Primary Biliary Cirrhosis

The value of antinuclear antibodies in primary biliary cirrhosis

OBJECTIVE

Although autoantibodies have been used for the diagnosis of primary biliary cirrhosis (PBC), their role has not been clarified. In this study, we try to explore the value of gp210 antibody and anti-centromere antibodies (ACA) in PBC.

METHODS

Anti-gp210 and ACA were tested in 140 PBC patients by ELISA and indirect immunofluorescence respectively. Their association with clinical, pathological data and prognosis was analysed.

RESULTS

30.5% of PBC patients had positive anti-gp210 antibody and 29.2% had ACA. The anti-gp210 antibody positive group had higher Mayo risk scores and lower serum albumin levels compared to the negative one. Patients with positive anti-gp210 antibody were more likely to develop hepatic failure (p<0.05, OR=9.8460, 95% CI: 1.067-90.901) than patients with negative anti-gp210 antibody. More patients with positive ACA developed portal hypertension than patients with negative ACA (p<0.05, OR=9.259; 95% CI: 1.027-88.410). Furthermore, concurrent Sjögren's syndrome (SjS) and PBC was significantly more likely in the ACA positive group than in the negative ones (68.4% in ACA positive group, 20.7% in ACA negative group p<0.001).

CONCLUSIONS

Both anti-gp210 antibody and ACA are related to severe disease course and poor prognosis. For PBC patients with positive ACA, further examinations should be made to detect underlying SjS.

Dermatological manifestations in primary biliary cirrhosis patients: a case control study

OBJECTIVES

Primary biliary cirrhosis (PBC), a disease of probable autoimmune etiology that affects the small intrahepatic bile ducts of mainly middle-aged women is commonly associated with pruritus, xanthomatous lesions, and melanosis. We conducted a prospective study to systematically describe the skin disorders of a group of PBC patients.

METHODS

A prospective evaluation and analysis of dermatological manifestations including oral and genital lesions was carried out, in 49 PBC patients (45 females and 4 males). Median age 63 yr (range 35-87 yr). They were compared with 45 age and sex matched controls, selected among persons attending the dermatologic outpatient clinic.

RESULTS

A total of 330 skin disorders were found in the 49 PBC patients versus 76 in the 45 controls; 31.5% of all lesions were skin fungal infections. Of all lesions analyzed with the Bonferroni rule of multiple comparisons significantly more common in PBC patients were plantar mycoses, onychomycoses, and interdigital mycoses. Pruritus was found in 69.3% of patients versus 22.2% of controls, xerosis in 69.3%versus 2.2%, dermographism in 57.1%versus 4.4%, and melanosis in 46.9%versus 0%. In 38.7% of the PBC patients the dermatologic lesion was the presenting symptom.

CONCLUSIONS

PBC patients present with a wide variety of cutaneous manifestations varying in severity. Multiple skin fungal infections have been found even in the early stages. Since in more than one third of our PBC patients the dermatologic lesion was the presenting sign or symptom leading to diagnosis we believe that physicians should be aware so that a prompt and early diagnosis may be achieved.

Autoantibodies against a 210 kDa glycoprotein of the nuclear pore complex as a prognostic marker in patients with primary biliary cirrhosis

It has been reported that the presence of anti-nuclear antibody against a 210 kDa glycoprotein of nuclear pore complex (anti-gp210) is highly specific for primary biliary cirrhosis (PBC). The aim of the present study was to investigate the significance of anti-gp210, especially as a prognostic marker. The presence of anti-gp210 was ascertained in 113 patients with PBC and 162 controls by indirect immunofluorescence assay using HepG2 cells and immunoblotting analysis using nuclear extracts from HeLa cells. Anti-gp210 was detected in 25 of the 113 (22.1%) patients. None of the 162 controls was positive for anti-gp210. The appearance and titre of anti-gp210 in the patients with PBC did not vary from the time of diagnosis and through their clinical course. Anti-mitochondrial antibodies (AMA), including antibodies against pyruvate dehydrogenase complex, branched chain alpha-ketoacid dehydrogenase complex and alpha-ketoglutarate dehydrogenase complex, were not detected by enzyme-linked immunosorbent assay in five of the 113 (4.4%) patients with PBC. However, anti-gp210 alone was positive in one of these five patients. The difference in prognosis was statistically significant; patients with PBC positive for anti-gp210 died from hepatic failure more frequently than those who were negative (P < 0.01), although there were no statistically significant differences in the frequency of jaundice and the histological stage at the time of diagnosis between the two groups. We suggest that the presence of anti-gp210 is one of the independent prognostic markers able to predict, at the time of diagnosis, a poor outcome in patients with PBC.

Autoantibodies against integral membrane proteins of the nuclear envelope in patients with primary biliary cirrhosis

BACKGROUND/AIMS

Autoantibodies against nuclear membrane proteins have been identified in patients with primary biliary cirrhosis (PBC). The aim of the present study was to determine the incidence of these autoantibodies in patients with PBC and examine their significance.

METHODS

An assay using recombinant polypeptides was designed to unequivocally detect autoantibodies against gp210 and the lamin B receptor, integral proteins of the nuclear membranes.

RESULTS

Autoantibodies against gp210 were detected in 15 of 159 patients with PBC and 0 of 46 controls. Autoantibodies against lamin B receptor were detected in 2 patients with PBC and 0 controls. The presence of these autoantibodies had a sensitivity of 11% and specificity of 100% for the diagnosis of PBC. Autoantibodies against gp210 were present in 4 of 19 (21%) patients with PBC who did not have detectable antimitochondrial antibodies. Patients with PBC and gp210 autoantibodies had a higher incidence of associated arthritis.

CONCLUSIONS

Autoantibodies against gp210 and the lamin B receptor are present in approximately 10% of patients with PBC. These autoantibodies are highly specific for the diagnosis of PBC and may be useful in diagnosing individuals without antimitochondrial antibodies and in identifying a subgroup of patients with an increased incidence of associated arthritis.

Epidemiology of primary biliary cirrhosis in a defined rural population in the northern part of Sweden

The northern part of Sweden is sparsely populated and must be regarded as a rural region. An investigation into the incidence and prevalence of primary biliary cirrhosis was conducted and the course of the disease was followed. In total, 111 patients with primary biliary cirrhosis were identified for the 10-yr period 1973 to 1982 in the northern health region of Sweden. The mean annual incidence amounted to 13.3 per million and the point prevalence was 151 per million, which is the highest reported so far. There was a significantly higher prevalence in the most northern county of Sweden, both with respect to total number of primary biliary cirrhosis patients and symptomatic patients. Asymptomatic patients amounted to 37%. During the study period 25 patients out of the 111 died (23%), 14 as a direct consequence of the liver disease. Three patients died of primary hepatocellular carcinoma, one having an asymptomatic liver disease without cirrhosis. Primary biliary cirrhosis seems to be more common in Sweden, especially in the northern part, than it is elsewhere. A high frequency of extrahepatic symptoms (85%), mainly musculoskeletal, was recorded. These symptoms may lead to the first contact with the health service, rather than signs of liver disease. Thus, an increasing number of patients are diagnosed with asymptomatic liver disease, who must be followed to check for the eventual development of symptoms.

Lecithin: cholesterol acyltransferase in liver disease

Lecithin: cholesterol acyltransferase (LCAT) activity in patients with liver disease has been found to be either normal or lower than normal, but no information on LCAT mass in these patients is available. In this study, LCAT mass concentration together with LCAT activity and cholesterol esterification rate were measured in the plasma of 19 patients with cholestatic liver disease and 21 patients with non-cholestatic liver disease. The LCAT mass in plasma correlated positively with serum albumin (r = 0.69, p less than 0.001) and pre-albumin (r = 0.77, p less than 0.001) and negatively with serum bilirubin (r = -0.42, p less than 0.01) and bile salts (r = -0.43, p less than 0.01), thus reflecting the severity of liver disease and liver protein synthesizing capacity. In plasma, LCAT mass concentration also correlated well with LCAT activity (r = 0.88, p less than 0.001) and cholesterol esterification rate (r = 0.73, p less than 0.001), thereby indicating that the decrease of LCAT activity and cholesterol esterification rate in liver disease is primarily a function of decreased LCAT mass.

Apolipoprotein A-I in liver disease

Apolipoprotein A-I and high-density lipoprotein concentrations in the plasma of patients with liver disease have been found to be either normal or lower than normal. In this study the apolipoprotein A-I concentration was measured in the plasma of 19 patients with cholestatic liver disease and 21 patients with noncholestatic liver disease. To evaluate the severity of liver disease, serum albumin, prealbumin, bilirubin, and bile salts were also measured. Apolipoprotein A-I concentrations in plasma correlated positively with serum albumin (r = 0.55, p less than 0.001) and prealbumin (r = 0.57, p less than 0.001) and negatively with serum bilirubin (r = -0.47, p less than 0.01) and bile salts (r = -0.54, p less than 0.001). The apolipoprotein A-I level thus seems to reflect the severity of liver disease. This is presumably due to a decreased liver synthesis of apolipoprotein A-I in liver disease.

Primary biliary cirrhosis. Subclinical inflammatory alveolitis in patients with normal chest roentgenograms

To determine whether a subclinical inflammatory alveolitis is associated with primary biliary cirrhosis (PBC), we compared the numbers and types of cells recovered by bronchoalveolar lavage from 12 patients with PBC, ten healthy control subjects, and nine patients with alcoholic cirrhosis (AC). All were free of clinical pulmonary symptoms and had normal findings on chest roentgenograms. Total BAL cell count did not differ among patients with PBC (mean 9.6 X 10(4) cells/ml), patients with AC (mean 14.8 X 10(4) cells/ml), and control subjects (mean 9.9 X 10(4) cells/ml). Patients with PBC but not patients with AC had an increased proportion of lymphocytes in bronchoalveolar lavage fluid (respectively 22.4 percent +/- 5.2 and 11.6 percent +/- 2.52 compared with the normal value of 9.9 percent +/- 1.5 p less than 0.05). In the same way, alveolar lymphocytosis of the lower respiratory tract from PBC patients predominantly comprised T4+ (helper/inducer) T-lymphocyte subset in patients showing an increased alveolar lymphocytosis. Alveolar macrophages from PBC patients showed a dramatic increased chemiluminescence response before and after stimulation by phorbol-myristate-acetate, regardless of the intensity of alveolar lymphocytosis. Thus, our data demonstrated that subclinical alveolar inflammation comprising T-lymphocytes and activated alveolar macrophages mimicking sarcoid alveolitis is present in a high proportion of patients with PBC.

Apolipoproteins A-I, A-II and E in cholestatic liver disease

Apolipoproteins A-I, A-II and E were determined in the plasma of nine patients (five females, four males) with cholestatic liver disease (eight patients with primary biliary cirrhosis and one patient with sclerosing cholangitis). Plasma concentrations were measured by electroimmunoassay in the fasting state, postprandially after ingestion of either 100 g fat as whipping cream or a light mixed meal with or without addition of wheat fibre. Concentrations of apolipoproteins A-I and A-II were low in patients with cholestatic liver disease and A-I levels correlated inversely with the severity of liver disease as measured by bilirubin levels (r = -0.66). No changes in plasma apolipoprotein A-I, A-II or E concentrations occurred postprandially. There was an inverse correlation between plasma concentrations of apolipoproteins A-I and E (p less than 0.05, r = -0.68). A close relation existed between the ratio of apolipoprotein E to apolipoprotein A-I and plasma bile salt concentration (r = 0.80, p less than 0.01) and serum bilirubin (r = 0.76, p less than 0.01). This implies that in cholestatic liver disease apolipoprotein E and A-I levels reflect the degree of cholestasis.

Interstitial lung disease in primary biliary cirrhosis

A 51-year-old woman with a 5-1/2 year history of primary biliary cirrhosis (PBC) developed interstitial lung disease (ILD). The initial pulmonary infiltrate consisted of unilateral nodules mimicking neoplastic disease and later progressed to involve both lungs with a diffuse interstitial process. Tissue obtained by open lung biopsy was compatible with lymphoid interstitial pneumonia. The pulmonary infiltrates cleared spontaneously but recurred on two more occasions with subsequent resolution. This pulmonary disease activity appeared unrelated to the chemical activity of the PBC, which progressed to a fatal termination. The association of ILD, especially of a recurrent nature, with PBC is rare.

Recurrence of primary biliary cirrhosis after liver transplantation

Three patients who had undergone orthrotopic liver transplantation for primary biliary cirrhosis and were being maintained on immunosuppressive therapy were investigated 31/2 to 41/2 years later because of the redevelopment of pruritus and mild jaundice. In one patient pigmentation was again evident, and all three had a rise in the titer of serum mitochondrial antibody after an initial fall. Liver histology showed features of primary biliary cirrhosis with non-suppurative destructive cholangitis, lymphoid aggregates, and increased deposition of copper-binding protein in the absence of cholestasis. None of these features was found in patients who had received grafts for other conditions and had lived for comparable periods, nor were they found in patients who had had rejection with bile-duct abnormalities. The overall findings indicate a recurrence of primary biliary cirrhosis in the donor organ.

Primary biliary cirrhosis as a collagen disease

Primary biliary cirrhosis is a disease of the small bile ducts with altered immunologic responsiveness often associated with various collagen diseases. All appear to be mediated by immune complex deposition. They probably are all different clinical manifestations of the same disease with different expressions determined by genetic and acquired factors. Therapy should be directed to the most immediate life-threatening problem.

Selected autoimmune diseases in the dog

In summary, previous attempts to explain the role of inheritance in autoimmune disorders through family studies have been hampered by the variable degree of phenotypic expression. Our evidence utilizing dogs in family studies is consistent with the concept that genetic factors play some role in determining disease susceptibility. Recognizing the complexity of the genetic components involved in these studies, we have proposed a hypothesis of two classes of genes, one that relates to immunoregulation and another that specifies pathologic lesions (and thus the clinical signs). This dual system of interacting genes provides a rational explanation for many of the observations previously encountered in both human and canine studies.

The morphology of cirrhosis. Recommendations on definition, nomenclature, and classification by a working group sponsored by the World Health Organization

This memorandum provides guidelines on the definition, nomenclature, and classification of cirrhosis, chronic hepatitis, and hepatic fibrosis. These are considered according to morphological characteristics and aetiology. It is hoped that this system will serve as a standard for diagnostic, research, and epidemiological purposes. The relationship of cirrhosis to liver cell carcinoma is briefly discussed and the possible morphological markers of an increased risk of malignancy are defined.

Normal alkaline phosphatase in primary biliary cirrhosis

A patient with primary biliary cirrhosis is described. Throughout her illness the serum alkaline phosphatase remained normal and this unique feature emphasizes the importance of histology in diagnosing the disease.

Histopathological features in mixed types of chronic aggressive hepatitis and primary biliary cirrhosis. Correlations of liver histology with mitochondrial antibodies of different specificity

A histopathological study was carried out on 27 patients with chronic inflammatory liver disease and clinical and/or biochemical evidence of cholestasis who had either mitochondrial antibodies against mitochondrial antigen fractions of 1.19 density ("PBC antigen"; 14 cases) or of 1.13 density ("CAH-PBC mixed-type antigen"; 13 cases). For comparison, the liver biopsies of 17 patients with chronic-aggressive hepatitis (CAH) and antinuclear and/or anti-smooth muscle antibodies but without cholestasis and mitochondrial antibodies, were evaluated. The 14 patients with mitochondrial antibodies against the PBC antigen showed the typical histological features of primary biliary cirrhosis (PBC). The 13 patients with mitochondrial antibodies against the CAH-PBC mixed-type antigen had heterogenous liver alterations. In 11 cases highly active CAH and/or active postnecrotic cirrhosis (AC) were found both with augmented ductular proliferation. Some of these cases showed distinct criteria of PBC as early bile duct lesions or absence of regular bile ducts. The liver histology of one case corresponded to classical PBC; another case to chronic persistent hepatitis. The CAH-patients without cholestasis and mitochondrial antibodies only occasionally showed bile duct proliferation. In conclusion, a high correlation was found between mitochondrial antibodies against the CAH-PBC mixed-type antigen and highly active CAH or early AC with augmented ductular proliferation. This represents an overlapping of CAH and PBC. In contrast, the cases with antibodies reacting to the PBC antigen showed the slowly progressive liver changes of typical PBC.