Autoimmune hepatitis and overlap syndromes

High seroprevalence of anti-Hepatitis E antibodies in Austrian patients with autoimmune hepatitis

BACKGROUND & AIMS

Increasing numbers of autochthonous hepatitis E virus infections have been reported in Europe. Chronic infections have been shown in immune-compromised patients after solid organ transplantation. Hepatitis E virus might be a possible trigger for autoimmune hepatitis and might cause disease flares or relapses in the further course of disease. Aim of this study was to investigate the presence of hepatitis E virus antibodies and hepatitis E virus RNA, and to analyse their impact on immunosuppressive treatment in patients with autoimmune hepatitis.

METHODS

Sera from 92 autoimmune hepatitis patients (73/79.3% female, age: 42.2 ± 16.3 years [mean ± SD]) were tested. Patients were scored according to the simplified and revised scoring systems of the International Autoimmune Hepatitis Group. The prevalence of anti- hepatitis E virus antibodies (Beijing Wantai Biological Pharmacy Enterprises Co., Ltd, Beijing, China) and hepatitis E virus RNA was determined.

RESULTS

19/20.7% autoimmune hepatitis patients tested positive for hepatitis E virus-IgG, which was higher than in previous reports of healthy Austrian individuals (12.4%, P = 0.031); hepatitis E virus RNA was not detectable in any patient. Anti-hepatitis E virus positive patients were older (49.5 ± 9.5 vs 40.4 ± 17.2 years [mean ± SD], P = 0.033) but did not differ in laboratory findings at diagnosis (AST: 14.6 [1.3-70.6] vs 9.5 [0.7-62.7] × ULN [median/range]; P = 0.387, alanine aminotransferase: 18.3 [1.6-62.7] vs. 12.9 [0.8-62.6] × ULN; P = 0.511; IgG: 1.4 [1.0-2.5] vs 1.3 [0.6-3.8] g/dL × ULN; P = 0.278) nor in alanine aminotransferase levels after six months (0.7 [0.5-2.4] vs 1.0 U/L × ULN [0.1-22.4]; P = 0.077).

CONCLUSIONS

No chronic hepatitis E virus infection was observed in our cohort of autoimmune hepatitis patients. Anti- hepatitis E virus-IgG positive patients were older and the seroprevalence was nearly twice as high as reported previously in healthy Austrian individuals, suggesting that hepatitis E virus-infection might act as trigger for the development of autoimmune hepatitis.

Contrasting Pattern of Chronic Inflammatory Bowel Disease in Primary and Autoimmune Sclerosing Cholangitis

Background

Primary sclerosing cholangitis (PSC) and autoimmune sclerosing cholangitis (AISC) are related, but distinct chronic liver diseases. PSC is associated with a high prevalence of ulcerative colitis while the intestinal inflammation associated with AISC is less well characterised.

Aims

To assess and contrast aspects of intestinal inflammation in patients with AISC and PSC and compare the clinical features with those of patients with ulcerative colitis and Crohn's disease.

Methods

23 and 22 patients with AISC and PSC, respectively, underwent review of colonoscopy and biopsy findings, capsule enteroscopy and assessment of clinical and inflammatory (faecal calprotectin) disease activity, which was compared with that of patients with ulcerative colitis and Crohn's disease (n = 55 each).

Findings

Five and 6 patients with AISC and PSC, respectively, had normal colonoscopy and faecal calprotectin levels of 34.4 ± 8.3 and 39.7 ± 8.4 μg/g, respectively (normal < 50 μg/g), whereas 18 and 16, respectively, had identical variably severe, right sided colitis with frequent rectal sparing, consistent with ulcerative colitis. Mean (± SD) faecal calprotectin levels did not differ significantly (p > 0.05) between patients with intestinal inflammation in AISC (588 ± 549 μg/g), PSC (421 ± 351 μg/g), ulcerative colitis (501 ± 656 μg/g) or Crohn's disease (476 ± 571 μg/g). Capsule enteroscopy showed that 7 of 18 (39%) (p < 0.03) of those with AISC had small bowel mucosal breaks whereas no patient with PSC had these findings.

Interpretation

Collectively these findings lend support to the suggestion that the chronic inflammatory bowel disease associated with PSC and in particular AISC may represent a distinct nosologic entity different from classic ulcerative colitis and Crohn's disease.

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The ulcerative colitis (UC) associated with autoimmune and primary sclerosing cholangitis behaves differently to classic UC.

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Patients with autoimmune and primary sclerosing cholangitis have similar pattern of colitis, resembling ulcerative colitis.

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39% of those with autoimmune sclerosing cholangitis had small intestinal mucosal breaks resembling Crohn’s disease.

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The colitis associated with these chronic liver diseases differs distinctively from classic inflammatory bowel disease.

Most patients with the chronic liver disease primary sclerosing cholangitis have a colitis, which is classified as ulcerative colitis. Here we show that patients with a related liver disease, namely autoimmune sclerosing cholangitis, have an identical colitis, but 39% also have small bowel erosions or ulcers which is more suggestive of Crohn's disease. Intestinal inflammatory activity was similar in these patients as compared with patients with ulcerative colitis and Crohn's disease. Collectively these findings and the contrasting natural history of the colitis of chronic liver suggests that this represents a separate nosologic entity from classic inflammatory bowel disease.

Diagnosis and treatment of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a generally progressive, chronic liver disease of unknown etiology, relatively uncommon, associated with chronic hepatic inflammation. An environmental agent is hypothesized to trigger an immune-mediated attack directed against liver antigens in genetically predisposed individuals. The disease can lead to potentially fatal liver dysfunction. AIH is characterized by female predominance (sex ratio 3.6:1), hypergammaglobulinemia, circulating autoantibodies and association with human leukocyte antigens DR3 or DR4. The diagnosis of AIH is based on the revised descriptive criteria reported by the International Autoimmune Hepatitis Group in 1999. Without appropriate immunosuppressive therapy AIH has a very poor prognosis with 10-year survival rates as low as 10%, but usually very good response to immunosuppression, and survival rates of responders to the treatment are similar to those of healthy counterparts from the same population.

CLINICOLABORATORY CHARACTERISTICS OF JAPANESE PATIENTS WITH PRIMARY BILIARY CIRRHOSIS-AUTOIMMUNE HEPATITIS OVERLAP

To clarify the clinicolaboratory characteristics of patients with primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap, we analyzed their clinicolaboratory findings and compared them with those of patients with AIH or PBC retrospectively. We analyzed the laboratory findings of 177 patients that diagnosed 103 PBC and 74 AIH patients at our department during the period from January 1990 to April 2005. Of 103 PBC patients with a diagnosis of PBC, we identified 10 cases (9.7%) of PBC-AIH overlap (2 male, 8 female; mean age 56.5 years). PBC preceded AIH in 2 patients, and both diseases occurred simultaneously in the other 8 patients. There is no patients AIH preceded PBC. Positive frequency of anti-smooth muscle antibody (ASMA), IgG and IgM levels were significantly higher in patients with overlap than in those with AIH or PBC. Ursodeoxychoric acid (UDCA) was administered to all 10 patients initially, and later an immunosuppressant, prednisolone or azathioprine, was added in 6 patients. Two of the 10 patients died of liver failure 5 and 12 years after diagnosis, respectively. Both patients had been treated by either prednisolone or UDCA alone. We conclude that in patients with PBC-AIH overlap, the clinical characteristics of both PBC and AIH exist in an enhanced manner.

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[Primary biliary liver cirrhosis and overlap syndrome. Diagnosis and therapy]

Primary biliary cirrhosis represents a chronic cholestatic liver disease of unknown etiology. It primarily affects females, is associated with extrahepatic immune-mediated syndromes, shows an immunogenetic association with HLA DR8, and displays serum autoantibodies, which makes an autoimmune etiology likely. The diagnosis is reached in patients with elevated alkaline phosphatase, gamma glutamyl transferase and bilirubin levels who exhibit normal bile ducts upon ultrasound examination, and in whom specific antimitochondrial autoantibodies are detectable. Half of all PBC patients additionally show specific antinuclear autoantibodies. Immunosuppressive therapy is ineffective; steroids, transplant immunosuppressants, colchicine, d-penicillamine and methotrexate are of limited clinical benefit. Ursodeoxycholic acid has few side effects and leads to a biochemical response and a delay of disease progression in most cases. When ursodeoxycholic acid therapy is ineffective an overlap syndrome with autoimmune hepatitis can be present, which can respond to steroid treatment. The only curative option is liver transplantation which should be considered when bilirubin levels exceed 100 microM/l.

Frequency and predictive factors for overlap syndrome between autoimmune hepatitis and primary cholestatic liver disease

OBJECTIVES

To evaluate the frequency of cholestatic pattern in patients with autoimmune hepatitis (AIH) and to identify predictive factors associated with the development of the overlap syndrome.

METHODS

Eighty-two consecutive patients diagnosed with AIH at the referral centre between January 1998 and June 2002 were included in the study. The new scoring system modified by the International Autoimmune Hepatitis Group was used to classify patients as definite/probable. Overlap syndrome was considered when the patient had clinical, serological and histological characteristics of two conditions: AIH and primary biliary cirrhosis (PBC) or AIH and primary sclerosing cholangitis (PSC).

RESULTS

From the 82 AIH patients (76 female and six male), 84.1% presented definite AIH (> 15 points) and 15.9% probable AIH (10 - 15 points). The frequency of the overlap syndrome was 20%: 13% with PBC and 7% with PSC. In the univariate analysis the overlap syndrome was associated with male gender (P = 0.01), age < 35 years (P < 0.0001), histopathological aspect of cholestasis (P < 0.0001), suboptimal response to treatment (P < 0.0001) and probable AIH (P < 0.0001). Age < 35 years, probable AIH and the absence of anti-nuclear antibody (ANA) have been identified as independent indicators of the overlap diagnosis by the logistic regression analysis.

CONCLUSION

Patients with overlap syndrome between AIH and primary cholestatic liver disease are frequently diagnosed in clinical practice, representing 20% of AIH cases in our study. The independent predictive factors associated with the diagnosis of overlap syndrome are young age, ANA(-) profile, and probable diagnosis according with the scoring system for AIH.