The problem of chronic liver disease in young women

Autoimmune Hepatitis: From Evolution to Current Status-A Pathologist's Perspective

Autoimmune hepatitis (AIH) is a chronic, relapsing and remitting, immune-mediated liver disease that progresses to cirrhosis if left untreated. A significant number of patients may present with acute hepatitis or acute liver failure, which are often misdiagnosed as toxic liver injury. AIH shows a preponderance in young women but may be seen in children and the elderly. Diagnosis requires the integration of clinical, biochemical, and serologic parameters, along with supportive liver histology and exclusion of other causes of liver disease. Liver biopsy is a prerequisite for diagnosis of AIH, to assess severity and stage of disease, exclude other entities, and recognize any concurrent morbidities. No single biomarker or histologic feature is pathognomonic for AIH. The diagnostic and histologic criteria have undergone several modifications since the original scoring system was proposed by the International Autoimmune Hepatitis Group (IAIHG) in 1993. Recently, the IAIHG has proposed consensus recommendations for histologic criteria, relevant for both acute and chronic AIH. This review article will describe the evolving diagnostic criteria for AIH, with their limitations and utility, and with an emphasis on the role of liver histology in the diagnosis and management of AIH.

Tendon Disorders in Chronic Liver Disease: A Retrospective Cohort Study in Taiwan

To investigate the relationship between chronic liver disease and tendon disorder, a retrospective cohort study was conducted using the Kaohsiung Veterans General Hospital database. Patients >18 years with newly diagnosed liver disease and with at least a two-year follow-up in the hospital were included. An equal number of 20,479 cases were enrolled in both the liver-disease and non-liver-disease groups using a propensity score matching method. Disease was defined using ICD-9 or ICD-10 codes. The primary outcome was the development of tendon disorder. Demographic characteristics, comorbidities, use of tendon-toxic drugs, and status of HBV/HCV infection were included for analysis. The results showed 348 (1.7%) and 219 (1.1%) individuals developed tendon disorder in the chronic liver disease group and non-liver-disease group. Concomitant use of glucocorticoids and statins may have further raised the risk of tendon disorder in the liver disease group. The co-existence of HBV/HCV infection did not increase the risk of tendon disorder in the patients with liver disease. Considering these findings, physicians should be more aware of tendon issues in advance, and a prophylactic strategy should be adopted in patients with chronic liver disease.

Role of age in presentation, response to therapy and outcome of autoimmune hepatitis

BACKGROUND

Few studies with diverging results and a small sample size have compared autoimmune hepatitis (AIH) in the elderly to younger patients.

AIM

To unbiasedly investigate the role of age in behaviour and treatment outcome of AIH.

METHODS

All patients with probable or definite AIH type 1 in four tertiary academic centres were included in this retrospective-and since 2006 prospective-cohort study. Influence of age on presentation, remission and outcome of AIH were investigated.

RESULTS

359 patients were included. Presence of cirrhosis at AIH diagnosis around 30% was independent of age. ALAT was higher at age 30-60 years on AIH diagnosis, and above age 60 there were less acute onset, less jaundice and more concurrent autoimmune disease. Remission was reached in 80.2%, incomplete remission in 18.7%, only 1.1% (all aged 50-65) was treatment-refractory. Age was not an independent predictor of remission, while cirrhosis was. Above age 45 there was more diabetes, above age 60 more loss of remission. Rate of progression to cirrhosis was 10% in the 10 years after diagnosis and unrelated to age at AIH diagnosis. With onset below age 30, there was more development of decompensated cirrhosis over time. With higher age at AIH diagnosis there was a lower survival free of liver-related death or liver transplantation.

CONCLUSIONS

AIH presents at all ages. Age influences features at diagnosis, but not response to treatment, while survival without liver-related death or liver transplantation decreases with higher age at diagnosis.

Global Disparities and Their Implications in the Occurrence and Outcome of Autoimmune Hepatitis

Autoimmune hepatitis has a variable occurrence, clinical phenotype, and outcome, and the factors contributing to this variability are uncertain. The goals of this review are to examine the global disparities in the occurrence and outcome of autoimmune hepatitis, suggest bases for these disparities, and encourage investigations that extend beyond single-center experiences. Disparities in the incidence and prevalence of autoimmune hepatitis in different age groups, genders, ethnicities, and geographical regions suggest that factors other than genetic predisposition are involved. Age- and gender-related antigen exposures from the external (infections, toxins, and medications) and internal (intestinal microbiome) environment may affect the incidence of the disease, and the timeliness and nature of treatment may influence its prevalence. The increasing incidence of autoimmune hepatitis in Spain, Denmark, and the Netherlands suggests that a new etiological trigger has been introduced or that the susceptible population has changed. Variations in mortality between Western and Asian-Pacific countries may result from differences in disease detection or management, and variations in gender predilection, peak age of onset, frequency of concurrent immune diseases, and serological profile may reflect gender-biased and age-related antigen exposures and genetic predispositions. Global collaborations, population-based epidemiological studies that identify case clustering, and controlled interview-based surveys are mechanisms by which to understand these disparities and improve management. In conclusion, autoimmune hepatitis has a rising incidence in some countries and variable occurrence, phenotype, and outcome between countries and subgroups within countries. These disparities suggest that unrecognized population-based environmental, infectious, or socioeconomic factors are affecting its character.

Liver Governs Tendon: A Theory from Traditional Chinese Medicine-Evidence from a Population-Based Matched Cohort Study in Taiwan for the Association of Chronic Liver Disease and Common Diseases in the Chiropractic Office

In traditional Chinese medicine (TCM) theory, the liver governs the tendons. This retrospective cohort study investigated the relationship between chronic liver disease and common orthopedic conditions by utilizing the National Health Insurance Research Database of Taiwan. The populations included within this study were chronic liver disease patients (International Classification of Diseases/ICD-9 code: 571) and a comparison group composed of patients with nonchronic liver disease. The medical event that was evaluated was internal derangement of joints (ICD-9 codes: 717-718). In comparison with the control group, patients with chronic liver disease were 1.29 times more likely to develop internal derangement of joints when major trauma had also occurred. We did not find the association of viral hepatitis with internal derangement of joints. Patients with chronic liver disease as well as anemia were 3.01 times more likely to develop joint derangements. Our study shows that patients with anemia in addition to chronic liver disease are more prone to develop joint derangements. This is the first documented research study that endorses “the liver governs the tendons which gives the body the ability to move” theory of TCM. The incidence rate of internal derangement of knee joints was higher in patients with chronic liver disease.

"Lupoid hepatitis" in SLE patients and mice with experimental lupus

The unusual subset of patients with severe hepatitis, hypergammaglobulinemia, arthritis, and LE cells in the blood reported by Henry Kunkel and others suggested to these investigators that "lupoid" hepatitis might share pathogenic mechanisms with SLE. More than half a century later, the etiology of autoimmune hepatitis remains unclear. The occurrence of autoimmune hepatitis in a small fraction (about 3%) of SLE patients in our lupus cohort and in two mouse models of SLE supports their conclusion that lupoid hepatitis may be share pathogenic mechanisms with SLE. The development of autoimmune hepatitis in mice with pristane-induced lupus provides an opportunity to further explore the potential link between these two autoimmune disorders.

Systematic review with meta-analysis: clinical manifestations and management of autoimmune hepatitis in the elderly

BACKGROUND

Autoimmune hepatitis is an uncommon chronic progressive inflammatory disease of the liver, characterised by hypergammaglobulianemia, circulating autoantibodies, and interface hepatitis histologically. It is traditionally thought to be a disease of young women. However, recent epidemiological and retrospective studies suggest that it might be a disease predominantly of older women. Studies of AIH in elderly patients have been fairly limited.

AIM

To investigate the differences in the clinical presentations and the management of AIH in the elderly and the younger patients.

METHODS

We conducted a search on MEDLINE (from 1946), PubMed (1946) and EMBASE (1949) through to November 2013 using the terms 'autoimmune hepatitis in the elderly', and the combinations of 'Autoimmune hepatitis' AND the following terms: 'elderly', 'aging', 'older patients', and 'older'. The reference lists of relevant articles were also searched for appropriate studies.

RESULTS

A total of 1063 patients were identified with AIH in 10 retrospective studies. The definition of 'elderly' ranged from 60 to 65 years; 264 elderly and 592 younger patients were included for analysis. Elderly, 24.8%, were more likely to present asymptomatically, cirrhotic at presentation and HLA-DR4-positive. They are less likely to be HLA-DR3-positive and to relapse after treatment withdrawal after complete remission.

CONCLUSIONS

AIH is an important differential in elderly patients with cirrhosis or abnormal LFTs. Elderly are more likely to be cirrhotic and asymptomatic at presentation. Glucocorticoids use should be readily considered in the elderly patients as the current evidence suggests that they respond well to the therapy, with less relapse after treatment withdrawal.

Autoimmune hepatitis in diverse ethnic populations and geographical regions

Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.

Autoimmune hepatitis

Autoimmune hepatitis was one of the first liver diseases for which an effective treatment was developed and the benefit proven by randomized controlled trials. Nonetheless, both the diagnosis and the treatment of autoimmune hepatitis remain full of challenges. The clinical spectrum is very wide, ranging from subclinical non-progressive disease to fulminant hepatic failure. Diagnostic criteria based on elevation of IgG, demonstration of characteristic autoantibodies, and histological features of hepatitis in the absence of viral disease are very helpful. However, in some patients, diagnosis remains a clinical challenge. Adequately dosed steroids are the mainstay of remission induction treatment, while remission maintenance is best achieved by azathioprine. Therapeutic alternatives are required in a small group of patients responding insufficiently to these drugs or intolerant to their side effects.

A 50-year experience with autoimmune hepatitis: and where are we now?

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.

Population-based epidemiology study of autoimmune hepatitis: a disease of older women?

BACKGROUND AND AIM

The etiology of autoimmune hepatitis (AIH) is unknown, and limited epidemiological data are available. Our aim was to perform a population based epidemiological study of AIH in Canterbury, New Zealand.

METHODS

To calculate point prevalence, all adult and pediatric outpatient clinics and hospital discharge summaries were searched to identify all cases of AIH in the Canterbury region. Incident cases were recruited prospectively in 2008. Demographic and clinical data were extracted from case notes. Both the original revised AIH criteria and the simplified criteria were applied and cases were included in the study if they had definite or probable AIH.

RESULTS

When the original revised criteria were used, 138 cases (123 definite and 14 probable AIH), were identified. Prospective incidence in 2008 was 2.0/100,000 (95% confidence interval [CI] 0.8-3.3/100,000). Point prevalence on 31 December 2008 was 24.5/100,000 (95% CI 20.1-28.9). Age-standardized (World Health Organization standard population) incidence and prevalence were 1.7 and 18.9 per 100,000, respectively. Gender-specific prevalence confirmed a female predominance, while ethnicity-specific prevalence showed higher prevalence in Caucasians. 72% of cases presented after 40 years of age and the peak age of presentation was in the sixth decade of life.

CONCLUSIONS

This is the first and largest population-based epidemiology study of AIH in a geographically defined region using standardized inclusion criteria. The observed incidence and prevalence rates are among the highest reported. The present study confirms that AIH presents predominantly in older women, with a peak in the sixth decade, contrary to the classical description of the disease.

Non-classical phenotypes of autoimmune hepatitis and advances in diagnosis and treatment

Non-classical manifestations of autoimmune hepatitis can delay diagnosis and treatment. Our aims were to describe the clinical phenotypes that can confound the diagnosis, detail scoring systems that can ensure their recognition, and outline advances in treatment that can improve their outcome. Prime source and review articles in English were selected through Medline from 1970-2008 and assimilated into personal libraries spanning 32 years. Acute severe or asymptomatic presentations and atypical histological findings, including centrilobular zone 3 necrosis and concurrent bile duct changes, are compatible with the diagnosis. Cholangiographic abnormalities may be present in children and adults with the disease, and autoimmune hepatitis must be considered in patients without autoantibodies or with antimitochondrial antibodies and no other cholestatic features. Asymptomatic patients frequently become symptomatic; mild disease can progress; and there are no confident indices that justify withholding treatment. Two diagnostic scoring systems with complementary virtues have been developed to evaluate patients with confusing features. Normal liver tests and tissue constitute the optimal end point of treatment, and the first relapse is an indication for long-term azathioprine therapy. Cyclosporine, tacrolimus and mycophenolate mofetil are promising salvage therapies, and budesonide with azathioprine may be a superior frontline treatment. We conclude that the non-classical phenotypes of autoimmune hepatitis can be recognized promptly, diagnosed accurately, and treated effectively.

Safety issues in the management of autoimmune hepatitis

BACKGROUND

Prednisone and azathioprine are effective in the treatment of autoimmune hepatitis, but diverse side effects can diminish their net benefit.

OBJECTIVES

Describe the frequency and nature of these side effects and propose management strategies to minimize their impact.

METHODS

Pertinent articles published from 1970 to 2007 were identified by Medline search and through a personal library.

RESULTS

Medication is prematurely discontinued in 13% of patients mainly because of cosmetic changes, cytopenia, or osteopenia. Populations at high risk are the elderly, those with pre-existent co-morbidities, patients with near-zero thiopurine methyltransferase activity, individuals who are treatment-dependent, pregnant women, and asymptomatic patients who are over-treated.

CONCLUSIONS

Proper patient selection, effective pre-treatment counseling, preemptive protective measures, realistic treatment objectives, and early identification of problematic patients can reduce complications. Individualized dosing schedules and the emergence of non-steroidal medications are realistic expectations.

Historical reflections on autoimmune hepatitis

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.

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.

Esteatohepatitis no alcohólica asociada a hiperplasia estromal ovárica

Alterations in liver function tests have previously been reported in patients with ovarian disease. We report the case of a woman with prolonged hypertransaminasemia, significant hirsutism and android phenotype who was diagnosed with nonalcoholic steatohepatitis and ovarian stromal hyperplasia.

Abnormal aminotransferase activity in women with polycystic ovary syndrome

Alanine aminotransferase (ALT) activity was abnormal in 30% of 70 female infertility patients with polycystic ovary syndrome in whom causes other than nonalcoholic fatty liver disease were excluded by history and serum testing. Women with elevated ALT had significantly higher body mass index, waist circumference, serum triglycerides, total cholesterol-to-HDL-cholesterol ratio, and degree of insulin resistance.

Henry Kunkel Festschrift

This Festschift by his former trainees is dedicated to the memory of Dr Henry G Kunkel. Dr Kunkel spent most of his academic life at The Rockefeller University. He has been called the father of Clinical Immunology. His trainees became professors and leaders in this field. Dr Kunkel's laboratory led to the elucidation of the immunology of the LE cell, the significance of anti-DNA and immune deposits in lupus nephritis, the recognition of antibodies to other nucleic acids and cellular constituents, the role of complement, genetics, hormones and cellular immunology--in the area of lupus and other rheumatic diseases.

Acute autoimmune hepatitis presenting with centrizonal liver disease: case report and review of the literature

Relatively little is known about the histological appearance of autoimmune hepatitis during the early stage of disease. We describe a case of autoimmune hepatitis in a 20-yr-old woman in which the initial liver biopsy was characterized by a marked predominance of centrizonal injury. Over the course of several months, the histological appearance evolved to what is more commonly associated with chronic autoimmune hepatitis. A review of the literature on this interesting entity is presented.

Pregnancy after liver transplantation

The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines.

Recent developments in autoimmune liver diseases

Several diseases are regarded as autoimmune liver diseases. Apart from the cholestatic liver diseases, primary biliary cirrhosis, primary sclerosing cholangitis, these include autoimmune hepatitis, hepatitis as part of the autoimmune polyendocrine syndrome type 1 (APS-1) and particular overlap syndromes such as autoimmune cholangitis (also called antimitochondrial antibody negative primary biliary cirrhosis [PBC]), overlap syndrome chronic active hepatitis (CAH)/PBC and the overlap syndrome primary sclerosing hepatitis (PSC)/CAH. In addition, auto-antibodies may be observed during the course of chronic viral hepatitis, in particular chronic hepatitis C and D. Finally, a small number of drug-induced liver diseases is immune mediated. The following article will review our recent progress in the field of autoimmune hepatitis including APS-1 and autoimmunity in viral hepatitis and immune-mediated drug-induced liver disease.

Reproductive function after liver transplantation

Successful pregnancy outcomes are possible after liver transplantation. Although there are risks to the mother and fetus, there has not been an increased incidence of malformations noted in the newborn of liver recipients. Close, coordinated care involving the hepatologist, surgeon, and high-risk obstetrician is essential to ensure a favorable outcome. Immunosuppression peripartum should be maintained at appropriate levels. Of note, a small subset of recipients may suffer worsened graft function during pregnancy. Recurrent liver disease, especially viral hepatitis, and CMV infection appear to pose significant risks to mother and offspring, respectively, although the magnitude of the risks is unknown. It therefore would seem prudent to consider pregnancy only in female liver recipients who have passed at least 1 year with stable graft function. In addition, new immunosuppressive regimens further add to the lack of information regarding pregnancy safety. The NTPR is an ongoing database to collect information and pregnancy outcomes. That information should be helpful in counseling recipients and in pregnancy management.

RENAL INVOLVEMENT IN ACTIVE "JUVENILE" CIRRHOSIS

Twelve patients with active ;juvenile' cirrhosis (active chronic hepatitis, ;lupoid' hepatitis) and six subjects with other types of portal or postnecrotic cirrhosis were submitted to percutaneous renal biopsy. In addition, renal function was assessed in all patients by measurement of the 24-hour endogenous creatinine clearance, maximal urinary osmolality after deprivation of water, 24-hour urinary protein excretion, and routine urine analysis. Renal function was not significantly abnormal in either group of patients, but seven of the 12 patients with active ;juvenile' cirrhosis showed mild histological changes on renal biopsy. These changes are very similar to the lesions described in early ;lupus nephritis'.The significance of these findings in relation to the aetiology of active ;juvenile' cirrhosis is discussed.

THE VALUE OF JIRGL'S FLOCCULATION TEST IN THE DIAGNOSIS OF JAUNDICE

Jirgl's serum flocculation reaction was examined in a series of 121 patients with varying types of liver disease. Positive results were found in 90% of patients with proven extrahepatic obstructive jaundice. Strongly positive reactions were also obtained in primary biliary cirrhosis and chlorpromazine jaundice. One out of three cases of ;cholestatic' hepatitis gave a weakly positive reaction and the test may be of value in the diagnosis of this condition and in the rare recurrent conjugated hyperbilirubinaemia in which it is also negative.Eighty-four per cent of cases of portal cirrhosis were negative and the finding of a positive result in this condition may indicate the presence of a hepatoma.No correlation could be found either in intra- or extrahepatic obstructive jaundice between the degree of flocculation present and the severity of the obstruction as judged by serum bilirubin and alkaline phosphatase levels.

Autoimmune hepatitis. Definition--classification--histopathology--immunopathogenesis

Autoimmune hepatitis (AIH) is a distinct form of acute and chronic inflammatory liver disease in which immune reactions against host antigens are found to be the major pathological mechanism. If left untreated it carries an unfavourable prognosis, and the diagnosis should be made as soon as possible. The diagnostic approach has been greatly facilitated by the establishment of a panel of marker autoantibodies, which do not define distinct therapeutic groups of AIH, but do allow a subgrouping based on differences in patient populations, some clinical features and prognosis. The characterization of organ-specific components of the liver cell surface as targets of cellular and humoral autoimmune reactions give new insights into the pathogenesis of the disease, even though the primary event triggering the disease remains to be defined. The most important disease-promoting factor seems to be a genetically determined background for autoimmunity. Without this different environmental factors, including viruses, toxins, cytokines and drugs, are only able to induce transient autoimmune phenomena and not autoimmune disease. The histopathology of AIH is in keeping with the present pathogenetic concept. Although there is no pathognomonic feature distinguishing this type of hepatitis from virus-induced forms, some distinct morphological lesions are regarded as characteristic. Clinical research on AIH has benefited greatly from observations of experimental AIH in mice. Recognition of the critical role of autoreactive T-lymphocytes in the pathogenesis and the observation of spontaneous recovery from AIH in the animal model associated with antigen-specific and antigen-non-specific T-cell suppression have made basic contributions to our improved understanding of the natural course of AIH in humans.

Diagnosis and therapy of autoimmune liver disease

The diagnostic criteria for autoimmune hepatitis have been codified by international consensus. Standardized clinical criteria or a scoring system that grades each relevant feature secure the diagnosis. Three types of autoimmune hepatitis have been proposed based on immunoserologic markers, but various forms exist. Multiple autoantibodies have diagnostic capability, but their clinical relevancy remains uncertain. Prednisone alone or in combination with azathioprine is effective therapy in most patients. Poor outcomes justify alternative strategies and evaluation of promising new drugs.