Current therapy for autoimmune hepatitis

Curdlan-Decorated Fullerenes Mitigate Immune-Mediated Hepatic Injury for Autoimmune Hepatitis Therapeutics via Reducing Macrophage Infiltration

Autoimmune hepatitis (AIH) is a severe immune-mediated inflammatory liver disease whose standard of care is immunosuppressive treatment with inevitable undesired outcomes. Macrophage is acknowledged to aggravate liver damage, providing a promising AIH therapeutic target. Accordingly, in this study, a kind of curdlan-decorated fullerene nanoparticle (Cur-F) is fabricated to alleviate immune-mediated hepatic injury for treating AIH via reducing macrophage infiltration in a concanavalin A (Con A)-induced AIH mouse model. After intravenous administration, Cur-F primarily distributes in liver tissues, efficiently eliminates the excessive reactive oxygen species, significantly attenuates oxidative stress, and subsequently suppresses the nuclear factor kappa-B-gene binding (NF-κB) signal pathway, resulting in the lowered production of pro-inflammatory cytokines and the balancing of the immune homeostasis with the prevention of macrophage infiltration in the liver. The regulation of hepatic inflammation contributes to inhibiting inflammatory cytokines-induced hepatocyte apoptosis, decreasing the serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) contents and thus ameliorating immune-mediated hepatic injury. Notably, there is no detectable toxicity to the body. Our findings may open up novel avenues for AIH based on curdlan and fullerene materials.

[Treatment of Autoimmune Hepatitis]

Autoimmune hepatitis (AIH) is a chronic liver disease, characterized by elevated levels of transaminases, immunoglobulin G, and positive autoantibodies. The disease course is dynamic and presents heterogeneous disease manifestations at diagnosis. This review summarizes the issues regarding the treatment and monitoring of AIH in adult patients. Glucocorticoids and azathioprine are the first line of treatment. Alternative first-line treatments include budesonide or mycophenolate mofetil (MMF). Although no randomized controlled trials have been performed, MMF, cyclosporine, tacrolimus, 6-mercaptopurine, 6-thioguanine, allopurinol, sirolimus, everolimus, infliximab, or rituximab have been attempted in patients not responding to or intolerant to first-line treatments. Most patients require life-long special monitoring, with or without maintenance treatment.

Mitochondrial-encoded MOTS-c prevents pancreatic islet destruction in autoimmune diabetes

Mitochondria are principal metabolic organelles that are increasingly unveiled as immune regulators. However, it is currently not known whether mitochondrial-encoded peptides modulate T cells to induce changes in phenotype and function. In this study, we found that MOTS-c (mitochondrial open reading frame of the 12S rRNA type-c) prevented autoimmune β cell destruction by targeting T cells in non-obese diabetic (NOD) mice. MOTS-c ameliorated the development of hyperglycemia and reduced islet-infiltrating immune cells. Furthermore, adoptive transfer of T cells from MOTS-c-treated NOD mice significantly decreased the incidence of diabetes in NOD-severe combined immunodeficiency (SCID) mice. Metabolic and genomic analyses revealed that MOTS-c modulated T cell phenotype and function by regulating T cell receptor (TCR)/mTOR complex 1 (mTORC1) signaling. Type 1 diabetes (T1D) patients had a lower serum MOTS-c level than did healthy controls. Furthermore, MOTS-c reduced T cell activation by alleviating T cells from the glycolytic stress in T1D patients, suggesting therapeutic potential. Our findings indicate that MOTS-c regulates the T cell phenotype and suppresses autoimmune diabetes.

Prognostic factors for remission, relapse, and treatment complications in type 1 autoimmune hepatitis

Background and aim

Autoimmune hepatitis (AIH) is a rare chronic form of hepatitis, the prognosis for which has not been definitively established. The current study aimed to define the prognostic factors for remission and compare the median time to remission, complications, and relapse rate between type 1 AIH patients treated with prednisolone monotherapy and those treated using prednisolone in combination with azathioprine.

Materials and methods

The data of 86 patients diagnosed with type 1 AIH between January 1998 and January 2018 were retrospectively reviewed. Clinical, serological, and histological parameters were obtained. Cox-proportional hazard and logistic regression analyses were applied to the data.

Results

The prognostic factors related to complete remission were absence of liver cirrhosis, hypertension, and azathioprine exposure. The median time to complete remission of the prednisolone group (92 days; 95%CI; 65–264 days) was significantly shorter (P = 0.01) than that of the combination group (336 days; 95%CI; 161–562 days); however, the prednisolone group had higher rates of treatment complications—including skin and soft tissue infections (P = 0.010) and cushingoid appearance (P = 0.011)—than the combination group. The prednisolone group also had a higher relapse rate (odds ratio 6.13, 95% CI 1.72–21.80, P = 0.005).

Conclusions

The absence of liver cirrhosis and hypertension at the time of diagnosis and no azathioprine exposure during the treatment period were favorable prognostic factors for complete remission. The prednisolone group had a significantly shorter median time to complete remission but higher rates of treatment complications and a higher relapse rate than the combination group.

Validation of the Simplified Criteria for the Diagnosis of Autoimmune Hepatitis in Chilean-Hispanic Patients

INTRODUCTION AND AIM

In 2008 the International autoimmune hepatitis (AIH) Group proposed the simplified diagnostic criteria for this disease. The original cohort study was performed in 11 international centers, but validation studies are scarce in Latin-America. The aim of this study is validate these criteria in Hispanic patients.

MATERIAL AND METHODS

A retrospective cohort of patients undergoing percutaneous liver biopsy and follow-up of at least 12 months was recruited from a Chilean University hospital. Patients with previous immunosuppressive therapy and liver transplant recipients were excluded. The diagnostic accuracy was analyzed using as gold standard the clinical course during long-term follow-up. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) and area under the ROC curve (AUROC) were calculated.

RESULTS

Four hundred eighty one patients were evaluated, 294 were included. 218 (74.15%) were female, mean age 48.5 (± 12.3) years, mean follow-up 34 (± 18) months. 66 patients had AIH or overlap syndrome (22.45%), 96 (32.65%) non-alcoholic steatohepatitis, 40 (13.61%) primary biliary cholangitis, 31 (10.54%) hepatitis C, 8 (2.72%) hepatitis B, 53 (18.02%) other etiologies. The AUROC for AIH simplified criteria was 0.976. Using a cutoff ≥ 6 and ≥ 7 points, the sensitivity was 86.4% and 54.6%; specificity, 98.7% and 99.6%; PPV, 95% and 97.3%; and NPV, 96.2% and 88.6%, respectively.

CONCLUSION

Simplified criteria for the diagnosis of AIH have a high accuracy in our Chilean-Hispanic cohort. The female gender is strongly associated to AIH and could help in difficult cases. Further studies with a prospective design are necessary to confirm these observations.

Imaging of autoimmune hepatitis and overlap syndromes

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.

The clinical phenotypes of autoimmune hepatitis: A comprehensive review

Autoimmune hepatitis (AIH) fulfills the generally accepted contemporary criteria of an autoimmune liver disease: the presence of autoantibodies and autoreactive T cells, a female gender bias, association with other autoimmune diseases, response to immunosuppressive therapy and strong associations with the major histocompatibility complex HLA loci. It occurs worldwide in both children and adults and is marked by both etiopathogenic and clinical heterogeneity, differing from the other putative autoimmune liver diseases, primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), albeit occasionally presenting with overlapping features of PBC or PSC. Although diagnostic criteria have been established and validated, there are still major issues to be clarified due to its variability, such as autoantibody-negative AIH, drug-induced AIH, AIH sharing features with PBC or PSC, and post-transplant de novo AIH. In view of the diverse presentations and courses, including classical chronic onset, acute and acute severe onset, cirrhosis and decompensated cirrhosis, individualized management of patients is indicated. Each patient should receive a personalized analysis of the benefits and side effect risks of drugs. Herein we describe a comprehensive review of the clinical phenotypes of AIH underscoring its clinical heterogeneity.

mTOR signaling in T cell immunity and autoimmunity

The mammalian target of rapamycin (mTOR), a phosphoinositide-3-kinase-related protein kinase, acts as a rheostat capable of integrating a variety of environmental cues in the form of nutrients, energy, and growth factors to modulate organismal processes and homeostasis. Recently, there is a growing appreciation of mTOR in adaptive immunity for its crucial roles in keeping a proper balance between T cell quiescence and activation. Under steady-state circumstances, mTOR is subtly inhibited by multiple mechanisms to maintain normal T cell homeostasis. Antigen recognition by naïve T cells leads to mTOR activation, which subsequently promotes the differentiation of these cells into distinct effector T cell subsets. This review focuses primarily on the recent literature with respect to the regulatory effects and mechanisms of mTOR signaling in dictating T cell fate, and discusses the therapeutic implications of mTOR modulation in T-cell-mediated autoimmunity.

Autoimmune hepatitis: a noninfectious killer

PURPOSE

This article reviews autoimmune hepatitis (AIH) to promote early recognition, diagnosis, and referral for nurse practitioners (NPs) encountering this rare condition.

DATA SOURCES

Selected research and clinical articles from Medline, PubMed, and CINAHL.

CONCLUSIONS

AIH is a rare condition of unknown etiology affecting women 3.6 times more than men and may result in liver failure, subsequent liver transplantation, and death. Untreated AH is associated with up to 80% mortality. Collaboration and referral to gastroenterologists, hepatologists, and other specialists are needed to improve outcomes for this potentially devastating disease.

IMPLICATIONS FOR PRACTICE

Corticosteroid treatment has long been the mainstay of treatment of AIH, although newer therapies are promising. NPs can dramatically improve outcomes by early recognition, diagnosis, referral, and monitoring for common side effects of treatment working collaboratively with specialists.

Tissue-specific modulation of mineralocorticoid receptor function by 11β-hydroxysteroid dehydrogenases: an overview

In the last decade significant progress has been made in the understanding of mineralocorticoid receptor (MR) function and its implications for physiology and disease. The knowledge on the essential role of MR in the regulation of electrolyte concentrations and blood pressure has been significantly extended, and the relevance of excessive MR activation in promoting inflammation, fibrosis and heart disease as well as its role in modulating neuronal cell viability and brain function is now widely recognized. Despite considerable progress, the mechanisms of MR function in various cell-types are still poorly understood. Key modulators of MR function include the glucocorticoid receptor (GR), which may affect MR function by formation of heterodimers and by differential genomic and non-genomic responses on gene expression, and 11β-hydroxysteroid dehydrogenases (11β-HSDs), which determine the availability of intracellular concentrations of active glucocorticoids. In this review we attempted to provide an overview of the knowledge on MR expression with regard to the presence or absence of GR, 11β-HSD2 and 11β-HSD1/hexose-6-phosphate dehydrogenase (H6PDH) in various tissues and cell types. The consequences of cell-specific differences in the coexpression of MR with these proteins need to be further investigated in order to understand the role of this receptor in a given tissue as well as its systemic impact.

Treatment of autoimmune hepatitis: a review of current and evolving therapies

Autoimmune hepatitis (AIH) is an immune-mediated necroinflammatory condition of the liver. Presentation can vary from the asymptomatic individual with abnormal liver function test to fulminant liver failure. The diagnosis is based on the combination of biochemical, autoimmune, and histological parameters, and exclusion of other liver diseases. Standard therapy consists of a combination of corticosteroids and azathioprine, which is efficacious in 80% of patients. Alternative therapies are increasingly being explored in patients who do not respond to the standard treatment and/or have unacceptable adverse effects. This review examines the role of alternative drugs (second-line agents) available for AIH treatment non-responders. These agents include budesonide, mycophenolate mofetil, cyclosporin, tacrolimus, 6-mercaptopurine, 6-thioguanine, rituximab, ursodeoxycholic acid, rapamycin, and methotrexate. In addition, the risk of opportunistic infections and malignancies are discussed. A treatment algorithm is proposed for the management of patients with AIH treatment non-responders.

Apolipoprotein A-II suppressed concanavalin A-induced hepatitis via the inhibition of CD4 T cell function

Con A-induced hepatitis has been used as a model of human autoimmune or viral hepatitis. During the process of identifying immunologically bioactive proteins in human plasma, we found that apolipoprotein A-II (ApoA-II), the second major apolipoprotein of high-density lipoprotein, inhibited the production of IFN-γ by Con A-stimulated mouse and human CD4 T cells. Con A-induced hepatitis was attenuated by the administration of ApoA-II. The beneficial effect of ApoA-II was associated with reduced leukocyte infiltration and decreased production of T cell-related cytokines and chemokines in the liver. ApoA-II inhibited the Con A-induced activation of ERK-MAPK and nuclear translocation of NFAT in CD4 T cells. Interestingly, exacerbated hepatitis was observed in ApoA-II-deficient mice, indicating that ApoA-II plays a suppressive role in Con A-induced hepatitis under physiological conditions. Moreover, the administration of ApoA-II after the onset of Con A-induced hepatitis was sufficient to suppress disease. Thus, the therapeutic effect of ApoA-II could be useful for patients with CD4 T cell-related autoimmune and viral hepatitis.

Autoimmune hepatitis: Single-center experience of clinical presentation, response to treatment and prognosis in Saudi Arabia

BACKGROUND/AIM

Autoimmune hepatitis (AIH) is a common cause of end-stage liver disease worldwide. It is a disease prevalent in children and adults, with female predominance and variable clinical presentations. AIH has favorable responses to steroids and immunomodulators. Diagnosis of AIH is based on clinical and laboratory criteria, as suggested by the International Autoimmune Hepatitis Group. Data on the disease pattern of AIH from the Middle East countries is scarce.

MATERIALS AND METHODS

In this retrospective analysis, we studied clinical and laboratory features, immunological data, radiological findings, liver biopsy findings and response to therapy in patients with AIH from the hepatology clinics of King Abdul Aziz, University Hospital, Jeddah, from 1994 to 2008.

RESULTS

We diagnosed 41 patients with AIH, and 33 were included in the analysis. The mean age was 32.3 years, with female predominance of 75.7%. De-compensated cirrhosis at presentation was found in 45.5% of the patients. Acute hepatitis was associated with significantly higher levels of the serum ALT and bilirubin (P=0.001 and P=0.03, respectively). All our patients had type 1 AIH. Treatment with prednisolone and azathioprine resulted in complete or partial remission in majority of the patients (54.8%). However, patients with advanced disease showed a poorer response to treatment (P=0.016). Six patients with poor compliance had relapse of AIH. Two patients had a flare of the disease during pregnancy, and they responded well with prednisolone. The longest follow-up was 14 years and the shortest was 2 months. Four patients died from liver disease.

CONCLUSION

AIH patients in Saudi Arabia are likely to present with advanced disease at a young age and would have a poorer response to therapy as compared with patients in other countries worldwide.

Rapidity of treatment response and outcome in type 1 autoimmune hepatitis

BACKGROUND/AIMS

Corticosteroid therapy is effective in type 1 autoimmune hepatitis. This study determines if the rapidity of response affects outcome.

METHODS

The duration of treatment to improve clinical and laboratory indices was determined retrospectively in 146 patients and correlated with outcome.

RESULTS

Sixteen patients (11%) responded after < or =6 months, and 20 patients did so after 36 months (14%). The rapid responders were older than those who responded slowly (54+/-3 years versus 41+/-4 years, P=0.007), and they had a lower frequency of HLA DRB1 *03 (36% versus 76%, P=0.03). Patients aged > or =60 years responded within 6 months more commonly than adults aged <40 years (18% versus 2%, P=0.02), and most had responded within 24 months (94% versus 64%, P=0.003). Elderly patients who responded quickly had HLA DRB1 *04 more commonly than adults aged <40 years (75% versus 8%, P=0.0001). Progression to cirrhosis (18% versus 54%, P=0.03) and liver transplantation (2% versus 15%, P<0.05) was less common in the rapid responders. The frequencies of a sustained remission (19% versus 10%, P=0.6) and relapse after drug withdrawal (81% versus 90%, P=0.6) were similar between patients with an early and late response.

CONCLUSIONS

A rapid treatment response decreases progression to cirrhosis and liver transplantation, but it does not alter the frequency of sustained remission or relapse after drug withdrawal. Elderly patients respond more quickly to treatment than adults aged <40 years, and they are characterized by HLA DRB1 *04.

Features and consequences of untreated type 1 autoimmune hepatitis

BACKGROUND/AIM

The existence of a mild form of autoimmune hepatitis that does not require treatment remains controversial. The aim of this study was to determine the existence, characteristics and outcome of this form.

METHODS

Untreated patients with type 1 autoimmune hepatitis who did not satisfy pre-established criteria for severe disease were identified retrospectively and compared with treated patients.

RESULTS

Twenty-one of 282 patients (7%) who were evaluated during a 32-year period did not receive corticosteroid treatment. These asymptomatic patients constituted 15% of 137 patients who satisfied similar criteria for mild disease. Untreated patients with mild disease were indistinguishable from 116 treated patients with mild disease, and they differed from 145 treated patients with severe disease only by the pre-established features that defined disease severity. The eight untreated patients with follow-up assessments satisfied remission criteria less commonly than treated patients with mild or severe disease during 77+/-31 months of observation (12 vs 63%, P=0.006), and they had a lower 10-year survival (67 vs 98%, P=0.01). Four patients did improve spontaneously albeit short of remission criteria and remained well for 28+/-15 months (range, 5-73 months). Four patients worsened during 125+/-51 months of observation (range, 32-239 months), including two of three patients with cirrhosis who died of liver failure.

CONCLUSIONS

Mild type 1 autoimmune hepatitis does exist, and it may be as frequent as severe disease. Untreated patients with mild disease can improve spontaneously, but there are no confident indices by which to identify this subgroup and justify withholding treatment.

Current and future treatments of autoimmune hepatitis

Corticosteroid therapy induces clinical, laboratory and histological improvements in 80% of patients with autoimmune hepatitis. Prednisone, alone or at a lower dose in combination with azathioprine, increases the 20-year life expectancy to 80% and prevents or reduces hepatic fibrosis in 79% of patients. The combination regimen is preferred and treatment should be considered in all patients with active disease. The duration of therapy is finite and the medication should be discontinued after resolution of all manifestations of inflammatory activity, including the histological changes. Relapse after drug withdrawal occurs in 50-79% of patients, and it should be treated with long-term azathioprine (2 mg/kg daily). Salvage therapies for individuals intolerant of or refractory to the conventional regimens include high-dose corticosteroids, with or without high-dose azathioprine, 6-mercaptopurine, mycophenolate mofetil, tacrolimus or ciclosporin. Liver transplantation should be considered in patients with hepatic failure unresponsive to corticosteroid treatment, decompensated cirrhosis with a Model for End-Stage Liver Disease score of at least 15 points, or hepatocellular carcinoma that meets transplantation criteria. Autoimmune hepatitis recurs after transplantation in at least 17% of patients, and it typically improves after adjustments in the immunosuppressive regimen. Future therapies are likely to include mesenchymal stem cell transplantation, adoptive transfer of T regulatory cells, and cytokine manipulation. The emergence of new treatments will require the development of a collaborative network of clinical and basic investigators, as the complexity and specificity of current management problems require solutions that exceed the capabilities of single institutions.

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

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

Immunoregulatory functions of mTOR inhibition

The potent immunosuppressive action of rapamycin is commonly ascribed to inhibition of growth factor-induced T cell proliferation. However, it is now evident that the serine/threonine protein kinase mammalian target of rapamycin (mTOR) has an important role in the modulation of both innate and adaptive immune responses. mTOR regulates diverse functions of professional antigen-presenting cells, such as dendritic cells (DCs), and has important roles in the activation of effector T cells and the function and proliferation of regulatory T cells. In this Review, we discuss our current understanding of the mTOR pathway and the consequences of mTOR inhibition, both in DCs and T cells, including new data on the regulation of forkhead box P3 expression.

Nonviral Hepatitis

Chronic liver diseases are a significant cause of death worldwide. Cirrhosis is most frequently caused by hepatitis C or alcohol abuse, but other nonviral etiologies are now recognized as important contributors to the development of hepatitis. Nonalcoholic fatty liver disease, caused by abnormal accumulation of lipids in hepatocytes, can progress from simple steatosis to necroimflammation and cirrhosis. It is estimated to occur in up to 40% of the general population, and its pathophysiology is closely linked to features of metabolic syndrome. There is currently no proven treatment for nonalcoholic fatty liver disease. Management strategies largely address identification and treatment of associated risk factors and include drug therapy for obesity, insulin resistance (eg, metformin, thiazolidinediones), and dyslipidemia (eg, fibrates, HMG-CoA reductase inhibitors). Autoimmune hepatitis is characterized by necroinflammation mediated by autoantibody attack against liver antigens in genetically predisposed patients. It is considered a rare form of chronic liver disease but can progress to cirrhosis if unrecognized and untreated. Autoimmune hepatitis usually responds well to long-established immunosuppressive regimens with prednisone and azathioprine; however, new approaches are required for those patients who do not achieve or sustain desired outcomes or are intolerant to standard therapy.

A single center review of the use of mycophenolate mofetil in the treatment of autoimmune hepatitis

BACKGROUND & AIMS

Standard treatment for autoimmune hepatitis (AIH) involves immune suppression by using prednisone alone or in combination with azathioprine (AZA). Although this regimen achieves remission in approximately 80%, some patients are intolerant or do not respond. Mycophenolate mofetil (MMF) is a potent immunosuppressant. However, its utility in AIH is not well-defined.

METHODS

We performed a retrospective longitudinal analysis of patients with AIH.

RESULTS

We identified 128 patients with AIH: mean age, 42.8 years; 83% female; 69% white. At presentation, median AST and ALT were 227 and 261 U/L, respectively, and bridging fibrosis and cirrhosis were present in 38% and 22%, respectively. Overall, 29 patients received MMF; 12 were switched to MMF after intolerance or nonresponse to prednisone +/- AZA, whereas 17 received MMF +/- prednisone as initial therapy. The main reasons for switching to MMF were nausea/vomiting (n = 4) and failure to normalize liver enzymes (n = 3). Ten of the 29 patients who received MMF therapy (34%) discontinued MMF as a result of side effects. Sixteen (84%) of the remaining 19 patients on MMF achieved remission, which closely matched the remission rate of those who remained on prednisone +/- AZA (82%). The only independent clinical factor that predicted the eventual need for the use of MMF was absence of cirrhosis (P = .0067).

CONCLUSIONS

(1) MMF was associated with a high rate of intolerance (34%). (2) In those who could tolerate it, it was associated with a high rate of remission (84%). (3) Absence of cirrhosis on presentation was the only independent factor associated with eventual need for MMF.

New insights into autoimmune liver diseases

Autoinflammatory liver disease represents an important aspect of global hepatological practice. The three principal disease divisions recognized are autoimmune hepatitis, primary sclerosing cholangitis and primary biliary cirrhosis. Largely, but not exclusively, these diseases are considered to be autoimmune in origin. Increased recognition of outlier and overlap syndromes, changes in presentation and natural history, as well as the increased awareness of IgG4-associated sclerosing cholangitis, all highlight the limitations of the classic terminology. New insights continue to improve the care given to patients, and have arisen from carefully conducted clinical studies, therapeutic trials, as well as genetic and laboratory investigations. The challenges remain to treat patients before liver injury becomes permanent and to prevent the development of organ failure.

Safety issues in the management of autoimmune hepatitis

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Autoimmune liver disease

PURPOSE OF REVIEW

To review studies that improve the diagnosis and treatment of autoimmune hepatitis and extend understanding of its pathogenic mechanisms.

RECENT FINDINGS

Black patients have more advanced disease and poorer outcomes than white patients. Genome-wide DNA microsatellite techniques have identified multiple regions that may confer susceptibility or resistance to the disease. Preferential inactivation of one parentally-derived X chromosome may favor autoreactivity in women. Acute and chronic hepatitis of undetermined cause can respond to corticosteroid therapy and represent autoantibody-negative autoimmune hepatitis. Outcomes can be improved by continuing therapies until resolution of all features and by early identification of problematic patients with the Model for End Stage Liver Disease. Serum levels of B-cell activating factor correlate with laboratory indices of liver injury. Tacrolimus and mycophenolate mofetil are promising therapies for problematic patients, and the antigenic targets of atypical antibodies to liver/kidney microsome may lead to diagnostic tests for de-novo autoimmune hepatitis after liver transplantation.

SUMMARY

Ethnic background and genetic predisposition affect the occurrence and outcome of autoimmune hepatitis. Susceptibility and resistance factors across the human genome underscore the genetic complexity of the disease. Outcomes can be improved by better use of current regimens and further evaluation of action-specific immunosuppressive agents.

[Medical therapy of complications in liver cirrhosis]

Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.

Hepatitis B and end-stage liver disease

Hepatitis B virus (HBV) is the most common cause of chronic hepatitis and end-stage liver disease worldwide. Untreated, chronic hepatitis B acquired early in life results in cirrhosis, liver failure, or hepatocellular carcinoma in up to 40% of individuals. Until recently, the options for a patient who had end-stage hepatitis B cirrhosis were severely limited, but during the past 15 years great strides have been made in prevention and treatment of hepatitis B cirrhosis. This article reviews recent advances in the understanding of the natural history, prevention, and medical management of HBV-related end-stage liver disease.