, the deposition of both IgM and complement component 3 was found in liver tissues. At 8 hours after the injection, serum aminotransferase levels were significantly increased in MoAb-injected mice compared with controls. Histological study revealed massive hepatocyte necrosis in MoAb-injected mice. In conclusion, human MoAb recognized a 190-kd molecule of both human and murine hepatocytes, and the injection of this MoAb to mice resulted in acute liver injury, indicating that this type of autoantibody may play an important role in the immunopathogenesis of AIH.

Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory

Unnecessary repeat requesting of tests can make up a large proportion of a laboratory's workload. This audit set out to establish the size of this problem and to identify the circumstances under which these repeat requests were made in a government tertiary hospital immunology laboratory. The numbers of tests for immunoglobulin measurement, common autoantibodies, and tumour markers that were repeated over a 12 month period were analysed by interrogating the Delphic laboratory computer system using a management information system for raw data enquiry protocol. Repeat requests within 12 weeks of a previous request made up 16.78% of the total workload. The total cost of the tests was estimated at 132 151 US dollars. The waste of technician time and reagents as a result of unnecessary repeat testing is excessive. Many of these tests might be eliminated with the use of interventions such as computerised reminders.

Detection of circulating autoantibodies directed against the asialoglycoprotein receptor using recombinant receptor subunit H1

BACKGROUND/AIMS

The asialoglycoprotein-receptor (ASGPR) is a major liver-specific target autoantigen in autoimmune hepatitis. ASGPR heteromers of two subunits H1 and H2 provide clearance of circulating asialoglycoproteins by receptor-mediated endocytosis. The aim of this study was to establish whether a recombinantly expressed subunit H1 presenting conformational epitopes is capable of detecting autoantibodies against ASGPR in patients with inflammatory liver disease.

METHODS

The major subunit H1 was expressed in human-embryo-kidney 293-cells and prepared by ligand-affinity-chromatography similar to the complete receptor from normal liver. Reactivities of anti-ASGPR positive sera from 219 patients with both recombinant H1 and natural receptor were compared using enzyme-immunoassay (EIA).

RESULTS

194 of 219 sera (88.6%) showed absorbance values on 293-H1 within a range of +/-15% compared to the natural receptor. 145 of 149 sera (97.3%) positive on ASGPR were also positive on recombinant H1. Titers of 61/62 sera (98.4%) revealed no deviation of more than one dilution step. ASGPR reactivity could be inhibited in 29 sera with up to 50 ng/microl of 293-H1.

CONCLUSIONS

These results indicate that the antigenic sites of the human ASGPR are mainly located on the mammalian-expressed subunit H1. Therefore, 293-H1 is a powerful tool for the detection of autoantibodies against ASGPR.