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Morgan MA, Khot R, Sundaram KM, Ludwig DR, Nair RT, Mittal PK, Ganeshan DM, Venkatesh SK. Primary sclerosing cholangitis: review for radiologists. Abdom Radiol (NY) 2023; 48:136-150. [PMID: 36063181 PMCID: PMC9852001 DOI: 10.1007/s00261-022-03655-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 01/22/2023]
Abstract
Primary sclerosing cholangitis is a rare chronic inflammatory disease affecting the bile ducts, which can eventually result in bile duct strictures, cholestasis and cirrhosis. Patients are often asymptomatic but may present with clinical features of cholestasis. Imaging plays an important role in the diagnosis and management. This review covers the pathophysiology, clinical features, imaging findings as well as methods of surveillance and post-transplant appearance.
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Affiliation(s)
- Matthew A. Morgan
- Department of Radiology, University of Pennsylvania Health System, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA, USA
| | - Rachita Khot
- Radiology and Medical Imaging, University of Virginia Health, 1215 Lee Street, Charlottesville, VA, USA
| | - Karthik M. Sundaram
- Department of Radiology, University of Pennsylvania Health System, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA, USA
| | - Daniel R. Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, Saint Louis, MO, USA
| | - Rashmi T. Nair
- Department of Radiology, University of Kentucky, 800 Rose Street, Room HX 313B, Lexington, KY 40536-0293, USA
| | - Pardeep K. Mittal
- Medical College of Georgia at Augusta University, 1120 15th street BA −1411, Augusta, GA 30912, USA
| | - Dhakshina M. Ganeshan
- The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1473, Houston, TX 77030, USA
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Gomes NBN, Torres US, Ferraz MLCG, D'Ippolito G. Autoimmune hepatitis in practice, from diagnosis to complications: What is the role of imaging? A clinicoradiological review. Clin Imaging 2021; 74:31-40. [PMID: 33429144 DOI: 10.1016/j.clinimag.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022]
Abstract
Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease of unknown origin that can lead to liver cirrhosis, hepatocellular carcinoma (HCC), liver transplantation or death. The diagnosis is performed upon a multifactorial score. Treatment is based on the combination of immunosuppressants and aims at clinical, laboratory and histological remission, the latter being the most difficult to be achieved and proven. The absence of liver inflammation, defined by biopsy, is the main determinant in remission or therapeutic modification. Imaging exams have a limited role in this clinical management and the main findings are those related to chronic liver disease. Imaging's relevance, therefore, lies mainly in helping to exclude overlapping syndromes and in assessing complications related to cirrhosis, such as in screening for HCC. In recent years, however, the radiological literature has been witnessing increasing advances with regard to imaging biomarkers in liver disease, leading some authors to consider a future of virtual liver biopsy performed by magnetic resonance imaging. The present study aims to review the role of imaging in the management of AIH in the light of recent advances in the current literature and to provide an illustrated guide with the main findings described in the disease.
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Affiliation(s)
- Natália Borges Nunes Gomes
- Fleury Group, São Paulo, Brazil; Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Ulysses S Torres
- Fleury Group, São Paulo, Brazil; Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.
| | | | - Giuseppe D'Ippolito
- Fleury Group, São Paulo, Brazil; Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Zizzo AN, Jimenez-Rivera C, Kim J, Schreiber RA, Ling SC, Yap J, Critch J, Ahmed N, Alvarez F, Kamath BM. A national retrospective study of paediatric end-stage liver disease as a predictor of change to second-line therapy in children with autoimmune hepatitis. Liver Int 2017; 37:1562-1570. [PMID: 28199778 DOI: 10.1111/liv.13387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 02/05/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Adult studies of autoimmune hepatitis (AIH) have shown that the model of end-stage liver disease is associated with resistance to first-line treatment. Using a multicentre retrospective database, we sought to determine if the paediatric end-stage liver disease (PELD) score would similarly predict treatment resistance in paediatric AIH. METHODS One hundred and seventy-one children from 13 Canadian centres who fulfilled the International Autoimmune Hepatitis Group (IAIHG) criteria were included and assessed for change to second-line therapy within 24 months of primary treatment onset. Those with PSC overlap at presentation, or missing data on the PELD variables were excluded. PELD was calculated for all remaining patients. Univariate analysis and receiver-operator characteristic (ROC) curves were performed to determine the predictive ability of the PELD score to change to second-line therapy. RESULTS A total of 103 children were included with median age of 11 years (range 2-17). Mean PELD was -2.51±8.58. Second-line therapy was used within 24 months of diagnosis in 13 patients. Univariate analysis revealed that change to second-line therapy was associated with higher PELD (P=.028) and internal normalized ratio (INR) (P=.011). ROC curves for PELD and its individual components were performed. The strength of association was strongest with INR (AUC 0.72; CI: 0.58-0.86) although the composite PELD score also showed some predictive ability (AUC 0.67; CI: 0.52-0.81). CONCLUSION In this paediatric AIH cohort, higher PELD at presentation predicted change to second-line therapy within the first 2 years of follow-up. INR appeared to be the main contributor to that association.
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Affiliation(s)
- Andréanne N Zizzo
- Division of Gastroenterology, Department of Paediatrics, London Children's Hospital, Western University, London, ON, Canada
| | - Carolina Jimenez-Rivera
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Joseph Kim
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Richard A Schreiber
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada.,Child and Family Research Institute, Vancouver, BC, Canada
| | - Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Jason Yap
- Division of Paediatric Gastroenterology and Nutrition, Department of Paediatrics, University of Alberta, Edmonton, AB, Canada
| | - Jeff Critch
- Department of Paediatrics, Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Najma Ahmed
- Division of Paediatric Gastroenterology and Nutrition, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Fernando Alvarez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Hôpital Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Bajer L, Kverka M, Kostovcik M, Macinga P, Dvorak J, Stehlikova Z, Brezina J, Wohl P, Spicak J, Drastich P. Distinct gut microbiota profiles in patients with primary sclerosing cholangitis and ulcerative colitis. World J Gastroenterol 2017; 23:4548-4558. [PMID: 28740343 PMCID: PMC5504370 DOI: 10.3748/wjg.v23.i25.4548] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/10/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize the gut bacterial microbiota of patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC).
METHODS Stool samples were collected and relevant clinical data obtained from 106 study participants, 43 PSC patients with (n = 32) or without (n = 11) concomitant inflammatory bowel disease, 32 UC patients, and 31 healthy controls. The V3 and V4 regions of the 16S ribosomal RNA gene were sequenced on Illumina MiSeq platform to cover low taxonomic levels. Data were further processed in QIIME employing MaAsLin and LEfSe tools for analysis of the output data.
RESULTS Microbial profiles in both PSC and UC were characterized by low bacterial diversity and significant change in global microbial composition. Rothia, Enterococcus, Streptococcus, Veillonella, and three other genera were markedly overrepresented in PSC regardless of concomitant inflammatory bowel disease (IBD). Rothia, Veillonella and Streptococcus were tracked to the species level to identify Rothia mucilaginosa, Streptococcus infantus, S. alactolyticus, and S. equi along with Veillonella parvula and V. dispar. PSC was further characterized by decreased abundance of Adlercreutzia equolifaciens and Prevotella copri. Decrease in genus Phascolarctobacterium was linked to presence of colonic inflammation regardless of IBD phenotype. Akkermansia muciniphila, Butyricicoccus pullicaecorum and Clostridium colinum were decreased in UC along with genus Roseburia. Low levels of serum albumin were significantly correlated with enrichment of order Actinomycetales.
CONCLUSION PSC is associated with specific gut microbes independently of concomitant IBD and several bacterial taxa clearly distinguish IBD phenotypes (PSC-IBD and UC).
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Liu XM, Xu Y, Bao J, Gao SJ, Hua J, Kang GL. Ursodeoxycholic acid combined with glucocorticoids for treatment of primary biliary cirrhosis with characteristics of autoimmune hepatitis. Shijie Huaren Xiaohua Zazhi 2017; 25:456-462. [DOI: 10.11569/wcjd.v25.i5.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To observe the efficacy of ursodeoxycholic acid (UDCA) combined with glucocorticoids in the treatment of primary biliary cirrhosis (PBC) with characteristics of autoimmune hepatitis (AIH).
METHODS Thirty-one patients with PBC with AIH characteristics were divided into two group: a UDCA alone group and a UDCA combined with glucocorticoid group. Blood biochemical indexes before and after treatment were retrospectively analyzed. Immunoglobulin indexes, liver pathological changes, and the status of response to treatment were also observed.
RESULTS In both groups, the levels of alkaline phosphatase (ALP), γ-glutamyl transferase (GGT) and immunoglobulin M (IgM) decreased after therapy, and the improvement of ALP and IgM had statistical significance (P < 0.05). In the combination group, alanine transaminase, aspartate transaminase, GGT, ALP, globulin, and immunoglobulin obviously improved compared with baseline values. Biochemical responses showed no significant difference between the two groups, although the combination group had a higher response rate. In patients with different pathological stages of disease, ALP response rate was statistically significant (P < 0.05). The degree and extent of liver inflammation or fibrosis and bile duct damage significantly improved after treatment in the combination group.
CONCLUSION For patients with PBC with AIH characteristics, a definitive diagnosis should be achieved as early as possible. UDCA plus glucocorticoid treatment is recommended to better control the progression of the disease.
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Abstract
Autoimmune hepatitis (AIH) is an uncommon, chronic inflammatory, and relapsing liver disease of unknown origin that may lead to liver cirrhosis, hepatocellular carcinoma, liver transplantation, or death. AIH occurs in all age groups and races but can frequently manifest as acute fulminant hepatitis. Clinical presentation of AIH can have features similar to primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), and these diseases may coexist leading to overlap syndromes. Although histological diagnosis is necessary, imaging features often can demonstrate characteristics that may be helpful to distinguish these diseases. Imaging features of AIH are those of chronic liver disease, and imaging plays important role in detection of complications and ruling out other possible causes of chronic liver disease. Emerging techniques such as elastography provide non-invasive options for diagnosis of significant fibrosis and cirrhosis during clinical follow-up as well as assessment of response to treatment. In this study, we will describe imaging findings in AIH and overlap syndromes.
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Abstract
Historically, liver biopsy has been used to determine the etiology of liver disease, the degree of inflammation, the stage of liver fibrosis, and the response to treatments. In the last decade, the advent of noninvasive tests has improved the diagnosis and management of autoimmune liver diseases. For example, serum markers can identify hepatic inflammation, whereas ultrasound and MRI can diagnose liver fibrosis. Physicians now have a much larger repertoire of diagnostic tests to assess the liver parenchyma compared with liver biopsy alone. In some rare cases, noninvasive tests may provide an alternative to liver biopsy. In general, however, these noninvasive tests complement liver biopsy and provide quick, accurate, and reliable adjunctive data.
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Bessone F, Poles N, Roma MG. Challenge of liver disease in systemic lupus erythematosus: Clues for diagnosis and hints for pathogenesis. World J Hepatol 2014; 6:394-409. [PMID: 25018850 PMCID: PMC4081614 DOI: 10.4254/wjh.v6.i6.394] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/08/2014] [Accepted: 05/14/2014] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) encompass a broad spectrum of liver diseases. We propose here to classify them as follows: (1) immunological comorbilities (overlap syndromes); (2) non-immunological comorbilities associated to SLE; and (3) a putative liver damage induced by SLE itself, referred to as "lupus hepatitis". In the first group, liver injury can be ascribed to overlapping hepatopathies triggered by autoimmune mechanisms other than SLE occurring with higher incidence in the context of lupus (e.g., autoimmune hepatitis, primary biliary cirrhosis). The second group includes non-autoimmune liver diseases, such as esteatosis, hepatitis C, hypercoagulation state-related liver lesions, hyperplasic parenchymal and vascular lesions, porphyria cutanea tarda, and drug-induced hepatotoxicity. Finally, the data in the literature to support the existence of a hepatic disease produced by SLE itself, or the occurrence of a SLE-associated prone condition that increases susceptibility to acquire other liver diseases, is critically discussed. The pathological mechanisms underlying each of these liver disorders are also reviewed. Despite the high heterogeneity in the literature regarding the prevalence of SLE-associated liver diseases and, in most cases, lack of histopathological evidence or clinical studies large enough to support their existence, it is becoming increasingly apparent that liver is an important target of SLE. Consequently, biochemical liver tests should be routinely carried out in SLE patients to discard liver disorders, particularly in those patients chronically exposed to potentially hepatotoxic drugs. Diagnosing liver disease in SLE patients is always challenging, and the systematization of the current information carried out in this review is expected to be of help both to attain a better understanding of pathogenesis and to build an appropriate work-up for diagnosis.
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Affiliation(s)
- Fernando Bessone
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
| | - Natalia Poles
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
| | - Marcelo G Roma
- Fernando Bessone, Natalia Poles, Gastroenterology and Hepatology Department, University of Rosario School of Medicine, Rosario 2000, Argentina
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Abstract
BACKGROUND Primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap syndrome is used to describe the coexistence of both diseases, with either a sequential or a simultaneous presentation in the same patient. Available studies have focused on the simultaneous form, whereas there is limited information on sequential PBC-AIH. We carried out a retrospective study of patients who sequentially developed PBC-AIH overlap syndrome. METHODS The medical data of 1065 patients diagnosed with PBC (n=483) and AIH (n=582) were retrospectively analyzed. RESULTS A sequential development of PBC-AIH was observed in 19 (1.8%) patients after a mean of 6.5 (1-14) years of follow-up. AIH developed in 12 (2.5%) PBC patients, whereas PBC occurred in seven (1.2%) patients with AIH. The baseline serologic and histological findings of patients who developed PBC-AIH were similar to those of patients with typical PBC or AIH. Eighteen patients were treated with a combination of ursodeoxycholic acid (UDCA) and immunosuppression after the diagnosis of PBC-AIH was established. One patient showed a spontaneous resolution of hepatitic flare under UDCA therapy. Biochemical remission was achieved in 16 patients, whereas three progressed to decompensated cirrhosis and required liver transplantation. CONCLUSION The sequential overlap of PBC-AIH can occur during the follow-up of patients with pure PBC or AIH. In our cohort, we could not identify any factors that predicted the development of this rare condition. The combination of UDCA and immunosuppression seems to be an appropriate therapy in the setting of PBC-AIH.
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Abstract
Overlap syndrome in hepatology is emerging as a diagnostic and therapeutic challenge, which is further complicated by the present gaps in the information regarding the immunopathogenesis of these diseases. The present review represents a concise review of literature on overlap syndromes with emphasis on prevalence, etiopathogenesis, clinical presentation, diagnosis, and management of true overlap syndromes.
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Affiliation(s)
- Pooja Dhiman
- Department of Biochemistry, JIPMER, Dhanvantari Nagar, Puducherry, India
| | - Sharad Malhotra
- Department of Medical Gastroenterology, Batra Hospital and Medical Research Centre, New Delhi, India,Address for correspondence: Dr. Sharad Malhotra, Consultant, Medical Gastroenterology, Batra Hospital and Medical Research Centre, New Delhi, India. E-mail:
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Type 2 autoimmune hepatitis overlapping with primary sclerosing cholangitis in a 10-year-old boy. Arch Pediatr 2013; 20:1325-8. [PMID: 24182664 DOI: 10.1016/j.arcped.2013.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/08/2013] [Accepted: 09/19/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Overlap syndrome of autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) is considered when the patient presents with the diagnostic criteria of both diseases at some stage of the medical history, either simultaneously or consecutively. AIM To report on a new case of overlap syndrome and describe the clinical presentation, progression, radiological studies, histological characteristics, and therapeutic options of this rare association. CASE REPORT A 10-year-old boy presented with jaundice and hepatosplenomegaly. Levels of plasma aminotransferases, gamma-glutamyl transferase, serum alkaline phosphatase and gammaglobulins were elevated. Anti-liver cytosol and perinuclear antineutrophilic cytoplasmic antibodies were positive. Liver biopsy showed features of interface hepatitis with ductopenia. Magnetic resonance cholangiography revealed bile duct stenosis and dilations. Serological findings associated with radiological and histological features confirmed the diagnosis of overlap syndrome of AIH with PSC. Treatment with prednisone, azathioprine, and ursodeoxycholic acid led to a good response. CONCLUSION The possibility of AIH-PSC overlap syndrome should be considered in all children with AIH and, with clinical, biochemical, or histological signs of PSC, complementary investigations should be done to confirm the diagnosis so as to urgently initiate appropriate treatment with immunosuppressive medication and ursodeoxycholic acid.
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Korkmaz H, Bugdaci MS, Temel T, Dagli M, Karabagli P. Autoimmune hepatitis-primary biliary cirrhosis overlap syndrome concomitant with immune hemolytic anemia and immune thrombocytopenic purpura (Evans syndrome). Clin Res Hepatol Gastroenterol 2013; 37:e45-50. [PMID: 23273499 DOI: 10.1016/j.clinre.2012.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/03/2012] [Accepted: 11/06/2012] [Indexed: 02/04/2023]
Abstract
Autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) associated with Evans syndrome; combination of autoimmune hemolytic anemia (AIHA) and immune thrombocytopenic purpura (ITP) has rarely been reported. We report the case of a 53-year-old patient who presented with weakness, myalgia, arthralgia, shortness of breath and purpura. Initial laboratory investigations revealed liver dysfunction, anemia and thrombocytopenia. Anti-nuclear (ANA) and antimitochondrial M2 (AMA M2) antibodies were positive. Diagnose of PBC-AIH overlap was made by clinical, serological and histological investigations. AIHA and ITP was identified with clinical-laboratory findings and bone marrow puncture. She was treated with IVIG followed by prednisolone and ursodeoxycholic acid. Hemoglobin-thrombocytes increased rapidly and transaminases improved at day 8. We have reported the first case in the literature with AIH-PBC overlap syndrome concurrent by ITP and AIHA which suggest the presence of shared genetic susceptibility factors in multiple autoimmune conditions including AIH, PBC, ITP and AIHA.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/blood
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Antibodies, Antinuclear/blood
- Autoantibodies/blood
- Cholagogues and Choleretics/therapeutic use
- Female
- Glucocorticoids/therapeutic use
- Hepatitis, Autoimmune/blood
- Hepatitis, Autoimmune/diagnosis
- Hepatitis, Autoimmune/drug therapy
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Liver Cirrhosis, Biliary/blood
- Liver Cirrhosis, Biliary/diagnosis
- Liver Cirrhosis, Biliary/drug therapy
- Middle Aged
- Mitochondria, Liver/immunology
- Prednisolone/therapeutic use
- Thrombocytopenia/blood
- Thrombocytopenia/diagnosis
- Thrombocytopenia/drug therapy
- Ursodeoxycholic Acid/therapeutic use
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Affiliation(s)
- Huseyin Korkmaz
- Selcuk University, Selcuklu medical faculty, department of internal medicine division of Gastroenterohepatology, Selcuklu, Konya, Turkey.
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Mitra S, Nayak PK, Padma A, Kurian G. Successful Pregnancy in Autoimmune Hepatitis/Primary Biliary Cirrhosis Overlap Syndrome: A Case Report. Gastroenterology Res 2012; 5:208-210. [PMID: 27785208 PMCID: PMC5051104 DOI: 10.4021/gr485w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 12/15/2022] Open
Abstract
Medical literature on pregnancy outcomes in hepatic overlap syndromes is limited. Autoimmune liver diseases are associated with sub-fertility and pregnancy is usually dissuaded in presence of portal hypertension and cirrhosis due to guarded prognosis for the pregnancy as well as the liver disease. We report a 24-year-old primigravida with autoimmune hepatitis/primary biliary cirrhosis overlap syndrome who had a successful pregnancy owing to intensive monitoring and meticulous treatment with drugs like immunosuppressants and ursodeoxycholic acid. She developed preterm prelabour rupture of membranes and delivered at 35 weeks without any major obstetric or hepatic complications.
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Affiliation(s)
- Subarna Mitra
- Pondicherry Institute Of Medical Sciences, Medical faculty, Obstetrics and Gynecology, Pondicherry, India
| | - Prasanta Kumar Nayak
- Pondicherry Institute Of Medical Sciences, Medical faculty, Obstetrics and Gynecology, Pondicherry, India
| | - Alaganandam Padma
- Pondicherry Institute Of Medical Sciences, Medical faculty, Obstetrics and Gynecology, Pondicherry, India
| | - George Kurian
- Pondicherry Institute Of Medical Sciences, Medical faculty, Gastroenterology, Pondicherry, India
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Zhao P, Han Y. Low incidence of positive smooth muscle antibody and high incidence of isolated IgM elevation in Chinese patients with autoimmune hepatitis and primary biliary cirrhosis overlap syndrome: a retrospective study. BMC Gastroenterol 2012; 12:1. [PMID: 22214224 PMCID: PMC3264530 DOI: 10.1186/1471-230x-12-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 01/03/2012] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED : BACKGROUND Up to now, few data are available regarding the clinical characteristics of autoimmune hepatitis and primary biliary cirrhosis overlap syndrome. The study was to investigate and analyze the prevalent and clinical features of Chinese patients with this disease. METHODS Clinical data on patients diagnosed as autoimmune hepatitis and primary biliary cirrhosis overlap syndrome in our hospital from January 2001 to December 2006 were collected and analyzed. RESULTS Overlap syndrome of autoimmune hepatitis and primary biliary cirrhosis accounted for 10.33% of patients with autoimmune liver diseases during the past six years. For these patients with overlap syndrome, xanthochromia, lethargy and anorexia were the predominant complaints; a low incidence (14/146) of smooth muscle antibody positivity and a high incidence (37/89) of isolated IgM elevation were the main serological characteristics. CONCLUSIONS Overlap syndrome of autoimmune hepatitis and primary biliary cirrhosis was not rare in Chinese patients with clinical manifests of autoimmune liver diseases. Overlap of the diseases should not be disregarded when isolated IgM elevation was exhibited, and smooth muscle antibody might have little diagnostic significance in the overlap syndrome. If it was difficult to make a definite diagnosis, liver biopsy was necessary.
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Affiliation(s)
- Pan Zhao
- Case-history Office, Beijing 302 Hospital, Beijing 100039, China
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In search of sustainable chemical processes: cloning, recombinant expression, and functional characterization of the 7α- and 7β-hydroxysteroid dehydrogenases from Clostridium absonum. Appl Microbiol Biotechnol 2011; 95:1221-33. [PMID: 22198717 DOI: 10.1007/s00253-011-3798-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 11/23/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
Abstract
Nicotinamide adenine dinucleotide phosphate-dependent 7α-hydroxysteroid dehydrogenase (7α-HSDH) and 7β-hydroxysteroid dehydrogenases (7β-HSDH) from Clostridium absonum catalyze the epimerization of primary bile acids through 7-keto bile acid intermediates and may be suitable as biocatalysts for the synthesis of bile acids derivatives of pharmacological interest. C. absonum 7α-HSDH has been purified to homogeneity and the N-terminal sequence has been determined by Edman sequencing. After PCR amplifications of a gene fragment with degenerate primers, cloning of the complete gene (786 nt) has been achieved by sequencing of C. absonum genomic DNA. The sequence coding for the 7β-HSDH (783 nt) has been obtained by sequencing of the genomic DNA region flanking the 5' termini of 7α-HSDH gene, the two genes being contiguous and presumably part of the same operon. After insertion in suitable expression vectors, both HSDHs have been successfully produced in recombinant form in Escherichia coli, purified by affinity chromatography and submitted to kinetic analysis for determination of Michaelis constants (K (m)) and specificity constants (k (cat)/K (m)) in the presence of various bile acids derivatives. Both enzymes showed a very strong substrate inhibition with all the tested substrates. The lowest K (S) values were observed with chenodeoxycholic acid and 12-ketochenodeoxycholic acid as substrates in the case of 7α-HSDH, whereas ursocholic acid was the most effective inhibitor of 7β-HSDH activity.
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Tanaka A, Harada K, Ebinuma H, Komori A, Yokokawa J, Yoshizawa K, Abe M, Miyake Y, Kikuchi K, Ohira H, Zeniya M, Yamamoto K, Ishibashi H, Onji M, Nakanuma Y, Tsubouchi H, Takikawa H. Primary biliary cirrhosis - Autoimmune hepatitis overlap syndrome: A rationale for corticosteroids use based on a nation-wide retrospective study in Japan. Hepatol Res 2011; 41:877-86. [PMID: 21883738 DOI: 10.1111/j.1872-034x.2011.00844.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS Primary biliary cirrhosis (PBC) and autoimmune hepatitis (AIH) may simultaneously coexist in some patients, designated as PBC-AIH overlap syndrome. Previous studies suggest that combination therapy of ursodeoxycholic acid (UDCA) and corticosteroids may be effective. In the current study, we aimed to describe clinical features of these cases and to propose a rationale for combination treatment in PBC-AIH overlap. METHODS We enrolled patients with PBC-AIH overlap from eight referral centers for liver diseases in Japan, and clinical, biochemical and immunological features were examined. Liver histology of all patients at diagnosis were analyzed altogether in detail. Eighty-nine and 44 patients with PBC and AIH alone were included and served as controls. RESULTS We identified 33 patients with PBC-AIH overlap. The mean follow-up period was 6.1 years. On liver histology, the HA (hepatitis activity) score was significantly higher than the CA (cholangitis activity) score (P < 0.001). At the end of the follow-up period, corticosteroids were used in 23 patients (72%), and neither liver-related death nor liver transplantation had been noted. The sensitivity and specificity of the simplified AIH scoring system for prediction of patients who required corticosteroids during clinical course was 92% and 75% in the training set (n = 17), and 91% and 80% in the validation set (n = 16) of overlap. Only 3% of PBC patients were diagnosed as having indication for corticosteroid use. CONCLUSION In PBC-AIH overlap, AIH-like features are dominant in liver histology. The simplified AIH scoring system could predict patients who needed corticosteroids with a higher specificity.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa Department of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo Clinical Research Center, NHO Nagasaki Medical Center, Omura Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Fukushima Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama The 4th Department of Internal Medicine, Teikyo University, School of Medicine, Kanagawa Division of Gastroenterology and Hepatology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo Department of Digestive and Life-Style Related Disease, Health Research Course, Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Comparison of simplified score with the revised original score for the diagnosis of autoimmune hepatitis: a new or a complementary diagnostic score? Dig Liver Dis 2010; 42:807-12. [PMID: 20399157 DOI: 10.1016/j.dld.2010.03.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 12/24/2009] [Accepted: 03/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The International Autoimmune Hepatitis Group developed a simplified score for autoimmune hepatitis. We assessed this "new scoring system" and compared it with the International Autoimmune Hepatitis Group original revised score. METHODS 502 patients were evaluated namely, 428 had liver diseases of various etiology [hepatitis B (n=109), hepatitis C (n=100), hepatitis D (n=4), alcoholic liver disease (n=28), non-alcoholic fatty liver disease (n=55), autoimmune cholestatic diseases (n=77), liver disorders of undefined origin (n=32) and miscellaneous hepatic disorders (n=23)], 13 had autoimmune hepatitis/overlap syndromes, 18 had autoimmune hepatitis/concurrent with other liver diseases and 43 had autoimmune hepatitis. RESULTS The specificity of the simplified score was similar to that of the revised score (97% vs. 97.9%). The sensitivity in unmasking autoimmune hepatitis in autoimmune hepatitis/overlap syndromes was also similar in both systems (53.8% and 61.5%). However, the sensitivity for autoimmune hepatitis diagnosis in autoimmune hepatitis patients with concurrent liver disorders was lower by the new score (p=0.001). Liver biopsy proved to be the only independent factor for unmasking autoimmune hepatitis component among patients (p=0.003). CONCLUSION The simplified score is a reliable and simple tool for excluding autoimmune hepatitis. However, both systems cannot unmask autoimmune hepatitis component efficiently in autoimmune hepatitis patients with concurrent autoimmune or non-autoimmune liver diseases. This study also strongly reiterates the importance of liver biopsy in the work-up of patients.
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Membranous glomerulonephritis associated with autoimmune hepatitis and primary biliary cirrhosis overlap syndrome: a very rare condition. Eur J Gastroenterol Hepatol 2010; 22:1149-50. [PMID: 20164780 DOI: 10.1097/meg.0b013e3283379768] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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19
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Efe C, Ozaslan E, Nasiroglu N, Tunca H, Purnak T, Altiparmak E. The development of autoimmune hepatitis and primary biliary cirrhosis overlap syndrome during the course of connective tissue diseases: report of three cases and review of the literature. Dig Dis Sci 2010; 55:2417-21. [PMID: 19826950 DOI: 10.1007/s10620-009-0996-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/15/2009] [Indexed: 12/15/2022]
MESH Headings
- Adult
- Angiotensin-Converting Enzyme Inhibitors
- Cholagogues and Choleretics/therapeutic use
- Cholangitis, Sclerosing/complications
- Cholangitis, Sclerosing/drug therapy
- Female
- Hepatitis, Autoimmune/complications
- Hepatitis, Autoimmune/drug therapy
- Humans
- Immunosuppressive Agents/therapeutic use
- Liver Cirrhosis, Biliary/complications
- Liver Cirrhosis, Biliary/drug therapy
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/drug therapy
- Middle Aged
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/drug therapy
- Sjogren's Syndrome/complications
- Sjogren's Syndrome/drug therapy
- Ursodeoxycholic Acid/therapeutic use
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Numune Education and Training Hospital, Ankara, Turkey.
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Cabibi D, Tarantino G, Barbaria F, Campione M, Craxì A, Di Marco V. Intrahepatic IgG/IgM plasma cells ratio helps in classifying autoimmune liver diseases. Dig Liver Dis 2010; 42:585-92. [PMID: 20060371 DOI: 10.1016/j.dld.2009.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 11/25/2009] [Accepted: 12/13/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Plasma cells infiltrate in the liver is a prototype lesion of autoimmune liver diseases. The possible role of plasma cells isotyping (IgM and IgG) in the liver in the diagnostic definition of autoimmune liver disease, and particularly in variant syndromes such as autoimmune cholangitis and the primary biliary cirrhosis/autoimmune hepatitis overlap syndrome, is less defined. METHODS We analysed the clinical, serological and histological features of 83 patients with autoimmune liver disease (40 primary biliary cirrhosis, 20 autoimmune hepatitis, 13 primary sclerosing cholangitis, 4 autoimmune cholangitis and 6 overlap syndrome) compared to 34 patients with chronic hepatitis C and evaluated the expression of IgM and IgG plasma cells in their liver by immunostaining. RESULTS By Spearman's correlation, the mean-counts of IgM plasma cells in portal tracts were significantly correlated with female gender, serum alkaline phosphatase, gamma-glutamyl transferase and IgM values, positivity for anti-mitochondrial antibody-M2 and, on liver biopsy, with bile duct changes, orcein-positive granules and granulomas. Whereas IgG plasma cells resulted more correlated with alanine aminotransferase levels. IgG/IgM ratio lower than 1 was found no only in primary biliary cirrhosis but also in all patients with autoimmune cholangitis. Conversely, all patients with overlap syndrome showed IgG/IgM ratio higher than 1. CONCLUSION Immunostaining for IgM and IgG plasma cells on liver tissue can be a valuable parameter for better diagnosis of autoimmune liver disease and also for variant or mixed syndromes.
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Affiliation(s)
- Daniela Cabibi
- Dipartimento di Patologia Umana, University of Palermo, Italy.
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21
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Lee H, Stapp RT, Ormsby AH, Shah VV. The usefulness of IgG and IgM immunostaining of periportal inflammatory cells (plasma cells and lymphocytes) for the distinction of autoimmune hepatitis and primary biliary cirrhosis and their staining pattern in autoimmune hepatitis-primary biliary cirrhosis overlap syndrome. Am J Clin Pathol 2010; 133:430-7. [PMID: 20154281 DOI: 10.1309/ajcpe93gzshuntai] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Autoimmune hepatitis (AIH)-primary biliary cirrhosis (PBC) overlap syndrome (OS) is a vaguely defined entity demonstrating features of AIH and PBC. We investigated the usefulness of IgG and IgM immunostaining for the distinction of AIH and PBC and their staining pattern in cases of possible OS. The approximate quantity of IgG+ and IgM+ periportal inflammatory cells in immunohistochemical analysis were compared in cases of AIH, PBC, and OS. AIH cases showed predominant IgG immunostaining of periportal inflammatory cells. A significant number of PBC cases also demonstrated IgG predominance rather than IgM. Six OS cases had IgG predominance, 4 had IgM predominance, and 1 was equivocal. The usefulness of IgG and IgM immunostaining is limited in PBC cases with IgM predominance for excluding AIH. IgG predominance is not specific for AIH. OS does not demonstrate either IgG or IgM predominance (P > .2) and does not help classify OS into either category.
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22
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Zepeda-Gomez S, Montaño-Loza A, Zapata-Colindres JC, Paz F, Olivera-Martinez M, López-Reyes A, Granados J, Vargas-Alarcón G. HLA-DR Allele Frequencies in Mexican Mestizos with Autoimmune Liver Diseases Including Overlap Syndromes. Immunol Invest 2009; 38:276-83. [DOI: 10.1080/08820130902846282] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Georgiadou SP, Zachou K, Liaskos C, Gabeta S, Rigopoulou EI, Dalekos GN. Occult hepatitis B virus infection in patients with autoimmune liver diseases. Liver Int 2009; 29:434-42. [PMID: 18694399 DOI: 10.1111/j.1478-3231.2008.01851.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Occult hepatitis B virus (HBV) infection is characterized by undetectable serum HBV surface antigen (HBsAg) but detectable HBV-DNA in serum or liver. AIMS To determine the prevalence and clinical impact of occult HBV in autoimmune liver diseases as similar data are missing. METHODS One hundred and ninety-six sera samples from HBsAg-negative patients, including 66 autoimmune hepatitis (AIH), 93 primary biliary cirrhosis (PBC) and 37 primary sclerosing cholangitis (PSC), were investigated for HBV-DNA using the polymerase chain reaction (PCR) before treatment initiation. One hundred and three serial samples from 38 AIH patients under immunosuppression and 282 selected blood donors (HBsAg negative; antibodies to HBV-core antigen positive) were also investigated. Fourteen available paraffin-embedded AIH liver samples were also investigated for HBV-DNA by nested-PCR. RESULTS Hepatitis B virus DNA was detected in the serum of 24/196 patients (12.2%) and 0/282 donors (P=0.0000). Nine patients had AIH (13.6%), eight had PBC (8.6%) and seven had PSC (18.9%) (P=0.0000 vs healthy). HBV-DNA detection in AIH livers was higher than in serum. HBV-DNA was associated neither with HBV markers nor with epidemiological, laboratory and clinical data. Serial testing of AIH patients revealed two HBV-DNA-negative patients before treatment becoming positive during treatment, while all HBV-DNA-positive patients before immunosuppression became negative. CONCLUSION Based mainly on serum HBV-DNA, we found a significant proportion of autoimmune liver disease patients with occult HBV compared with donors. However, taking into account our results in a small number of liver tissues, it should be emphasized that occult HBV could be even higher when both serum and liver specimens are investigated. Occult HBV does not seem to affect the clinical and laboratory features of the diseases, while AIH patients with occult HBV under immunosuppression do not deteriorate during follow-up.
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Affiliation(s)
- Sarah P Georgiadou
- Department of Medicine, Academic Liver Unit, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Larissa, Greece
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24
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Wendum D. [Primary biliary cirrhosis and the overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis]. Ann Pathol 2008; 28 Spec No 1:S54-5. [PMID: 18984300 DOI: 10.1016/j.annpat.2008.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Dominique Wendum
- Service d'anatomie pathologique, faculté de médecine Pierre-et-Marie-Curie Paris-6, hôpital Saint-Antoine, UPMC, AP-HP, 184, rue du faubourg Saint-Antoine, 75012 Paris, France.
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25
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Abstract
The three major immune disorders of the liver are autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). Variant forms of these diseases are generally called overlap syndromes, although there has been no standardized definition. Patients with overlap syndromes present with both hepatitic and cholestatic serum liver tests and have histological features of AIH and PBC or PSC. The AIH-PBC overlap syndrome is the most common form, affecting almost 10% of adults with AIH or PBC. Single cases of AIH and autoimmune cholangitis (AMA-negative PBC) overlap syndrome have also been reported. The AIH-PSC overlap syndrome is predominantly found in children, adolescents and young adults with AIH or PSC. Interestingly, transitions from one autoimmune to another have also been reported in a minority of patients, especially transitions from PBC to AIH-PBC overlap syndrome. Overlap syndromes show a progressive course towards liver cirrhosis and liver failure without treatment. Therapy for overlap syndromes is empiric, since controlled trials are not available in these rare disorders. Anticholestatic therapy with ursodeoxycholic acid is usually combined with immunosuppressive therapy with corticosteroids and/or azathioprine in both AIH-PBC and AIH-PSC overlap syndromes. In end-stage disease, liver transplantation is the treatment of choice.
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26
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Card TR, Solaymani-Dodaran M, West J. Incidence and mortality of primary sclerosing cholangitis in the UK: a population-based cohort study. J Hepatol 2008; 48:939-44. [PMID: 18433916 DOI: 10.1016/j.jhep.2008.02.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 01/25/2008] [Accepted: 02/19/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Little is known about the occurrence of Primary Sclerosing Cholangitis (PSC) in the population of the United Kingdom or its associated risks of mortality and malignancy. We aimed to fill these gaps in knowledge. METHODS We identified 223 people with PSC and 2217 control subjects from the General Practice Research Database in the UK. We calculated incidence rates (1991-2001) and mortality rates and used Poisson and Cox regression to make comparisons between populations. RESULTS There were 149 incident cases giving a rate of 0.41 per 100,000 person years (95% CI 0.34-0.48) and a prevalence in 2001 of 3.85 per 100,000 (95% CI 3.04 to 4.80). The incidence of PSC increased about 50% over the period studied and was higher in men compared with women. There was a three-fold mortality rate increase (Hazard ratio 2.92 (95% CI 2.16-3.94) in people with PSC compared to the general population, a two-fold increase in risk of any malignancy and a 40-fold increase in the risk of primary liver cancer (HR 2.23 and 37.44, respectively). CONCLUSIONS We believe this paper provides the most reliable estimates of the occurrence of PSC and of its risk in terms of death and malignancy in the UK available to date.
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Affiliation(s)
- Tim R Card
- University of Nottingham Medical School, Division of Epidemiology and Public Health, Medical School, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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27
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Papamichalis PA, Zachou K, Koukoulis GK, Veloni A, Karacosta EG, Kypri L, Mamaloudis I, Gabeta S, Rigopoulou EI, Lohse AW, Dalekos GN. The revised international autoimmune hepatitis score in chronic liver diseases including autoimmune hepatitis/overlap syndromes and autoimmune hepatitis with concurrent other liver disorders. JOURNAL OF AUTOIMMUNE DISEASES 2007; 4:3. [PMID: 17603886 PMCID: PMC1933536 DOI: 10.1186/1740-2557-4-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 06/29/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND We conducted a study in order to determine the usefulness and diagnostic value of International Autoimmune Hepatitis Group (IAHG) score in non-autoimmune hepatitis (AIH) hepatic disorders as well as in AIH/overlap syndromes and in cases with coexistence of AIH and other liver diseases. METHODS We applied the IAHG score in 423 patients with liver diseases excluding patients with AIH, AIH/overlap syndromes and AIH with concurrent other liver disease namely, patients with chronic hepatitis B (n = 109), chronic hepatitis C (n = 95), chronic hepatitis D (n = 4), alchoholic liver disease (n = 28), non-alcoholic fatty liver disease (n = 55), autoimmune cholestatic liver diseases (n = 77), liver disorders of undefined origin (n = 32) and with miscellaneous hepatic disorders (n = 23). 24 patients with AIH associated with any kind of liver disorder including 10 patients with AIH/overlap syndromes and 14 AIH with concurrent other liver disease were also investigated. 43 patients with AIH consisted the control group. RESULTS The specificity of the score was 98.1% while the sensitivity in unmasking AIH in patients with either AIH/overlap syndromes or AIH with concurrent other liver diseases was only 50% and 78.6%. In the binary logistic regression model, the presence of other autoimmune diseases (p < 0.001), the total histological score (p < 0.001) and positivity for autoantibodies (p < 0.05) were identified as independent predictors for the presnce of AIH/ovea syndromes o AI with concurren other liver diseass. CONCLUSION The IAHG scoring system has very good specificity for excluding AIH in patients with chronic liver diseases but not that sensitivity in order to unmask AIH/overlap syndromes or AIH with concurrent other liver diseases. The presence of other autoimmune diseases or autoantibody markers in the absence of hepatitis viral markers should alarm physicians for the possible presence of AIH either as "pure" AIH or in association with other liver disorders (AIH/overlap syndromes or AIH with concurrent other liver diseases). Under these conditions, liver histology seems essential and it must always be included in the work up of hepatic patients.
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Affiliation(s)
- Panagiotis A Papamichalis
- Dept of Medicine, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Kalliopi Zachou
- Dept of Medicine, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - George K Koukoulis
- Dept. of Pathology, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Aikaterini Veloni
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Efthimia G Karacosta
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Lampros Kypri
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Ioannis Mamaloudis
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Stella Gabeta
- Dept of Medicine, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Eirini I Rigopoulou
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
| | - Ansgar W Lohse
- Dept. of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - George N Dalekos
- Dept of Medicine, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
- Dept. of Medicine, Academic Liver Unit, Medical School, University of Thessaly, 22 Papakiriazi str, Larissa 41222, Greece
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Gabeta S, Norman GL, Liaskos C, Papamichalis PA, Zografos T, Garagounis A, Rigopoulou EI, Dalekos GN. Diagnostic relevance and clinical significance of the new enhanced performance M2 (MIT3) ELISA for the detection of IgA and IgG antimitochondrial antibodies in primary biliary cirrhosis. J Clin Immunol 2007; 27:378-87. [PMID: 17514501 DOI: 10.1007/s10875-007-9092-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 03/08/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Antimitochondrial antibodies (AMAs) are the serological hallmark of primary biliary cirrhosis (PBC). We evaluated the sensitivity and specificity of a new M2 enhanced performance enzyme-linked immunosorbent assay (ELISA) (MIT3) for the detection of IgG- and IgA-specific isotypes of AMA in PBC patients including a number of PBC patients negative for AMA by indirect immunofluorescence (IIF) as well as in patients with diverse, non-PBC disorders. We also investigated the clinical significance of IgG and IgA AMA in PBC. METHODS One hundred and three Greek PBC patients including 27 with AMA IIF-negative at the time of the investigation, 29 with autoimmune hepatitis-1 (AIH-1), 12 with primary sclerosing cholangitis (PSC), 26 with hepatitis C virus (HCV), 15 with hepatitis B virus (HBV), and 29 healthy were investigated for AMA (IgG and IgA) using the MIT3-based ELISAs (INOVA Diagnostics, San Diego, CA). The samples were also tested by conventional anti-M2 ELISA (INOVA Diagnostics, Inc.). RESULTS The IgG MIT3-based ELISA significantly increased AMA detection in the cohort of PBC patients, over 26% of whom were AMA IIF-negative, from 63.1% by the conventional anti-M2, and 73.7% by IIF to 79.6% by MIT3-based ELISA (p<0.001). IgA AMAs were detected in 47.6% patients. Overall, IgG/IgA AMAs were detected in 84/103 (81.6%). IgG MIT3-based ELISA detected 12/27 IIF AMA-negative samples (44.4%), while IgG/IgA MIT3-based ELISAs detected 13/27 IIF AMA-negative patients (48.1%). The specificities of MIT3-based ELISAs (IgG and IgA) were 82.8% and 89.7%, respectively, in AIH-1, 100% and 93.3%, respectively, in HBV, 100% in PSC, and 96% and 93.3%, respectively, in HCV. Patients positive for IgG AMA had significantly more severe disease as shown by worse histology and elevated biochemical markers; IgG and IgA AMA titers were associated positively with the Mayo risk score but none of the isotypes were able to predict disease outcome. CONCLUSIONS The new IgG and IgA MIT3-based ELISAs seem to have higher specificity and sensitivity for AMA detection than IIF and the conventional anti-M2. Interestingly, these assays were able to unmask AMA presence in almost half of the AMA-negative samples by IIF. These findings may suggest the use of MIT3-based ELISAs as first-line investigation for AMA detection, particularly, when the laboratories are unfamiliar with the use and interpretation of the IIF patterns of AMA. The presence of IgG AMA seems to characterize PBC patients with more severe disease, but both IgG and IgA isotypes of AMAs were not predictive markers of disease outcome.
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Affiliation(s)
- Stella Gabeta
- Department of Medicine, Research Laboratory of Internal Medicine, Larissa Medical School, University of Thessaly, Larissa, Greece
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Abstract
The three main categories of autoimmune liver disease are autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC); all are well-defined entities with diagnosis based upon a constellation of clinical, serologic, and liver pathology findings. Although these diseases are considered autoimmune in nature, the etiology and possible environmental triggers of each remain obscure. The characteristic morphologic patterns of injury are a chronic hepatitis pattern of injury with prominent plasma cells in AIH, destruction of small intrahepatic bile ducts and canals of Hering in PBC, and periductal fibrosis and inflammation involving larger bile ducts with variable small duct damage in PSC. Serological findings include the presence of antimitochondrial antibodies in PBC, antinuclear, anti-smooth muscle, and anti-LKM antibodies in AIH, and pANCA in PSC. Although most cases of autoimmune liver disease fit readily into one of these three categories, overlap syndromes (primarily of AIH with PBC or PSC) may comprise up to 10% of cases, and variant syndromes such as antimitochondrial antibody-negative PBC also occur. Sequential syndromes with transition from one form of autoimmune liver disease to another are rare.
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Affiliation(s)
- Mary K Washington
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Carrasco I, Arguis P, Miquel R, González-Martín J. Varón de 73 años con fiebre prolongada y alteración de las pruebas hepáticas. Med Clin (Barc) 2007; 128:111-7. [PMID: 17288926 DOI: 10.1016/s0025-7753(07)72503-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Ignasi Carrasco
- Servei de Medicina Interna, Hospital Municipal de Badalona, Badalona, Barcelona, Spain
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31
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Pausch J, Gatzen M. [Treatment of cholestatic hepatic diseases: more than the substitution of fat soluble vitamins?]. Internist (Berl) 2006; 47:1239-40, 1242-4. [PMID: 17077981 DOI: 10.1007/s00108-006-1732-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The clinical-biochemical syndrome of cholestasis is characterized by an alteration in bile constituents. As a consequence, the concentrations of bilirubin, bile acids, phospholipids and cholesterol are elevated. The main clinical symptoms of cholestasis are icterus and pruritus, and in severe cases xanthelasma and xanthoma. Primary intrahepatic cholestasis, caused by impaired bile secretion in the liver, should be separated from the extrahepatic secondary cholestasis which is a consequence of a biliary obstruction. This paper evaluates the therapy of liver diseases which developed as consequence of a primary disturbance in bile secretion.
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Affiliation(s)
- J Pausch
- Medizinische Klinik I, Klinikum Kassel GmbH, Kassel. med-klinik1@klinikum-kassel
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Fossati E, Polentini F, Carrea G, Riva S. Exploitation of the alcohol dehydrogenase-acetone NADP-regeneration system for the enzymatic preparative-scale production of 12-ketochenodeoxycholic acid. Biotechnol Bioeng 2006; 93:1216-20. [PMID: 16245351 DOI: 10.1002/bit.20753] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The performance of a new NADP-regeneration system, based on the use of alcohol dehydrogenase (ADH)-acetone, has been investigated for the regioselective oxidation of cholic acid (1) to 12-ketochenodeoxycholic acid (2). Enzymes stabilities and substrate and/or product inhibitory effects under defined synthetic reaction conditions have been evaluated. The optimized system, based on a 4% w/v solution of 1 in a reaction mixture containing 25% v/v acetone, allowed the preparative scale transformation of 1 into 2 with a 92% conversion.
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Affiliation(s)
- Elena Fossati
- Istituto di Chimica del Riconoscimento Molecolare, C.N.R., Via Mario Bianco 9, 20131 Milano, Italy
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Zachou K, Liaskos C, Rigopoulou E, Gabeta S, Papamichalis P, Gatselis N, Georgiadou S, Dalekos GN. Presence of high avidity anticardiolipin antibodies in patients with autoimmune cholestatic liver diseases. Clin Immunol 2006; 119:203-12. [PMID: 16500150 DOI: 10.1016/j.clim.2006.01.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Revised: 01/11/2006] [Accepted: 01/14/2006] [Indexed: 01/04/2023]
Abstract
We studied the prevalence and clinical significance of anticardiolipin antibodies (aCL) in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) as similar data are missing. Ninety-nine PBC patients, 41 PSC, 228 HCV, 50 HBV, 111 with other non-viral and non-autoimmune liver disorders and 267 healthy were investigated. In order to evaluate the avidity of aCL, urea 2 M was used. IgG and/or IgM aCL were detected in 40% of PBC and PSC patients, in 26.2% of disease controls (P < 0.05) and 2.25% of healthy (P < 0.05). In PBC, IgG aCL associated with presence of cirrhosis, increased Mayo risk score and thrombocytopenia, while in PSC with longer disease duration and biochemical activity. Anti-beta2-GPI was detected in only three patients. Both in PBC and PSC, resistance of aCL to urea was high, similar to that observed in antiphospholipid syndrome (APS). We demonstrated a significantly higher prevalence of aCL in PBC and PSC compared to other liver diseases and healthy. aCL were associated with more severe disease in PBC and biochemical activity in PSC, but they rather seem to be "non-pathogenic" (co-factor-independent). However, their avidity was comparable with that of APS, indicating the need for prospective studies in order to address whether aCL in PBC and PSC may contribute to APS development or the progression of hepatic disease.
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Affiliation(s)
- Kalliopi Zachou
- Department of Medicine, Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Larissa, Greece
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Affiliation(s)
- Yung Sang Lee
- Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Korea.
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