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Fawzy A, Sutton H, Vandriel SM, Sonnenberg M, Kamath BM. Outcomes and management in paediatric autoimmune hepatitis presenting as acute liver failure: Individual patient data meta-analysis. Liver Int 2024; 44:1797-1807. [PMID: 38700362 DOI: 10.1111/liv.15943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND AIMS Autoimmune hepatitis (AIH) in children presenting in acute liver failure (ALF) can be fatal and often requires liver transplantation (LTx). This individual patient data meta-analysis (IPD) aims to examine management and outcomes of this population, given the lack of large cohort studies on paediatric AIH first presenting as ALF (AIH-ALF). METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses of IPD statement using PubMed and Excerpta Medica dataBASE, and included English studies published between 2000 and 2020. The study included patients under 21 years of age, diagnosed with type 1 or 2 AIH and presenting with ALF. Data extracted included clinical and biochemical characteristics, interventions, and outcomes. RESULTS Three hundred and thirty eligible patients from 61 studies were identified, with an additional five patients from our institution. The majority were female (66.8%), with a median age of 10. Overall, 59.7% achieved native liver survival (NLS), 35% underwent LTx, and 5% died before LTx. The use of corticosteroids with non-steroid immunomodulators increased the likelihood of NLS by 2.5-fold compared to corticosteroids alone. AIH-1 was associated with 3.3-fold odds for NLS, compared to AIH-2. However, on multivariate analysis, only AIH-1 was identified as an independent predictor for NLS (OR 3.8 [95% CI 1.03-14.2], p = .04). CONCLUSION While corticosteroids and non-steroid immunomodulators treatment may offer enhanced probability of achieving NLS, treatment regimens for AIH-ALF may need to consider patient-specific factors, especially AIH type. This highlights the potential for NLS in AIH-ALF and suggest a need to identify biomarkers which predict the need for combination immunosuppression to avoid LTx.
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Affiliation(s)
- Aly Fawzy
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harry Sutton
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Shannon M Vandriel
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Mikayla Sonnenberg
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Spangmose AL, Jørgensen MH, Jakobsen C, Wewer V, Rod NH, Ingels H, Pinborg A, Malham M. Pre- and perinatal exposures associated with developing pediatric-onset immune-mediated inflammatory disease: A Danish nation-wide cohort study. J Autoimmun 2023; 136:103032. [PMID: 36996697 DOI: 10.1016/j.jaut.2023.103032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES We aimed to identify pre- and perinatal risk factors for developing pediatric-onset immune-mediated inflammatory (pIMID). METHODS This nation-wide, cohort study included all children born in Denmark from 1994 to 2014 identified from the Danish Medical Birth registry. Individuals were followed through 2014 and cross-linked to the continuously updated national socioeconomic and healthcare registers to obtain data on pre- and perinatal exposures (maternal age, educational level, smoking, maternal IMID, parity, mode of conception and delivery, plurality, child's sex, and birth season). The primary outcome was a pIMID diagnosis (inflammatory bowel disease, autoimmune hepatitis, primary sclerosing cholangitis, juvenile idiopathic arthritis, or systemic lupus erythematosus) before 18 years of age. Risk estimates were calculated using Cox proportional hazards model and presented by hazard ratios (HR) with 95% confidence intervals (95%CI). RESULTS We included 1,350,353 children with a follow-up time of 14,158,433 person-years. Among these, 2,728 were diagnosed with a pIMID. We found a higher risk of pIMID in children born to women with a preconception IMID diagnosis (HR: 3.5 [95%CI: 2.7-4.6]), children born by Caesarean section (HR: 1.2 [95%CI: 1.0-1.3]), and among females (1.5 [95%CI: 1.4-1.6]) than among children without these characteristics. Plural pregnancies were associated with a lower risk of pIMID than single pregnancies (HR: 0.7 [95%CI: 0.6-0.9]). CONCLUSIONS Our results indicate a high genetic burden in pIMID but also identifies intervenable risk factors, such as Cesarean section. Physicians should, keep this in mind when caring for high-risk populations and pregnant women previously diagnosed with an IMID.
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Affiliation(s)
- Anne Lærke Spangmose
- The Fertility Department, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Hørby Jørgensen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Christian Jakobsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescent and Adults, Copenhagen University Hospital, Hvidovre, Denmark
| | - Vibeke Wewer
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescent and Adults, Copenhagen University Hospital, Hvidovre, Denmark
| | - Naja Hulvej Rod
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Helene Ingels
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anja Pinborg
- The Fertility Department, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Malham
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescent and Adults, Copenhagen University Hospital, Hvidovre, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Abstract
Autoimmune hepatitis is an inflammatory disease of the liver of unknown cause that may progress to liver cirrhosis and end stage liver failure if diagnosis is overlooked and treatment delayed. The clinical presentation is often that of acute hepatitis, sometimes very severe; less frequently, it can be insidious or completely asymptomatic. The disease can affect people of any age and is more common in women; its incidence and prevalence seem to be on the rise worldwide. An abnormal immune response targeting liver autoantigens and inducing persistent and self-perpetuating liver inflammation is the pathogenic mechanism of the disease. A specific set of autoantibodies, increased IgG concentrations, and histological demonstration of interface hepatitis and periportal necrosis are the diagnostic hallmarks of autoimmune hepatitis. Prompt response to treatment with corticosteroids and other immunomodulatory drugs is almost universal and supports the diagnosis. The aims of treatment are to induce and maintain long term remission of liver inflammation. Treatment can often even reverse liver fibrosis, thus preventing progression to advanced cirrhosis and its complications. Most patients need lifelong maintenance therapy, and repeated follow-up in experienced hands improves the quality of care and quality of life for affected patients.
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Affiliation(s)
- Luigi Muratori
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Marco Lenzi
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
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Jansson S, Malham M, Wewer V, Rask CU. Psychiatric comorbidity in childhood onset immune-mediated diseases-A systematic review and meta-analysis. Acta Paediatr 2022; 111:490-499. [PMID: 34986519 DOI: 10.1111/apa.16246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/08/2021] [Accepted: 01/04/2022] [Indexed: 12/01/2022]
Abstract
AIM To estimate psychiatric comorbidity in childhood onset immune-mediated inflammatory diseases (IMID). METHODS The PRISMA guidelines were followed, and the protocol was registered at Prospero (ID: CRD42021233890). Literature was searched in PubMed, PsycINFO and Embase. Original papers on prevalence rates of diagnosed psychiatric disorders and/or suicide in paediatric onset inflammatory bowel disease (pIBD), rheumatic diseases (RD) and autoimmune liver diseases were selected. Pooled prevalence rates of psychiatric disorders (grouped according to ICD-10 criteria) within the various IMID were calculated using random-effects meta-analysis. Risk of bias was evaluated by the Newcastle-Ottawa scale. RESULTS Twenty-three studies were included; 13 describing psychiatric disorders in pIBD and 10 in RD. Anxiety and mood disorders were mostly investigated with pooled prevalence rates in pIBD of 6% (95% confidence interval (CI): 4%-9%) and 4% (95%CI: 2%-8%), respectively, in register-based studies, and 33% (95%CI: 25%-41%) and 18% (95%CI: 12%-26%), respectively, in studies using psychiatric assessment. In RD, rates were 13% (95%CI: 12%-15%) for anxiety disorders and 20% (95%CI: 15%-26%) for mood disorders based on psychiatric assessment. CONCLUSION Anxiety and depression are commonly reported in childhood onset IMID. Physicians should be attentive to mental health problems in these patients as they seem overlooked.
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Affiliation(s)
- Sabine Jansson
- The Pediatric Department Copenhagen University Hospital Hvidovre Denmark
- Department of Child and Adolescent Psychiatry Aarhus University Hospital Aarhus Denmark
| | - Mikkel Malham
- The Pediatric Department Copenhagen University Hospital Hvidovre Denmark
- The Pediatric Department Holbaek Hospital Holbaek Denmark
| | - Vibeke Wewer
- The Pediatric Department Copenhagen University Hospital Hvidovre Denmark
| | - Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Hospital Aarhus Denmark
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Haggård L, Glimberg I, Lebwohl B, Sharma R, Verna EC, Green PHR, Ludvigsson JF. High prevalence of celiac disease in autoimmune hepatitis: Systematic review and meta-analysis. Liver Int 2021; 41:2693-2702. [PMID: 34219350 DOI: 10.1111/liv.15000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous studies investigating the prevalence of celiac disease (CD) in individuals with autoimmune hepatitis (AIH) have shown highly variable results. We therefore aimed to examine the prevalence of CD in individuals with AIH. METHODS Two professional librarians searched PubMed, EMBASE, Cochrane and Web of Science Core Collection up until 7 February 2020. The search terms included 'celiac disease', 'celiac', 'transglutaminases', 'gluten', 'gliadin', 'EMA', 'TTG' and 'villous' combined with 'autoimmune', 'hepatitis', 'ANA', 'SMA' and 'LKM'. This search yielded 2419 unique publications. A systematic review based on the PRISMA guidelines resulted in 31 articles eligible for full text review. Fifteen articles were deemed relevant, with 8 being included in our main analysis. A fixed-effect inverse variance-weighted model was used, and heterogeneity was calculated. RESULTS Our main analysis included 567 individuals with AIH from eight studies, where biopsy-verified CD (equivalent to Marsh III) was seen in 23 individuals (4.1%). The pooled prevalence of CD in AIH was 3.5% (95% CI = 1.6%-5.3%) (heterogeneity: P = .874; I2 = 0.0%), which is clearly higher than the 1% CD seen in most general populations. When also including studies where CD had been diagnosed through positive serology without biopsy (15 studies: n = 1817 individuals with AIH), the pooled prevalence of CD was 2.9% (95% CI = 2.1%-3.8%) (heterogeneity: P < .001; I2 = 66.8%). CONCLUSION Our results demonstrate a higher prevalence of CD in individuals with AIH compared to the general population. CD screening may be considered in patients with AIH.
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Affiliation(s)
- Linnea Haggård
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ida Glimberg
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rajani Sharma
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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