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Aksoy B, Baran M, Cagan Appak Y, Sag E, Cakir M, Guven B, Yavuz S, Emir B, Tumgor G. Efficiency of azathioprine monotherapy for maintenance treatment of autoimmune hepatitis in children. Eur J Gastroenterol Hepatol 2022; 34:92-97. [PMID: 32956178 DOI: 10.1097/meg.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Autoimmune hepatitis (AIH) is a common pediatric liver disease and long-term remission is usually maintained with low dose prednisolone and azathioprine (AZA). The aim of this study is to evaluate the efficiency of AZA monotherapy for maintenance treatment of children with AIH. MATERIALS AND METHODS This study was a retrospective analysis of the 55 children with AIH. Patients were divided into two groups: combination therapy (CT) and AZA group based on maintenance therapy. Results of these two different maintenance treatments were compared in children with AIH. RESULTS The mean age of the children was 10.67 ± 4.30 years (61.8% females) with a mean follow-up period of 46.8 ± 33.6 months. For maintenance treatment, 39 (70.9%) patients received AZA and 16 (29.1%) patients received CT. Relapse was observed in nine (19.6%) cases in the follow-up period; two were in the CT group (2/16; 12.5%) and seven (7/39; 17.9%) were in the AZA group (P = 0.620). In AZA group, the duration of remission was 22.2 ± 6.1 months and that was longer than CT group (P = 0.025). CONCLUSION Our study suggests that AZA monotherapy is an effective and safe therapy for maintaining remission in children with AIH. AZA monotherapy may be used for maintenance treatment of children with AIH, except in cases of overlap syndrome and also to avoid side effects of long-term used steroids and to improve treatment compliance in proper cases.
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Affiliation(s)
- Betul Aksoy
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, SBU Tepecik Training and Research Hospital
| | - Masallah Baran
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, İzmir Katip Çelebi University & SBU Tepecik Training and Research Hospital, Izmir
| | - Yeliz Cagan Appak
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, İzmir Katip Çelebi University & SBU Tepecik Training and Research Hospital, Izmir
| | - Elif Sag
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karadeniz Technical University, Trabzon
| | - Murat Cakir
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karadeniz Technical University, Trabzon
| | - Burcu Guven
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karadeniz Technical University, Trabzon
| | - Sibel Yavuz
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University, Adana
| | - Busra Emir
- Department of Biostatistics, Katip Celebi University, Izmir, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University, Adana
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Bovensiepen CS, Schakat M, Sebode M, Zenouzi R, Hartl J, Peiseler M, Li J, Henze L, Woestemeier A, Schramm C, Lohse AW, Herkel J, Weiler-Normann C. TNF-Producing Th1 Cells Are Selectively Expanded in Liver Infiltrates of Patients with Autoimmune Hepatitis. THE JOURNAL OF IMMUNOLOGY 2019; 203:3148-3156. [PMID: 31685647 DOI: 10.4049/jimmunol.1900124] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 10/03/2019] [Indexed: 12/23/2022]
Abstract
Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease that is believed to be driven by a CD4+ T cell response to liver Ags. However, the pathogenic function of CD4+ effector T cells in AIH is not fully understood. To characterize liver-infiltrating lymphocytes in AIH, we determined the cytokine production of infiltrating cells obtained from biopsy material by quantitative RT-PCR and flow cytometry. A cytokine quantitiative RT-PCR array of AIH specimens revealed that TNF was the most strongly upregulated cytokine, as compared with control livers. To confirm this finding, we determined the frequencies of TNF-producing CD4+ T cells in peripheral blood and in liver biopsy specimens in comparison with those of CD4+ T cells producing IFN-γ or IL-17. In AIH, TNF-producing CD4+ T cells were significantly expanded, both in blood and liver, whereas IL-17-producing CD4+ T cells were not. However, the majority of the TNF-producing CD4+ T cells in AIH also produced IFN-γ, suggesting that TNF producers might represent a pathogenic activation state of Th1 cells. Ag-specific stimulation of PBMC from AIH patients with the AIH-associated autoantigen SEPSECS resulted in significant TNF production only in patients manifesting SLA/LP autoantibodies targeting SEPSEC but not in healthy individuals who do not manifest this reactivity. Taken together, our findings indicated that TNF-producing CD4+ T cells are expanded in AIH, both in blood and in liver. TNF-producing CD4+ T cells in AIH seem to be aberrantly activated Th1 cells. Our findings provide a rationale for therapeutic efforts using TNF blockade in AIH.
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Affiliation(s)
- Claudia S Bovensiepen
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Miriam Schakat
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Marcial Sebode
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Roman Zenouzi
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Johannes Hartl
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Moritz Peiseler
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary Surgery and Transplantation, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany.,Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; and
| | - Lara Henze
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Anna Woestemeier
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; and
| | - Christoph Schramm
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ansgar W Lohse
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Johannes Herkel
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Christina Weiler-Normann
- Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; .,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
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Wehrman A, Waisbourd-Zinman O, Shah A, Hilmara D, Lin H, Rand EB. Steroid Free Treatment of Autoimmune Hepatitis in Selected Children. J Pediatr 2019; 207:244-247. [PMID: 30723013 DOI: 10.1016/j.jpeds.2018.12.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 12/29/2022]
Abstract
Current guidelines recommend steroids for induction of remission in all children diagnosed with autoimmune hepatitis regardless of the clinical presentation. In this report, we describe our experience in treating selected asymptomatic children with autoimmune hepatitis using a steroid-free regimen; this treatment strategy was safe and effective in inducing remission.
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Affiliation(s)
- Andrew Wehrman
- Children's Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Philadelphia, PA
| | - Orith Waisbourd-Zinman
- Children's Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Philadelphia, PA; Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amit Shah
- Children's Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Philadelphia, PA
| | - Didja Hilmara
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA
| | - Henry Lin
- Children's Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Philadelphia, PA
| | - Elizabeth B Rand
- Children's Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Philadelphia, PA.
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Hepatic Issues and Complications Associated With Inflammatory Bowel Disease: A Clinical Report From the NASPGHAN Inflammatory Bowel Disease and Hepatology Committees. J Pediatr Gastroenterol Nutr 2017; 64:639-652. [PMID: 27984347 DOI: 10.1097/mpg.0000000000001492] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatobiliary disorders are common in patients with inflammatory bowel disease (IBD), and persistent abnormal liver function tests are found in approximately 20% to 30% of individuals with IBD. In most cases, the cause of these elevations will fall into 1 of 3 main categories. They can be as a result of extraintestinal manifestations of the disease process, related to medication toxicity, or the result of an underlying primary hepatic disorder unrelated to IBD. This latter possibility is beyond the scope of this review article, but does need to be considered in anyone with elevated liver function tests. This review is provided as a clinical summary of some of the major hepatic issues that may occur in patients with IBD.
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Haerskjold A, Linder M, Henriksen L, Thomsen SF, Kieler H, Ravn H, Stensballe LG. Palivizumab Exposure and the Risk of Autoimmune Disease: A Cross-National Cohort Study. Paediatr Drugs 2016; 18:435-441. [PMID: 27665287 DOI: 10.1007/s40272-016-0191-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Treatment with biologic pharmaceuticals may be associated with an increased risk of immune-mediated disease. Palivizumab is a humanized monoclonal antibody designed to provide passive immunity against respiratory syncytial virus infection. Palivizumab is primarily used in preterm children known to be immunologically immature. The long-term effect of palivizumab in terms of autoimmune diseases has not yet been investigated. AIM Our objective was to investigate whether exposure to palivizumab was associated with the development of autoimmune diseases in children. METHODS This was a population-based cohort study including data from 769,523 Danish children born between 1 January 1999 and 31 December 2010 and data from 581,742 Swedish children born between 1 July 2005 and 31 December 2010. RESULTS Of the 1,351,265 children included, 1192 (0.09 %) were exposed to palivizumab. Nine cases of autoimmune disease were diagnosed among palivizumab-exposed children during the period of observation. Among the children exposed to palivizumab, one child in Denmark developed inflammatory bowel disease; in Sweden, children developed juvenile arthritis (one child), diabetes mellitus (two children), celiac disease (four children), and inflammatory bowel disease (one child). The risk of autoimmune disease was not significantly increased after palivizumab exposure (hazard ratio adjusted for age and country: 1.54; 95 % confidence interval 0.80-2.95). CONCLUSION The risk of autoimmune disease was not increased after palivizumab exposure. Given the small number of incident cases of autoimmune disease observed, this finding should be interpreted with caution.
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Affiliation(s)
- Ann Haerskjold
- The Child and Adolescent Clinic 4072, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Department of Dermato-Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Kildegaardsvej 28, Entrance 15, Hellerup, Denmark.
| | - Marie Linder
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Lonny Henriksen
- The Child and Adolescent Clinic 4072, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Helle Kieler
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | | | - Lone Graff Stensballe
- The Child and Adolescent Clinic 4072, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Liberal R, Mieli-Vergani G, Vergani D. Autoimmune hepatitis: From mechanisms to therapy. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Karakoyun M, Ecevit CO, Kilicoglu E, Aydogdu S, Yagci RV, Ozgenc F. Autoimmune hepatitis and long-term disease course in children in Turkey, a single-center experience. Eur J Gastroenterol Hepatol 2016; 28:927-30. [PMID: 27254777 DOI: 10.1097/meg.0000000000000648] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The aim of this study is to determine clinic and laboratory features, treatment protocols, treatment responses, and long term follow-up of children with autoimmune hepatitis (AIH) in a region of Turkey followed at Ege University. MATERIALS AND METHODS The records of 47 children with AIH between 1998 and 2012 were retrospectively analyzed for clinical profiles, treatment response, relapse rate, and long-term side effects. RESULTS The median age of the children was 10±4.1 years (55.3% females). A total of 29 patients presented with chronic hepatitis (61.7%). According to the autoantibody profiles, 40 (85.1%) and seven (14.9%) cases were classified as type 1 and type 2, respectively. Presentation with acute hepatitis and chronic hepatitis was significantly higher in type 1 disease. Laboratory findings at presentation was found similar among races as well as AIH types (P>0.05). The prednisolone was used for remission induction in 37 patients; 86.4% (n: 32) achieved a complete response, 2.7% (n: 1) achieved a partial response, and four patients (10.8%) showed no response. Maintenance was attained by low-dose steroid plus thiopurine and relapse in steroid responders (n: 32) was 9.4% (n: 3) at 8, 12, and 48 months. A total of 36% (n: 24) had neither acute nor chronic treatment side effects. Bone marrow suppression was observed in five patients and hyperglycemia was observed in one patient (10.6 and 2.1%), respectively. CONCLUSION AIH type 1 prevails in children in a region of Turkey during the second decade of life. Low-dose corticosteroids combined with azathioprine are found.
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Affiliation(s)
- Miray Karakoyun
- aDepartment of Pediatric Gastroenterology, Hepatalogy and Nutrition, Gaziantep Children's Hospital, Gaziantep bDepartment of Pediatric Gastroenterology, Hepatology and Nutrition cDepartment of Pediatrics, Dr. Behcet Uz Children's Hospital dDepartment of Pediatric Gastroenterology, Hepatology and Nutrition, Ege University, Izmir, Turkey
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Liberal R, Mieli-Vergani G, Vergani D. Autoimmune hepatitis: From mechanisms to therapy. Rev Clin Esp 2016; 216:372-383. [PMID: 27161382 DOI: 10.1016/j.rce.2016.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/02/2016] [Indexed: 12/13/2022]
Abstract
Autoimmune hepatitis (AIH) is a progressive inflammatory hepatopathy and an important cause of end-stage liver disease. Its aetiology remains unknown, though both genetic and environmental factors are involved in its development. The major mechanism of autoimmune liver damage involves immune reactions against host liver antigens. Numerical and functional defects of regulatory T-cells play a permissive role enabling autoimmune liver injury to occur and persist. The most typical features of AIH are female preponderance, hypergammaglobulinaemia, seropositivity for circulating autoantibodies and a picture of interface hepatitis on histology. Two types of AIH are distinguished according to serological profile: AIH type 1 patients are positive for anti-nuclear and/or anti-smooth muscle antibodies, whereas AIH type 2 patients are defined by the positivity for anti-liver kidney microsomal type 1 antibody and/or for anti-liver cytosol type 1 antibody. Clinical manifestations are variable, and AIH onset is often ill-defined, frequently mimicking acute hepatitis; its course may be fluctuating. AIH responds to immunosuppressive treatment in the majority of cases. Steroids with or without azathioprine should be instituted promptly upon diagnosis. Remission is achieved in some 80% of patients. For the remaining 20% of patients, alternative immunosuppressive agents such as mycophenolate mofetil and calcineurin inhibitors are an option. Liver transplantation should be considered for those patients who progress to cirrhosis and develop complications of end-stage liver disease, as well as for those presenting with acute liver failure; outcomes are excellent, although the disease may recur in the allograft.
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Affiliation(s)
- R Liberal
- Institute of Liver Studies, King's College London, Faculty of Life Sciences & Medicine, London, UK; Department of Gastroenterology, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - G Mieli-Vergani
- Institute of Liver Studies, King's College London, Faculty of Life Sciences & Medicine, London, UK; Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - D Vergani
- Institute of Liver Studies, King's College London, Faculty of Life Sciences & Medicine, London, UK.
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Liberal R, Vergani D, Mieli-Vergani G. Update on Autoimmune Hepatitis. J Clin Transl Hepatol 2015; 3:42-52. [PMID: 26357634 PMCID: PMC4542083 DOI: 10.14218/jcth.2014.00032] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 12/17/2022] Open
Abstract
Autoimmune hepatitis (AIH), a liver disorder affecting both children and adults, is characterized by inflammatory liver histology, elevated transaminase levels, circulating nonorganspecific autoantibodies, and increased levels of immunoglobulin G, in the absence of a known etiology. Two types of AIH are recognized according to seropositivity: smooth muscle antibody and/or antinuclear antibody define AIH type 1 and antibodies to liver-kidney microsome type 1 and/or liver cytosol type 1 define AIH type 2. AIH type 1 affects both adults and children, while AIH type 2 is mainly a paediatric disease, though it does occasionally affects young adults. AIH should be considered during the diagnostic workup of any patient with increased liver enzyme levels. AIH is exquisitely responsive to immunosuppressive treatment with prednisolone with or without azathioprine, with symptom free long-term survival for the majority of patients. For those who do not respond to standard treatment, or who are difficult-to-treat, mycophenolate mofetil and, in the absence of a response, calcineurin inhibitors should be tried in addition to steroids. The pathogenesis of AIH is not fully understood, although there is mounting evidence that genetic susceptibility, molecular mimicry and impaired immunoregulatory networks contribute to the initiation and perpetuation of the autoimmune attack. Liver damage is thought to be mediated primarily by CD4 T-cells, although recent studies support the involvement of diverse populations, including Th17 cells. A deeper understanding of the pathogenesis of AIH is likely to contribute to the development of novel treatments, such as the adoptive transfer of autologous expanded antigenspecific regulatory T-cells, which ultimately aim at restoring tolerance to liver-derived antigens.
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Affiliation(s)
- Rodrigo Liberal
- Paediatric Liver, GI & Nutrition Centre and Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, UK
| | - Diego Vergani
- Paediatric Liver, GI & Nutrition Centre and Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, UK
| | - Giorgina Mieli-Vergani
- Paediatric Liver, GI & Nutrition Centre and Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, UK
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Mieli-Vergani G, Vergani D. Budesonide for juvenile autoimmune hepatitis? Not yet. J Pediatr 2013; 163:1246-8. [PMID: 23932214 DOI: 10.1016/j.jpeds.2013.06.064] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 06/25/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Giorgina Mieli-Vergani
- Pediatric Liver, Gastrointestinal, and Nutrition Center Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, United Kingdom.
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Floreani A, Liberal R, Vergani D, Mieli-Vergani G. Autoimmune hepatitis: Contrasts and comparisons in children and adults - a comprehensive review. J Autoimmun 2013; 46:7-16. [PMID: 24035197 DOI: 10.1016/j.jaut.2013.08.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 08/13/2013] [Accepted: 08/14/2013] [Indexed: 12/24/2022]
Abstract
This review concentrates on autoimmune hepatitis (AIH), a liver disorder affecting both children and adults, characterized by inflammatory liver histology, elevated transaminase levels, circulating non-organ-specific autoantibodies, and increased levels of immunoglobulin G, in the absence of a known aetiology. Two types of AIH are recognized according to seropositivity: smooth muscle antibody and/or antinuclear antibody define AIH type 1, while antibodies to liver-kidney microsome type 1 and/or liver cytosol type 1 define AIH type 2. AIH type 1 affects both adults and children, while AIH type 2 is mainly a paediatric disease, though it does occasionally affects young adults. There is a female predominance in both types. AIH is particularly aggressive in children/adolescents, progressing rapidly unless immunosuppressive treatment is started promptly. With appropriate treatment 80% of patients achieve remission and long-term survival. In childhood/adolescence, sclerosing cholangitis with strong autoimmune features, including interface hepatitis and serological features identical to AIH type 1, is as prevalent as AIH, but it affects boys and girls equally. The differential diagnosis relies on cholangiographic studies. In autoimmune sclerosing cholangitis, liver parenchymal damage responds satisfactorily to immunosuppressive treatment, whereas bile duct disease progresses in 50% of cases, leading to a worse prognosis and higher transplantation requirement; it has a higher recurrence rate after transplant than AIH. AIH can arise de novo in patients transplanted for non-autoimmune liver disease. Post transplant de novo AIH affects children and adults and responds well to the same treatment schedule used for classical AIH, but not to that used for acute rejection.
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Affiliation(s)
- Annarosa Floreani
- Dept. of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy.
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12
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Epstein-barr virus as a trigger of autoimmune liver diseases. Adv Virol 2012; 2012:987471. [PMID: 22693505 PMCID: PMC3368154 DOI: 10.1155/2012/987471] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/09/2012] [Indexed: 02/08/2023] Open
Abstract
The pathogenesis of autoimmune diseases includes a combination of genetic factors and environmental exposures including infectious agents. Infectious triggers are commonly indicated as being involved in the induction of autoimmune disease, with Epstein-Barr virus (EBV) being implicated in several autoimmune disorders. EBV is appealing in the pathogenesis of autoimmune disease, due to its high prevalence worldwide, its persistency throughout life in the host's B lymphocytes, and its ability to alter the host's immune response and to inhibit apoptosis. However, the evidence in support of EBV in the pathogenesis varies among diseases. Autoimmune liver diseases (AiLDs), including autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC), have a potential causative link with EBV. The data surrounding EBV and AiLD are scarce. The lack of evidence surrounding EBV in AiLD may also be reflective of the rarity of these conditions. EBV infection has also been linked to other autoimmune conditions, which are often found to be concomitant with AiLD. This paper will critically examine the literature surrounding the link between EBV infection and AiLD development. The current evidence is far from being conclusive of the theory of a link between EBV and AiLD.
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Mieli-Vergani G, Vergani D. Autoimmune liver diseases in children - what is different from adulthood? Best Pract Res Clin Gastroenterol 2011; 25:783-95. [PMID: 22117642 DOI: 10.1016/j.bpg.2011.10.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 10/25/2011] [Indexed: 01/31/2023]
Abstract
Autoimmune liver disorders in childhood include autoimmune hepatitis, autoimmune sclerosing cholangitis and de novo autoimmune hepatitis after liver transplant. These inflammatory liver disorders are characterised histologically by interface hepatitis, biochemically by elevated transaminase levels and serologically by autoantibodies and increased levels of immunoglobulin G. Autoimmune hepatitis is particularly aggressive in children and progresses rapidly unless immunosuppressive treatment is started promptly. With appropriate treatment 80% of patients achieve remission and long-term survival. Autoimmune sclerosing cholangitis responds to the same treatment used for autoimmune hepatitis in regards to parenchymal inflammation, but bile duct disease progresses in about 50% of cases, leading to a worse prognosis and higher transplantation requirement; it has a high recurrence rate post-liver transplant. De novo autoimmune hepatitis after liver transplant affects children transplanted for non-autoimmune conditions and responds well to the same treatment schedule used for autoimmune hepatitis, but not to the schedule used for acute rejection.
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Affiliation(s)
- Giorgina Mieli-Vergani
- King's College London School of Medicine at King's College Hospital, Paediatric Liver, GI and Nutrition Centre, Denmark Hill, London SE5 9RS, UK
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Clinico-laboratory study on children with auto-immune hepatitis in Upper Egypt. Arab J Gastroenterol 2011; 12:178-83. [DOI: 10.1016/j.ajg.2011.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 06/24/2011] [Accepted: 11/14/2011] [Indexed: 12/31/2022]
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Zhao Y, Zhang Y, Liu YM, Liu Y, Feng X, Liao HY, Vergani D, Ma Y, Yan HP. Identification of T cell epitopes on soluble liver antigen in Chinese patients with auto-immune hepatitis. Liver Int 2011; 31:721-9. [PMID: 21457445 DOI: 10.1111/j.1478-3231.2011.02487.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM To identify soluble liver antigen (SLA)-specific dominant epitopes and analyse the correlation between SLA-specific T cell response and the status of the disease. METHODS A cross-sectional analysis of SLA-specific T cell responses to 54 overlapping peptides covering the entire SLA sequence was performed using an interferon (IFN)-γ ELISpot assay in 31 patients with auto-immune hepatitis (AIH)-1, 15 patients with primary biliary cirrhosis, 16 hepatitis B virus, seven hepatitis C virus infection and 10 healthy subjects, in order to assess the correlation between SLA-specific T cell responses and the clinical outcome. RESULTS Soluble liver antigen-specific IFN-γ responses in AIH were significantly more frequent in AIH patients (58.1%) than those in controls (6.7% in PBC, P=0.001; 4.3% in hepatitis B/C, P<0.001 and 0% in healthy subjects, P=0.0015). Among 31 AIH patients, the frequency of recognition and the magnitude of response to SLA peptides in anti-SLA antibody-positive patients were higher and stronger than those negative for anti-SLA antibodies (P=0.02 and 0.037 respectively). We further analysed T-cell restriction and found that six individual SLA peptides (4, 9, 11, 12, 41 and 44) were recognized by CD4 T cells, and the most frequently recognized peptides were peptides 12 (61.1% of participants), followed by peptide 4 and peptide 44 (55.6 and 38.9% respectively). Moreover, a positive association was found between the breadth of recognition of SLA peptides and the indices of liver damage. CONCLUSION T cell response to SLA in Chinese patients with AIH is broad and associated with hepatocyte damage.
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Affiliation(s)
- Yan Zhao
- Clinical Research Centre for Autoimmune Liver Disease, Beijing YouAn Hospital, Capital Medical University, Beijing, China
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Della Corte C, Ranucci G, Tufano M, Alessio M, Iorio R. Autoimmune hepatitis type 2 arising in PFAPA syndrome: coincidences or possible correlations? Pediatrics 2010; 125:e683-6. [PMID: 20142286 DOI: 10.1542/peds.2009-2630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PFAPA syndrome is a chronic disease classified in the group of autoinflammatory syndromes characterized by periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis in young children. The etiology of this disorder is still unknown, but a primary dysfunction of the innate immune system seems to be involved. According to Marshall criteria, it is not possible to diagnose PFAPA in the presence of autoimmune diseases. We present here the case report of an 8-month girl with PFAPA who developed autoimmune hepatitis type 2 at the age of 18 months. We suppose that the dysregulation in innate immunity that is typical of patients with PFAPA could trigger autoimmune disorders such as autoimmune hepatitis in susceptible subjects. The possible relationships between immune-system dysfunction peculiar to this syndrome and autoimmune hepatitis are discussed.
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Affiliation(s)
- Claudia Della Corte
- University Federico II, Department of Pediatrics, Via S Pansini 5, 80131 Naples, Italy
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Long-term treatment reduction and steroids withdrawal in children with autoimmune hepatitis: a single centre experience on 55 children. Eur J Gastroenterol Hepatol 2009; 21:1413-8. [PMID: 19907227 DOI: 10.1097/meg.0b013e32832ad5f7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The combination of corticosteroids and azathioprine is the standard therapy for autoimmune hepatitis. The aim of this study was to describe our experience on long-term corticosteroid doses reducing and withdrawal in a large cohort of children with autoimmune hepatitis (AIH). METHODS All children presenting with AIH in our institution, from 1990 to 2006, were retrospectively included. RESULTS The study population included 55 children [38 females, 17 males, median age 8 years (ranging from 0.8 to 15)] with type 1 (74.5%), type 2 (20%) or seronegative (5.5%) AIH. The diagnosis was made in 41 of them at the time of acute hepatitis (75%); the other 14 were diagnosed as chronic liver disease (25%). Treatment consisted of corticosteroids and azathioprine in 45 patients or corticosteroids alone in five patients. Complete remission was obtained within 1 year in 31 (69%) patients. The median initial dose of corticosteroids was 1.6 mg/kg/day, and the dose was progressively reduced to 0.32 mg/kg/day at 1 year, 0.24 mg/kg/day at 3 years, 0.11 mg/kg/day at 5 years and 0.05 mg/kg/day at 10 years. Corticosteroids withdrawal was possible in 0% of patients at 1 year, 75% at 3 years, 78% at 5 years and 90% at 10 years. At the end of follow-up, azathioprine was maintained in 36 patients (80%). Total treatment withdrawal was obtained in four patients. CONCLUSION Our results strongly confirm that long-term corticosteroids withdrawal is possible in a large majority of children with autoimmune hepatitis.
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Mieli-Vergani G, Heller S, Jara P, Vergani D, Chang MH, Fujisawa T, González-Peralta RP, Kelly D, Mohan N, Shah U, Murray KF. Autoimmune hepatitis. J Pediatr Gastroenterol Nutr 2009; 49:158-64. [PMID: 19561543 DOI: 10.1097/mpg.0b013e3181a1c265] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune hepatitis is characterized by inflammatory liver histology, circulating nonorgan-specific autoantibodies, and increased levels of immunoglobulin G, in the absence of a known etiology. Two types of juvenile autoimmune hepatitis (AIH) are recognized according to seropositivity for smooth muscle and/or anti-nuclear antibody (AIH type 1) or liver kidney microsomal antibody (AIH type 2). There is a female predominance in both. AIH type 2 presents more acutely, at a younger age and commonly with immunoglobulin A deficiency, whereas duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in the 2 groups. Immunosuppressive treatment with steroids and azathioprine, which should be instituted promptly to avoid progression to cirrhosis, induces remission in 80% of cases. Relapses are common, often due to nonadherence. Drugs effective in refractory cases include cyclosporine and mycophenolate mofetil. Long-term treatment is usually required, with only some 20% of AIH type 1 patients able to discontinue therapy successfully. In childhood, sclerosing cholangitis with strong autoimmune features, including interface hepatitis and serological features identical to AIH type 1, is as prevalent as AIH, but it affects boys and girls equally. Differential diagnosis relies on cholangiographic studies. In autoimmune sclerosing cholangitis liver parenchymal damage responds satisfactorily to immunosuppressive treatment, whereas bile duct disease tends to progress. In this article we review the state of the art of diagnosis, monitoring, and treatment for children with AIH.
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Longhi MS, Mitry RR, Samyn M, Scalori A, Hussain MJ, Quaglia A, Mieli-Vergani G, Ma Y, Vergani D. Vigorous activation of monocytes in juvenile autoimmune liver disease escapes the control of regulatory T-cells. Hepatology 2009; 50:130-42. [PMID: 19437492 DOI: 10.1002/hep.22914] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED Interface hepatitis, the histological lesion typical of autoimmune hepatitis (AIH), is composed of CD4 and CD8 T lymphocytes and of innate immunity cells, particularly monocytes. Studies in AIH have focused on autoreactive CD4 and CD8 T cells and impairment of CD4+CD25+ regulatory T cells (T-regs), whereas little is known about the role of monocytes and their relationship with T-regs. We have investigated 51 patients with autoimmune liver disease (AILD) and 27 healthy subjects, finding that monocytes were higher in number (P = 0.044), had a more vigorous spontaneous migration (P < 0.0005 in patients with inactive disease [ID], and P < 0.001 in those with active disease [AD]), displayed a higher tumor necrosis factor alpha (TNF-alpha) over interleukin (IL)-10 production (P = 0.07 in ID and P = 0.0005 in AD), and expressed higher levels of Toll-like receptor (TLR) 4 (P = 0.048 in ID and P = 0.03 in AD). Addition of conventional T-regs (cT-regs) in AILD enhanced monocyte migration (P = 0.05 in ID and P = 0.08 in AD), magnified TNF-alpha over IL-10 production (P = 0.0005 in ID and P = 0.006 in AD), and markedly increased TLR4 expression levels (P = 0.01 in ID and P = 0.004 in AD), whereas in normal subjects it either restrained or left unchanged monocyte function. Because a CD127-negative subpopulation within CD4+CD25+ T cells exerts the strongest regulatory activity, we performed additional experiments using purified CD4+CD25+CD127- T cells (true T-regs [tT-regs]). Addition of tT-regs to monocytes decreased monocyte migration (P = 0.03) and promoted IL-10 production (P = 0.009), leaving unchanged TLR4 expression in healthy subjects, whereas in patients with AILD it induced only a marginal increase in IL-10 production (P = 0.045 in ID and P = 0.13 in AD). CONCLUSION Monocyte overactivation and inability of cT-regs and tT-regs to restrain it may contribute to the loss of immune tolerance and perpetuation of the autoimmune attack in AILD.
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Affiliation(s)
- Maria Serena Longhi
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, UK
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Abstract
Liver disorders with a likely autoimmune pathogenesis in childhood include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is divided into two subtypes according to seropositivity for smooth muscle and/or antinuclear antibody (SMA/ANA, type 1) or liver kidney microsomal antibody (LKM1, type 2). There is a female predominance in both. LKM1 positive patients tend to present more acutely, at a younger age, and commonly have partial IgA deficiency, while duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in both groups. The most common type of paediatric sclerosing cholangitis is ASC. The clinical, biochemical, immunological, and histological presentation of ASC is often indistinguishable from that of AIH type 1. In both, there are high IgG, non-organ specific autoantibodies, and interface hepatitis. Diagnosis is made by cholangiography. Children with ASC respond to immunosuppression satisfactorily and similarly to AIH in respect to remission and relapse rates, times to normalization of biochemical parameters, and decreased inflammatory activity on follow up liver biopsies. However, the cholangiopathy can progress. There may be evolution from AIH to ASC over the years, despite treatment. De novo AIH after liver transplantation affects patients not transplanted for autoimmune disorders and is strikingly reminiscent of classical AIH, including elevated titres of serum antibodies, hypergammaglobulinaemia, and histological findings of interface hepatitis, bridging fibrosis, and collapse. Like classical AIH, it responds to treatment with prednisolone and azathioprine. De novo AIH post liver transplantation may derive from interference by calcineurin inhibitors with the intrathymic physiological mechanisms of T-cell maturation and selection. Whether this condition is a distinct entity or a form of atypical rejection in individuals susceptible to the development of autoimmune phenomena is unclear. Whatever its etiology, the recognition of this potentially life-threatening syndrome is important since its management differs from that of standard anti-rejection therapy.
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Longhi MS, Meda F, Wang P, Samyn M, Mieli-Vergani G, Vergani D, Ma Y. Expansion and de novo generation of potentially therapeutic regulatory T cells in patients with autoimmune hepatitis. Hepatology 2008; 47:581-91. [PMID: 18220288 DOI: 10.1002/hep.22071] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED CD4+CD25+ regulatory T cells (T-regs) are central to the maintenance of immune tolerance and represent an immune intervention candidate in autoimmune hepatitis (AIH), a condition characterized by impaired T-reg number and function. We investigated whether T-regs can be expanded from the existing CD4+CD25+ T cell pool and generated de novo from CD4+CD25- T cells in AIH patients and healthy controls. Purified CD4+CD25+ and CD4+CD25- T cells from 24 patients with type 1 AIH and 22 healthy controls were cultured for up to 5 weeks with anti-CD3/anti-CD28 T cell expander and high-dose interleukin-2 (IL-2). Cell phenotypes, suppressor ability, forkhead winged/helix transcription factor box P3 (FOXP3) gene, and protein expression were assessed weekly by cytofluorimetry, proliferation assay, real-time polymerase chain reaction (PCR), and immunoblot. During culture, the number of CD4+CD25+ T cells derived from the existing T-reg pool (expanded T-regs) and generated de novo from CD4+CD25- T cells (newly generated T-regs) increased constantly up to week 4 in both healthy controls and, to a lesser extent, in AIH patients. Expanded T-regs retained conventional T-reg phenotype and, compared with baseline, demonstrated more vigorous suppressive function and increased FOXP3 gene and protein expression. Newly generated T-regs not only acquired T-reg phenotype but underwent greater growth and were more resistant to apoptosis than expanded T-regs. Their suppressive function augmented throughout culture, reaching a peak at week 4, preceded by a peak FOXP3 gene and protein expression at week 2. Suppressor function and FOXP3 expression of both expanded and newly generated T-regs were higher in normal controls than in AIH patients. CONCLUSION Functionally enhanced T-regs can be expanded and generated de novo in patients with AIH. This finding may assist in reconstituting impaired immune regulation and restoring peripheral tolerance through T-reg infusion in this condition.
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Affiliation(s)
- Maria Serena Longhi
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, Denmark Hill, London, UK
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Seyam M, Neuberger JM, Gunson BK, Hübscher SG. Cirrhosis after orthotopic liver transplantation in the absence of primary disease recurrence. Liver Transpl 2007; 13:966-74. [PMID: 17370332 DOI: 10.1002/lt.21060] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver allograft cirrhosis is a relatively uncommon complication of liver transplantation. Most cases can be attributed to disease recurrence, particularly recurrent hepatitis C. Little is known about the frequency, etiology, and natural history of liver allograft cirrhosis occurring without evidence of recurrent disease. The aim of the present study was to review the clinicopathological features in this group of patients. We retrospectively reviewed data from all adult patients who were transplanted between 1982 and 2002 and survived >12 months after orthotopic liver transplantation (n = 1,287). Cases of histologically proven cirrhosis were identified from histopathological data entered into the Liver Unit Database. A total of 48 patients (3.7%) developed cirrhosis. In 29 of them, cirrhosis could be attributed to recurrent disease (hepatitis C, 11; hepatitis B, 4; autoimmune hepatitis, 4; primary biliary cirrhosis, 2; primary sclerosing cholangitis, 3; nonalcoholic steatohepatitis, 4; alcoholic liver disease, 1). In 9 of the 19 patients without evidence of disease recurrence, another cause of cirrhosis could be identified (de novo autoimmune hepatitis, 4; biliary complications, 4; acquired hepatitis B, 1). In the remaining 10 cases, the cause of cirrhosis remained unknown; their previous biopsies had shown features of chronic hepatitis of uncertain etiology. Three patients in this group died, and the remaining 7 are alive with good graft function 3-12 years after cirrhosis was first diagnosed. The prevalence of "cryptogenic" posttransplant cirrhosis was significantly higher in patients initially transplanted for fulminant seronegative hepatitis (6%) than in those transplanted for other diseases (0.3%). In conclusion, posttransplant cirrhosis without disease recurrence is uncommon, but it is more frequent in patients transplanted for fulminant seronegative hepatitis. Chronic hepatitis is the most frequent underlying pathological process in cases where the cause of cirrhosis remains uncertain.
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Affiliation(s)
- Moataz Seyam
- Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Venick RS, McDiarmid SV, Farmer DG, Gornbein J, Martin MG, Vargas JH, Ament ME, Busuttil RW. Rejection and steroid dependence: unique risk factors in the development of pediatric posttransplant de novo autoimmune hepatitis. Am J Transplant 2007; 7:955-63. [PMID: 17391135 DOI: 10.1111/j.1600-6143.2006.01717.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Posttransplant de novo autoimmune hepatitis (d-AIH) is increasingly described as a long-term complication after pediatric liver transplantation (LT). d-AIH is characterized by graft dysfunction, the development of autoimmune antibodies and histologic evidence of hepatitis in liver transplant recipients without previous history of autoimmune liver disease. This study is a matched case-control, univariate analysis aimed at identifying risk factors for the development of d-AIH and evaluating response to treatment. From 1984 to 2003, 619 children received 788 LTs at a single center. Forty-one patients developed d-AIH and were matched with controls for year of LT, age at time of LT and diagnosis. The following variables were insignificant in the development of d-AIH: age, gender, race, initial diagnosis, ischemia time, graft type, Epstein-Barr virus and cytomegalovirus status, HLA typing and primary immunosuppression. Compared to controls, d-AIH patients were less likely to be on monotherapy immunosuppression or weaned off prednisone at the time of diagnosis. The d-AIH group relative to the controls had statistically significant greater numbers of rejection episodes. d-AIH was treated with prednisone and/or MMF in 39 of 41 patients and lead to significant improvements in liver function tests. Thirty-nine patients are alive at a mean of 4.0 years follow-up after diagnosis. Three have required retransplantation.
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Affiliation(s)
- R S Venick
- Department of Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Sipe WE, Rosenthal P. Autoimmune hepatitis in children: diagnosis, pathology and treatment. Expert Rev Clin Immunol 2007; 3:159-69. [PMID: 20477105 DOI: 10.1586/1744666x.3.2.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune hepatitis (AIH) is characterized by progressive inflammation of the liver and destruction of liver parenchyma. Rare in absolute terms, it is nevertheless an important cause of noninfectious chronic liver disease in children. In many ways, the diagnosis and treatment of children with AIH has changed little over the last 10 years. However, in recent years, steady progress in defining the genetic, immunologic and potential environmental triggers that underlie this disease, in addition to increasing experience with a wider array of therapeutic agents, promises to expand our understanding and ability to treat AIH effectively. This review will summarize the current clinical and pathophysiological understanding of AIH in children, along with therapeutic options.
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Affiliation(s)
- Walter Eb Sipe
- University of California, Division of Pediatric Gastroenterology, Hepatology and Nutrition, 500 Parnassus Avenue, Box 0136, San Francisco, CA 94143-0136, USA.
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Kerkar N, Annunziato RA, Foley L, Schmeidler J, Rumbo C, Emre S, Shneider B, Shemesh E. Prospective analysis of nonadherence in autoimmune hepatitis: a common problem. J Pediatr Gastroenterol Nutr 2006; 43:629-34. [PMID: 17130740 DOI: 10.1097/01.mpg.0000239735.87111.ba] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To prospectively assess nonadherence to medications, the relationship between nonadherence and medical outcome and the relationship between a psychiatric risk factor (posttraumatic stress) and nonadherence in patients with a diagnosis of autoimmune hepatitis. PATIENTS AND METHODS Data were obtained in children with autoimmune hepatitis, who had consented to prospective monitoring of adherence, during 1 year of follow-up in our pediatric liver program. An electronic monitoring device as well as posttransplant trough blood levels of tacrolimus was used to evaluate adherence. A validated self-report questionnaire was used to assess posttraumatic stress. The medical outcome measure was the maximal alanine transaminase (ALT) for each monitored patient. RESULTS Of 37 pediatric patients, 34 (15 posttransplant) enrolled. Fourteen (41%) used the monitoring device as directed. Monitor readings ranged between 28% and 94% of optimal adherence (100%). No patient took the medications exactly as prescribed. Electronic monitoring device readings correlated inversely with maximal ALT (P = 0.03, r = -0.59), and were also correlated with the tacrolimus level variability as a measure of adherence (P = 0.04, r = -0.72). Posttraumatic stress disorder questionnaire scores were correlated with both measures of adherence (for electronic monitoring, P = 0.02, r = -0.70, for tacrolimus levels, P = 0.03, r = 0.62). CONCLUSIONS Nonadherence to immunosuppressants was common in this cohort, and it correlated with higher maximal ALT. Nonadherence is therefore an important risk factor for poor outcome in patients with autoimmune hepatitis. Posttraumatic stress symptoms, which were correlated with nonadherence, may serve as a focus for adherence-improving interventions.
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Affiliation(s)
- Nanda Kerkar
- Department of Pediatrics, Division of Pediatric Hepatology, Recanati Miller Transplant Institute, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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Kerkar N, Cohen S, Dugan C, Morotti RA, Phelps RG, Herold B, Shneider B, Emre S. Bullous pemphigoid after liver transplantation for liver failure. Liver Transpl 2006; 12:1705-10. [PMID: 17058253 DOI: 10.1002/lt.20930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coomb's positive autoimmune hemolytic anemia with giant cell hepatitis (GCH) is a rare cause of liver failure and is usually associated with poor prognosis. A child with liver kidney microsomal (LKM) antibody positivity underwent successful liver transplantation for liver failure secondary to GCH with Coomb's positive hemolytic anemia. Autoimmune neutropenia developed ten months after transplant. Four months later, pemphigoid skin lesions developed. The diagnosis of bullous pemphigoid (BP) was made on the basis of skin biopsy, direct and indirect immunofluorescence test results. Treatment was with immunosuppressants - prednisone and azathioprine/rapamycin, with addition of dapsone when lesions persisted. This child is unique in that his liver function and hemolytic anemia appeared to normalize after liver transplant, but neutropenia and BP both thought to be autoimmune in etiology, developed more than a year post-transplant.
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Affiliation(s)
- Nanda Kerkar
- Division of Pediatric Hepatology, Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA.
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Banerjee S, Rahhal R, Bishop WP. Azathioprine monotherapy for maintenance of remission in pediatric patients with autoimmune hepatitis. J Pediatr Gastroenterol Nutr 2006; 43:353-6. [PMID: 16954959 DOI: 10.1097/01.mpg.0000232331.93052.dd] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Autoimmune hepatitis (AIH) is a chronic disorder characterized by unresolving liver inflammation and has a fluctuating clinical course. Standard therapy has been corticosteroids given daily, alone or in combination with azathioprine (AZA). The potential for significant side effects from prolonged corticosteroid use remains high. To date, no pediatric literature describes long-term AZA monotherapy after induction of remission with corticosteroids. We conducted a retrospective chart review from 1990 to 2002, which revealed 8 patients with AIH. Three patients were excluded because of other diseases requiring continued or intermittent use of corticosteroids. The time to complete biochemical remission on corticosteroids and AZA was 230 days (range, 74-288 days). Azathioprine was introduced early following the diagnosis (range, 1-35 days). All 5 patients were successfully weaned off corticosteroids after a median of 378 days and were maintained on AZA monotherapy for a median of 37 months (range, 28-82 months). One patient had a disease exacerbation on AZA monotherapy 75 months after the discontinuation of corticosteroids. She responded quickly to a corticosteroid burst and has been on AZA monotherapy for 7 months. One patient relapsed after self-discontinuing all medications. Long-term remission of AIH was possible in our case series with the early introduction and maintenance treatment with AZA as monotherapy.
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Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR, Dhawan A, Rosenthal P, Rodriguez-Baez N, Murray KF, Horslen S, Martin MG, Lopez MJ, Soriano H, McGuire BM, Jonas MM, Yazigi N, Shepherd RW, Schwarz K, Lobritto S, Thomas DW, Lavine JE, Karpen S, Ng V, Kelly D, Simonds N, Hynan LS. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 2006; 148:652-658. [PMID: 16737880 PMCID: PMC2662127 DOI: 10.1016/j.jpeds.2005.12.051] [Citation(s) in RCA: 538] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2005] [Revised: 10/03/2005] [Accepted: 12/19/2005] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To determine short-term outcome for children with acute liver failure (ALF) as it relates to cause, clinical status, and patient demographics and to determine prognostic factors. STUDY DESIGN A prospective, multicenter case study collecting demographic, clinical, laboratory, and short-term outcome data on children from birth to 18 years with ALF. Patients without encephalopathy were included if the prothrombin time and international normalized ratio remained > or = 20 seconds and/or >2, respectively, despite vitamin K. Primary outcome measures 3 weeks after study entry were death, death after transplantation, alive with native liver, and alive with transplanted organ. RESULTS The cause of ALF in 348 children included acute acetaminophen toxicity (14%), metabolic disease (10%), autoimmune liver disease (6%), non-acetaminophen drug-related hepatotoxicity (5%), infections (6%), other diagnosed conditions (10%); 49% were indeterminate. Outcome varied between patient sub-groups; 20% with non-acetaminophen ALF died or underwent liver transplantation and never had clinical encephalopathy. CONCLUSIONS Causes of ALF in children differ from in adults. Clinical encephalopathy may not be present in children. The high percentage of indeterminate cases provides an opportunity for investigation.
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Affiliation(s)
- Robert H Squires
- University of Pittsburgh, Children's Hospital of Pittsburgh, PA 15213, USA.
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Bellomo-Brandão MA, Costa-Pinto EALD, De Tommaso AMA, Hessel G. Clinical and biochemical features of autoimmune hepatitis in 36 pediatric patients. ARQUIVOS DE GASTROENTEROLOGIA 2006; 43:45-9. [PMID: 16699618 DOI: 10.1590/s0004-28032006000100012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Few studies on autoimmune hepatitis have enrolled non-Caucasian groups. AIMS: To evaluate Brazilian children with type 1 and 2 autoimmune hepatitis regarding outcome and clinical and biochemical parameters. PATIENTS AND METHODS: Thirty-six patients were submitted to a protocol that evaluated the clinical history, physical and biochemical data, and the course of the disease. Twenty-four children had type 1 autoimmune hepatitis, seven had type 2 and five had unclassified autoimmune hepatitis. Most patients were females (77%), with a median age at diagnosis of 11 years, and the median duration of symptoms was 5.5 and 8 months for types 1 and 2, respectively. Jaundice and choluria were the most common clinical manifestations. RESULTS: Treatment with azathioprine and prednisone was successful in patients with type 1 and 2 autoimmune hepatitis. AST and ALT decreased after 4 to 8 weeks of treatment compared to pretreatment levels in type 1 autoimmune hepatitis. Increased GGT values returned to pretreatment levels after 1 year in the two types. Three patients died and three other patients underwent liver transplantation. CONCLUSIONS: Non-Caucasian children had a similar disease when compared to Caucasian ones with autoimmune hepatitis. Increased levels of GGT during the first year of treatment should not be the only parameter for the indication of cholangiopathy.
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Lykavieris P, Benichou JJ, Benkerrou M, Feriot JP, Bernard O, Debray D. Autoimmune liver disease in three children with sickle cell disease. J Pediatr Gastroenterol Nutr 2006; 42:104-8. [PMID: 16385263 DOI: 10.1097/01.mpg.0000162480.81900.af] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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White FV, Dehner LP. Viral diseases of the liver in children: diagnostic and differential diagnostic considerations. Pediatr Dev Pathol 2004; 7:552-67. [PMID: 15630523 DOI: 10.1007/s10024-004-8101-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 09/01/2004] [Indexed: 01/04/2023]
Abstract
This review summarizes the general histologic features of acute and chronic hepatitides and highlights those morphologic findings that may suggest or be diagnostic of a specific agent or etiology. The main epidemiologic, clinical, and pathologic features of the hepatotropic viruses are discussed, with an emphasis on pediatric studies and the differential diagnosis of hepatitis in childhood.
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Affiliation(s)
- Frances V White
- Department of Pathology and Immunology, Lauren V. Ackerman Laboratory of Surgical Pathology,St. Louis Children's Hospital at the Washington University Medical Center, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Bridoux-Henno L, Maggiore G, Johanet C, Fabre M, Vajro P, Dommergues JP, Reinert P, Bernard O. Features and outcome of autoimmune hepatitis type 2 presenting with isolated positivity for anti-liver cytosol antibody. Clin Gastroenterol Hepatol 2004; 2:825-30. [PMID: 15354284 DOI: 10.1016/s1542-3565(04)00354-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Autoimmune hepatitis (AIH) type 2 is identified by the presence in the serum of anti-liver/kidney microsome type 1 autoantibody. Anti-liver cytosol autoantibody has been reported in children with autoimmune liver disorders mostly in association with anti-liver/kidney microsome reactivity. However, its role as a sole marker of AIH type 2 is debated. We describe here a series of 18 children and adolescents (15 girls, 3 boys) with AIH with serum anti-liver cytosol type 1 (aLC1) as the only autoimmune marker. METHODS A retrospective review was conducted from 3 pediatric hepatology units of all children with an autoimmune liver disease associated with aLC1 as found by immunofluorescence and/or immunodiffusion or immunoblotting. RESULTS Age at first symptoms ranged from 11 months to 14 years; 12 children presented with acute hepatitis, 1 with progressive jaundice, and 5 were asymptomatic. Anti-liver/kidney microsome, antimitochondria, and anti-actin autoantibodies were not detected. Signs of cirrhosis were present in 11 children. Immunosuppressive treatment was effective in all except 2 children who had subfulminant hepatic failure and who required liver transplantation. Sixteen patients (14 with their native liver) currently are alive; 14 patients still are on immunosuppressive therapy after 1 to 22 years. According to the international scoring system for the diagnosis of AIH, 16 patients corresponded to a definite diagnosis and 2 corresponded to a probable diagnosis. CONCLUSIONS The presence of aLC1 in children with acute or chronic liver disease of unknown origin strongly supports a diagnosis of AIH and is an indication for early immunosuppressive therapy.
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Affiliation(s)
- Laure Bridoux-Henno
- Service d'Hépatologie Pédiatrique, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
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Abstract
Autoimmune hepatitis can affect diverse ethnic groups, and its clinical expression and outcome can vary accordingly. An asymptomatic presentation may identify patients who respond more readily to medication. Celiac sprue is important to recognize and treat by gluten restriction. Centrilobular necrosis and coincidental destructive cholangitis do not preclude the diagnosis, and antibodies to soluble liver antigen/liver pancreas may identify patients susceptible to relapse. Women, who have non-DRB1*0401 DR4 alleles more commonly than do men, may respond to a diverse range of autoantigens. DRB1*1301 is associated with autoimmune hepatitis in Brazil, especially among children, and it may favor an indigenous triggering agent. Variant syndromes are heterogenous conditions that probably reflect referral biases, and molecular mimicry between foreign and self-antigens is the basis for most theories of pathogenesis. Immunosuppressive medications (eg, cyclosporine, mycophenolate mofetil) have been used empirically with success, and recurrent and de novo disease after liver transplantation must be considered in all patients with graft dysfunction.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
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