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Moßhammer D, Reichert MC. [Laboratory diagnostics of autoimmune liver diseases in primary care settings - short review]. Dtsch Med Wochenschr 2024; 149:1282-1286. [PMID: 39384210 DOI: 10.1055/a-2367-9603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2024]
Abstract
BACKGROUND AND AIMS Elevated liver enzymes (ELE) are common in Germany. Primary care physicians are paramount in the early detection of liver diseases. The aim of this article is to provide an overview of autoimmune liver disease for primary care physicians (PCP) with a focus on laboratory diagnostics. METHODS The national and international guidelines and review articles serve as a reference, supplemented by the current prevalence data from the German Zentralinstitut of the kassenärztliche Vereinigung (ZI). RESULTS In 2022, of the approximately 59 million PCP patients aged 20 years and older, around 50-60/100 000 received a confirmed diagnosis of autoimmune hepatitis or primary biliary cholangitis (according to ICD-10-GM diagnosis). The diagnoses were made 2 to 6 times more frequently in women than in men. Primary sclerosing cholangitis occurred in around 10/100 000 people treated by PCPs; women were affected up to twice as often, especially from the age of 60. Data on etiology, clinical, laboratory and diagnostic parameters, treatment options and prognosis data for the 3 disease entities are presented concisely in this article. CONCLUSION Laboratory diagnostics is the central step in the diagnosis of autoimmune liver diseases. However, general laboratory screening for ELE is not advisable. Rather, it is important to recognize, that no validated key figures are yet available for these markers in the primary care setting. The interpretation of these laboratory values is therefore complex. It is therefore advisable to consider determining these specific laboratory parameters, taking into account the common (and less common) causes that can lead to ELE.
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Affiliation(s)
- Dirk Moßhammer
- Hausarztpraxis Oferdingen, Lindberghstraße 3, 72768 Reutlingen
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Roberts SB, Choi WJ, Worobetz L, Vincent C, Flemming JA, Cheung A, Qumosani K, Swain M, Grbic D, Ko HH, Peltekian KM, Abrahamyan L, Saini M, Tirona K, Aziz B, Lytvyak E, Invernizzi P, Ponsioen CY, Bruns T, Cazzagon N, Lindor K, Dalekos GN, Gatselis NK, Verhelst X, Floreani A, Corpechot C, Mayo MJ, Levy C, Londoño MC, Battezzati PM, Pares A, Nevens F, van der Meer A, Kowdley KV, Trivedi PJ, Lleo A, Thorburn D, Carbone M, Selzner N, Gulamhusein AF, Janssen HLA, Montano-Loza AJ, Mason AL, Hirschfield GM, Hansen BE. Loss of biochemical response at any time worsens outcomes in UDCA-treated patients with primary biliary cholangitis. JHEP Rep 2024; 6:101168. [PMID: 39380718 PMCID: PMC11460452 DOI: 10.1016/j.jhepr.2024.101168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/28/2024] [Accepted: 07/04/2024] [Indexed: 10/10/2024] Open
Abstract
Background & Aims Biochemical response to ursodeoxycholic acid (UDCA) therapy is associated with good prognosis in people living with primary biliary cholangitis (PBC). Biochemical response is typically assessed early in disease and it is not known what proportion of patients lose previously attained biochemical response, nor whether this impacts long-term liver transplant (LT)-free survival. Methods We identified all UDCA-treated patients with PBC from the Canadian Network for Autoimmune Liver disease with biochemical measurements at 1 year, and evaluated their liver biochemistry over time. Inadequate biochemical response was defined as serum alkaline phosphatase ≥1.67x the upper limit of normal or abnormal serum total bilirubin at 1 year of UDCA therapy and all time points thereafter. Multistate Markov models were used to estimate transition rates between biochemical response states and from each state to LT or death. Results were validated in an external cohort (GLOBAL PBC registry). Results A total of 823 patients from eight centers were included. Mean age at diagnosis was 53 years, 91% were female, 33% had inadequate biochemical response to UDCA at 1 year (n = 269). Patients who retained initial adequate response had lower rates of LT or death compared to patients who subsequently lost response (relative rate 0.102, 95% CI 0.047-0.223). Patients who regained adequate response had lower rates than patients who did not (0.016, 95% CI 0.001-0.568), and patients who lost response once more (0.010, 95% CI 0.001-0.340). Patients who regained adequate response for a third time also had lower rates than patients who did not (0.151, 95% CI 0.040-0.566). Analyses in the GLOBAL PBC registry (n = 2,237) validated these results. Conclusion Loss of biochemical response at any time is associated with heightened risks of LT or death in people living with PBC. Achievement of biochemical response is an important goal throughout follow-up, regardless of biochemical response profile early in therapy. Impact and implications Early biochemical response to ursodeoxycholic acid is associated with good prognosis in patients with primary biliary cholangitis (PBC). Our work demonstrates that patients with PBC transition between biochemical response states over time, and that these transitions correspond with changes in risk of liver transplantation or death. Clinicians should re-evaluate risk and optimize treatment decisions for patients with PBC throughout follow-up, regardless of early biochemical response to therapy.
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Affiliation(s)
- Surain B. Roberts
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Woo Jin Choi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Lawrence Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | | | | | - Angela Cheung
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Karim Qumosani
- Department of Medicine, Western University, London, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Dusanka Grbic
- Départment de Médecine, Université de Sherbrooke, Sherbrooke, Canada
| | - Hin Hin Ko
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Monika Saini
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Kattleya Tirona
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Bishoi Aziz
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ellina Lytvyak
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Pietro Invernizzi
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Cyriel Y. Ponsioen
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Tony Bruns
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | | | | | - George N. Dalekos
- European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Xavier Verhelst
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Annarosa Floreani
- University of Padova, Padova, Italy
- Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy
| | - Christophe Corpechot
- Reference center for inflammatory biliary diseases and autoimmune hepatitis, French network for rare liver diseases FILFOIE, European reference network RARE-LIVER, Saint-Antoine University Hospital, APHP & Sorbonne University, Paris, France
| | - Marlyn J. Mayo
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clinic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigació Pi i Sunyer (FRCB-IDIBAPS), CIBEREHD, European Reference Network on Hepatological Rare Diseases (ERN-Liver), University of Barcelona, Barcelona, Spain
| | | | - Albert Pares
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Frederik Nevens
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | - Adriaan van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Palak J. Trivedi
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham, College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Douglas Thorburn
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Marco Carbone
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nazia Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Aliya F. Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Harry LA. Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Andrew L. Mason
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Gideon M. Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Bettina E. Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands
| | - the Canadian Network for Autoimmune Liver disease (CaNAL)
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Saskatchewan, Saskatoon, Canada
- Département de Médecine, Université de Montréal, Montréal, Canada
- Department of Medicine, Queen’s University, Kingston, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Department of Medicine, Western University, London, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Départment de Médecine, Université de Sherbrooke, Sherbrooke, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medicine, Dalhousie University, Halifax, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
- University of Padova, Padova, Italy
- Mayo Clinic, Scottsdale, Arizona, USA
- European Reference Network on Hepatological Diseases, Barcelona, Spain
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
- Reference center for inflammatory biliary diseases and autoimmune hepatitis, French network for rare liver diseases FILFOIE, European reference network RARE-LIVER, Saint-Antoine University Hospital, APHP & Sorbonne University, Paris, France
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
- Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
- Liver Unit, Hospital Clinic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigació Pi i Sunyer (FRCB-IDIBAPS), CIBEREHD, European Reference Network on Hepatological Rare Diseases (ERN-Liver), University of Barcelona, Barcelona, Spain
- Università degli Studi di Milano, Milan, Italy
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
- Liver Institute Northwest, Seattle, Washington, USA
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands
- National Institute for Health and Care Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham, College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
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Gupta V, Sehrawat TS, Pinzani M, Strazzabosco M. Portal Fibrosis and the Ductular Reaction: Pathophysiological Role in the Progression of Liver Disease and Translational Opportunities. Gastroenterology 2024:S0016-5085(24)05455-6. [PMID: 39251168 DOI: 10.1053/j.gastro.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/27/2024] [Accepted: 07/20/2024] [Indexed: 09/11/2024]
Abstract
A consistent feature of chronic liver diseases and the hallmark of pathologic repair is the so-called "ductular reaction." This is a histologic abnormality characterized by an expansion of dysmorphic cholangiocytes inside and around portal spaces infiltrated by inflammatory, mesenchymal, and vascular cells. The ductular reaction is a highly regulated response based on the reactivation of morphogenetic signaling mechanisms and a complex crosstalk among a multitude of cell types. The nature and mechanism of these exchanges determine the difference between healthy regenerative liver repair and pathologic repair. An orchestrated signaling among cell types directs mesenchymal cells to deposit a specific extracellular matrix with distinct physical and biochemical properties defined as portal fibrosis. Progression of fibrosis leads to vast architectural and vascular changes known as "liver cirrhosis." The signals regulating the ecology of this microenvironment are just beginning to be addressed. Contrary to the tumor microenvironment, immune modulation inside this "benign" microenvironment is scarcely known. One of the reasons for this is that both the ductular reaction and portal fibrosis have been primarily considered a manifestation of cholestatic liver disease, whereas this phenomenon is also present, albeit with distinctive features, in all chronic human liver diseases. Novel human-derived cellular models and progress in "omics" technologies are increasing our knowledge at a fast pace. Most importantly, this knowledge is on the edge of generating new diagnostic and therapeutic advances. Here, we will critically review the latest advances, in terms of mechanisms, pathophysiology, and treatment prospects. In addition, we will delineate future avenues of research, including innovative translational opportunities.
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Affiliation(s)
- Vikas Gupta
- Liver Center and Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Tejasav S Sehrawat
- Liver Center and Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Massimo Pinzani
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, UK; University of Pittsburgh Medical Center-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Mario Strazzabosco
- Liver Center and Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut.
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Ahmed MA, Krishna R, Rayad N, Albusaysi S, Mitra A, Shang E, Hon YY, AbuAsal B, Bakhaidar R, Roman YM, Bhattacharya I, Cloyd J, Patel M, Kartha RV, Younis IR. Getting the Dose Right in Drug Development for Rare Diseases: Barriers and Enablers. Clin Pharmacol Ther 2024. [PMID: 39148459 DOI: 10.1002/cpt.3407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024]
Abstract
In the relentless pursuit of optimizing drug development, the intricate process of determining the ideal dosage unfolds. This involves "dose-finding" studies, crucial for providing insights into subsequent registration trials. However, the challenges intensify when tackling rare diseases. The complexity arises from poorly understood pathophysiologies, scarcity of appropriate animal models, and limited natural history understanding. The inherent heterogeneity, coupled with challenges in defining clinical end points, poses substantial challenges, hindering the utility of available data. The small affected population, low disease awareness, and restricted healthcare access compound the difficulty in conducting dose-finding studies. This white paper delves into critical dose selection aspects, focusing on key therapeutic areas, such as oncology, neurology, hepatology, metabolic rare diseases. It also explores dose selection challenges posed by pediatric rare diseases as well as novel modalities, including enzyme replacement therapies, cell and gene therapies, and oligonucleotides. Several examples emphasize the pivotal role of clinical pharmacology in navigating the complexities associated with these diseases and emerging treatment modalities.
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Affiliation(s)
- Mariam A Ahmed
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - Rajesh Krishna
- Certara Drug Development Solutions, Certara USA, Inc., Princeton, New Jersey, USA
| | - Noha Rayad
- Parexel International (MA) Corporation, Mississauga, Ontario, Canada
- Clinical Pharmacology and Safety Sciences, Alexion, AstraZeneca Rare Disease, Mississauga, ON, Canada
| | - Salwa Albusaysi
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amitava Mitra
- Clinical Pharmacology, Kura Oncology Inc, Boston, Massachusetts, USA
| | - Elizabeth Shang
- Global Regulatory Affairs and Clinical Safety, Merck &Co., Inc., Rahway, New Jersey, USA
| | - Yuen Yi Hon
- Divsion of Rare Diseases and Medical Genetics, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bilal AbuAsal
- Division of Translational and Precision Medicine, Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rana Bakhaidar
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Youssef M Roman
- Division of Translational and Precision Medicine, Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Indranil Bhattacharya
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - James Cloyd
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Munjal Patel
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - Reena V Kartha
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Islam R Younis
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc., Rahway, New Jersey, USA
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Caines A, Trudeau S, Gordon SC. Evaluating the safety and efficacy of seladelpar for adults with primary biliary cholangitis. Expert Opin Pharmacother 2024; 25:1517-1523. [PMID: 39107982 DOI: 10.1080/14656566.2024.2390120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/05/2024] [Indexed: 08/13/2024]
Abstract
INTRODUCTION Seladelpar (MBX-8025) is a once-daily administered highly specific PPAR-δ agonist in Phase 3 and extension trials for use in patients with primary biliary cholangitis (PBC). AREAS COVERED This review provides background on current treatment options for PBC, and summarizes clinical trial data regarding the safety and effectiveness of seladelpar within the context of these treatments. EXPERT OPINION Clinical trials results demonstrate the safety and tolerability of seladelpar use for PBC, including in patients with cirrhosis. The primary composite endpoint (ALP <1.67 times ULN, decrease ≥ 15% from baseline, and TB ≤ULN) was met in 61.7% of the patients treated with seladelpar and in 20% receiving placebo (p < 0.001). Moreover, pruritus - a cardinal and often intractable symptom of PBC - was improved with seladelpar treatment, as were overall quality of life measurements. Improvements in markers of inflammation were likewise observed. These biochemical and clinical findings therefore represent landmark developments in PBC treatment and offer a therapeutic option for PBC.
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Affiliation(s)
- Allyce Caines
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
- School of Medicine, Michigan State University, E. Lansing, MI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
- School of Medicine, Wayne State University, Detroit, MI, USA
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Shamaa O, Ahmed A, Rupp L, Trudeau S, Gordon SC. Beyond the Surface: Unveiling Hidden Hurdles to Primary Biliary Cholangitis Care. Cureus 2024; 16:e64753. [PMID: 39156427 PMCID: PMC11329335 DOI: 10.7759/cureus.64753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/20/2024] Open
Abstract
INTRODUCTION Ursodeoxycholic acid (UDCA) slows disease progression among patients with primary biliary cholangitis (PBC), yet not all patients receive this standard-of-care medication. Our study aims to identify reasons why PBC patients did not receive the recommended UDCA treatment. METHODS Using medical record data collected by the Fibrotic Liver Disease (FOLD) Consortium for 2006-2016, we identified PBC patients from a single site with no UDCA therapy record. Two independent reviewers used a structured data collection instrument to systematically confirm and record the reasons for the lack of treatment. RESULTS Among 494 PBC patients (11% men and 13.2% Black patients) with a median follow-up of 5.2 years, 35 (7%) had never received UDCA (16% men and 24% Black patients). Of these, 18 (51%) had laboratory indications of PBC but were not formally diagnosed. Among the remaining 17 patients with recognized PBC, six were never offered UDCA, seven declined treatment, and four remained untreated despite being offered treatment. We did not find a statistically significant association between the lack of PBC diagnosis and treatment and patients' age (p = 0.139), gender (p = 0.222), race (p = 0.081), or insurance coverage (p = 0.456), perhaps due to our small sample size. CONCLUSIONS Multiple factors influencing the lack of evaluation and treatment in PBC patients were identified at the provider and patient levels. The most common reasons included financial barriers, loss to follow-up, severe decompensated disease at diagnosis, and lack of referral to specialists for further evaluation. Future interventions targeting modifiable provider and patient barriers may improve rates and timeliness of PBC diagnosis and treatment.
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Affiliation(s)
- Omar Shamaa
- Gastroenterology and Hepatology, Henry Ford Health System, Detroit, USA
| | - Abdul Ahmed
- Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, USA
| | - Lora Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Sheri Trudeau
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Stuart C Gordon
- Gastroenterology and Hepatology, Henry Ford Health System, Detroit, USA
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Cançado GGL, Gomes NMDF, Couto CA, Cançado ELR, Terrabuio DRB, Villela-Nogueira CA, Braga MH, Nardelli MJ, Faria LC, Oliveira EMG, Rotman V, Oliveira MB, Cunha SMCFD, Mazo DFDC, Mendes LSC, Ivantes CAP, Codes L, Borges VFDAE, Pace FHDL, Pessôa MG, Signorelli IV, Coral GP, Bittencourt PL, Fucuta P, Filho RJDC, Ferraz MLG. A new and simple score to predict adequate and deep response to ursodeoxycholic acid in patients with primary biliary cholangitis: the ALP-A score. Eur J Gastroenterol Hepatol 2024; 36:628-635. [PMID: 38555601 DOI: 10.1097/meg.0000000000002744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) is the standard treatment for primary biliary cholangitis (PBC), but a significant proportion of patients do not respond adequately, leading to increased risk of adverse outcomes. This study aims to develop a new and straightforward predictive score to identify PBC patients likely to achieve a complete response to UDCA. METHODS A logistic regression analysis was conducted using a derivation cohort of PBC patients to identify pre-treatment variables associated with response to UDCA. This analysis led to the development of the ALP-A score, calculated as: Age at diagnosis divided by (alkaline phosphatase at diagnosis/upper limit of normal). ALP-A score accuracy was evaluated using the area under the ROC curve, validated with a large external cohort from Brazil. Additionally, the correlation between the ALP-A score and the previously validated UDCA response score (URS) was assessed. RESULTS ALP-A score had good predictive power for adequate (AUC 0.794; 95% CI, 0.737-0.852) and deep (0.76; 95% CI, 0.69-0.83) UDCA response at 1 year of treatment. A cutoff score of 17 and 23 points was determined to be the optimal threshold for distinguishing adequate and deep responders, respectively, from non-responders. ALP-A score demonstrated a sensitivity of 73%, specificity of 71%, positive predictive value of 65%, negative predictive value of 78%, and overall accuracy of 72% for biochemical response. The URS displayed similar discriminative ability (AUC 0.798; 95% CI, 0.741-0.855). CONCLUSION ALP-A score performs comparably to URS but offers the great advantage of simplicity for routine clinical use. It serves as a valuable tool to identify PBC patients less likely to respond to UDCA treatment, facilitating early consideration of alternative therapeutic approaches.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais
| | | | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais
| | | | | | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais
| | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro
| | - Maria Beatriz Oliveira
- Ambulatório Municipal de Hepatites Virais de São José dos Campos, São José dos Campos, São Paulo
| | | | - Daniel Ferraz de Campos Mazo
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo
| | | | | | - Liana Codes
- Escola Bahiana de Medicina e Saúde Pública
- Hospital Português, Salvador, Bahia
| | | | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais
| | - Mário Guimarães Pessôa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo
| | | | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Patrícia Fucuta
- Disciplina de Gastroenterologia, Universidade Federal de São Paulo
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8
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Ellez HI, Danis N, Akarca US. Evaluation of patients with positive anti-mitochondiral antibody and normal alkaline phosphatase levels for primary biliary cholangitis. Acta Gastroenterol Belg 2024; 87:282-286. [PMID: 39210760 DOI: 10.51821/87.2.12041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Primary Biliary Cholangitis (PBC) is a chronic cholestatic liver disease typically diagnosed by elevated cholestatic liver enzymes and a positive anti-mitochondrial antibody (AMA) test. The clinical importance of AMA positivity in patients with normal cholestatic liver enzymes is unclear. The aim of this study was to determine the relationship between PBC and AMA positivity detected in individuals with normal cholestatic enzyme levels. The files of patients with AMA and/or AMA-M2 positivity between 2009 and 2018 and whose alkaline phosphatase (ALP) levels were below upper limit of normal (ULN) at initial admission were retrospectively analyzed. The ALP levels were normal in all patients. All patients had AMA positivity demonstrated by indirect immunofluorescence (IIF) or AMA-M2 positivity demonstrated by ELISA. A total of 16 patients underwent liver biopsy and seven (43.75%) showed changes consistent with those with PBC. A total of 12 patients were diagnosed with PBC and were treated and followed up with this diagnosis. People with AMA positivity and normal cholestasis enzyme levels are closely associated with PBC. Some of these patients were diagnosed with PBC as a result of biopsy and some were diagnosed by clinical and laboratory findings during follow-up.. The patients with an AMA titration of 1/20 were not associated with PBC. In our study, results similar to the studies confirmed by biopsies were obtained. In this regard, there is a need for prospective and retrospective studies with longer follow-up periods.
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Affiliation(s)
- Halil Ibrahim Ellez
- Department of Internal Medicine, Division of Medical Oncology, Dokuz Eylul University, Izmir, Turkey
| | - Nilay Danis
- Department of Internal Medicine, Division of Gastroenterology, Dokuz Eylul University, Izmir, Turkey
| | - Ulus Salih Akarca
- Department of Internal Medicine, Division of Gastroenterology, Ege University, Izmir, Turkey
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9
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Yang J, Jiang S, Fan Q, Wen D, Liu Y, Wang K, Yang H, Guo C, Zhou X, Guo G, Shang Y, Han Y. Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis. Front Med (Lausanne) 2024; 11:1346165. [PMID: 38487027 PMCID: PMC10937409 DOI: 10.3389/fmed.2024.1346165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background Sarcopenia adversely affects the treatment outcomes in Cirrhosis and NAFLD. However, such research is limited in primary biliary cholangitis (PBC) patients. This study was performed to examine the prevalence of sarcopenia and its impact on PBC patients' prognoses. Methods This study enrolled confirmed PBC patients who had an abdominal CT scan. Sarcopenia was determined by the L3-skeletal muscle index with a Chinese population-based cut-off value. Laboratory test values and liver stiffness measurements values were obtained from the electronic medical records. Results In total, 174 PBC patients with a median age of 54 (IQR, 48, 62) years old, were enrolled. 45 (25.9%) patients among them were diagnosed with sarcopenia. Univariate and multivariate logistic regression results illustrated that male gender (OR = 9.152, 95%CI = 3.131-26.751, p < 0.001) and LSM ≥ 12.8 kPa (OR = 4.539, 95%CI = 1.651, 12.478, p = 0.003) were the independent risk factors of sarcopenia in PBC patients. In the prognosis analysis, sarcopenia was determined as a risk factor for indicating adverse events in PBC patients (HR = 4.058, 95%CI = 1.955-8.424, p < 0.001) by Cox proportional hazards regression. Conclusion The current findings illustrate that comprehensive evaluation and management of sarcopenia may contribute to the improvement of treatment outcomes and life quality of PBC patients.
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Affiliation(s)
- Jiaqi Yang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Shuangshuang Jiang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Qingling Fan
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Didi Wen
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yansheng Liu
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Kemei Wang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Hui Yang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Changcun Guo
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xinmin Zhou
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Guanya Guo
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yulong Shang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Ying Han
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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10
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D'Amato D, Carbone M. Prognostic models and autoimmune liver diseases. Best Pract Res Clin Gastroenterol 2023; 67:101878. [PMID: 38103932 DOI: 10.1016/j.bpg.2023.101878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023]
Abstract
Autoimmune liver diseases (AILDs) are complex diseases with unknown causes and immune-mediated pathophysiology. In primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) disease modifying drugs are available which improve patient quality and quantity of life. In primary sclerosing cholangitis (PSC) no medical therapy is available and the only accepted treatment is liver transplantation (LT). PBC, PSC and AIH possess features that describe the archetype of patients within each disorder. On the other hand, the classical disorders are not homogeneous, and patients within each diagnosis may present with a range of clinical, biochemical, serological, and histological findings. Singularly, they are considered rare diseases, but together, they account for approximately 20% of LTs in Europe and USA. Management of these patients is complex, as AILDs are relatively uncommon in clinical practice with challenges in developing expertise, disease presentation can be sneaky, clinical phenotypes and disease course are heterogeneous. Prognostic models are key tools for clinicians to assess patients' risk and to provide personalized care to patients. Aim of this review is to discuss challenges of the management of AILDs and how the available prognostic models can help. We will discuss the prognostic models developed in AILDs, with a special focus on the prognostic models that can support the clinical management of patients with AILDs: in PBC models based on ursodeoxycholic acid (UDCA) response and markers of liver fibrosis; in PSC several markers including biochemistry, disease stage and radiological semiquantitative markers; and finally in AIH, markers of disease stage and disease activity.
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Affiliation(s)
- Daphne D'Amato
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
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11
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He H, Wu JJ. Human Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of ASC42, a Novel Farnesoid X Receptor Agonist. Drugs R D 2023; 23:453-464. [PMID: 37919483 PMCID: PMC10676321 DOI: 10.1007/s40268-023-00444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND ASC42 is a non-steroidal farnesoid X receptor agonist currently in clinical development for chronic liver diseases, such as nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) and primary biliary cirrhosis (PBC). OBJECTIVE The objective of this study was to assess the safety, pharmacokinetics (PK), and pharmacodynamics (PD) of ASC42 in healthy subjects. METHODS We conducted the first-in-human study of ASC42 following single and multiple ascending doses (SAD/MAD) and food effect in healthy subjects. The SAD study included five cohorts receiving 5-200 mg ASC42 or placebo and one cohort that was given 15 mg ASC42 with a high-fat meal. The MAD study included three cohorts receiving 5-50 mg ASC42 or placebo once-daily (QD) for 14 days. RESULTS A total of 65 healthy subjects were enrolled and one subject in the MAD study (cohort 8, ASC42 50 mg) withdrew from the study due to an unrelated serious adverse event (SAE) of atrial fibrillation. Pruritus was observed at the highest doses (200 mg cohort in SAD and 50 mg cohort in MAD). Most AEs were mild or moderate. No life-threatening or fatal AEs occurred. ASC42 showed a proportional increase in exposure and elimination half-life following both single and multiple dosing. There was a 21% and 37% decrease in area under the curve (AUC) and maximum plasma concentration (Cmax) when ASC42 was coadministered with food. The steady state was reached on day 4 with a mild accumulation (1.02-1.74-fold). ASC42 showed dose-dependent increases in fibroblast growth factor 19 and decreases in 7α-hydroxy-4-cholesten-3-one. Cholesterol remained within normal limits during study. CONCLUSION ASC42 was well tolerated with a pharmacokinetic profile suitable for QD dosing, and demonstrated dose-dependent targets engagement without altering plasma cholesterol in healthy subjects. TRIAL REGISTRATION NUMBER NCT04679129.
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Affiliation(s)
- Handan He
- Gannex Pharma Co., Ltd., Shanghai, China
| | - Jinzi J Wu
- Gannex Pharma Co., Ltd., Shanghai, China.
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12
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Nano O, Ivanov S, Kapoor T. Vanishing Bile Duct Syndrome in a Patient With Recurrent Hodgkin Lymphoma. J Med Cases 2023; 14:162-168. [PMID: 37303969 PMCID: PMC10251707 DOI: 10.14740/jmc4073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/06/2023] [Indexed: 06/13/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) is an acquired syndrome characterized by clinical and laboratory signs of cholestasis with pathologic findings of interlobular bile duct paucity in liver biopsy specimens. VBDS can result from a variety of conditions including infections, autoimmune diseases, adverse drug reactions, and neoplastic processes. Hodgkin lymphoma (HL) is a rare cause of VBDS. The mechanism by which HL leads to VBDS remains unknown. Development of VBDS in patients with HL portends an extremely poor prognosis due to the risk of progression to fulminant hepatic failure. Treatment of the underlying lymphoma has been demonstrated to offer increased probability of recovery from VBDS. The decision to treat and choice of treatment of the underlying lymphoma is often complicated by the hepatic dysfunction characteristic of VBDS. We present the case of a patient who presented with dyspnea and jaundice in the context of recurrent HL and VBDS. We additionally review the literature on HL complicated by VBDS with specific focus on treatment paradigms for management of these patients.
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Affiliation(s)
- Olger Nano
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL 33021, USA
- Department of Hematology and Oncology, Memorial Cancer Institute, Pembroke Pines, FL 33026, USA
| | - Stanislav Ivanov
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL 33021, USA
- Department of Hematology and Oncology, Memorial Cancer Institute, Pembroke Pines, FL 33026, USA
| | - Tarun Kapoor
- Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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13
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Yamashita Y, Umemura T, Kimura T, Joshita S, Hirohara J, Nakano T, Komori A, Tanaka A. Prognostic utility of albumin-bilirubin grade in Japanese patients with primary biliary cholangitis. JHEP Rep 2023; 5:100662. [PMID: 36873419 PMCID: PMC9976453 DOI: 10.1016/j.jhepr.2022.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/26/2022] Open
Abstract
Background & Aims The albumin-bilirubin (ALBI) score is calculated using serum levels of total bilirubin and albumin as a simple method to assess liver function. This study investigated the ability of baseline ALBI score/grade measurements to assess histological stage and disease progression in individuals with primary biliary cholangitis (PBC) in a large Japanese nationwide cohort. Methods A total of 8,768 Japanese patients with PBC were enrolled between 1980 and 2016 from 469 institutions, among whom 83% received ursodeoxycholic acid (UDCA) only, 9% received UDCA and bezafibrate, and 8% were given neither drug. Baseline clinical and laboratory parameters were retrospectively retrieved and reviewed from a central database. Associations of ALBI score/grade with histological stage, mortality, and need for liver transplantation (LT) were evaluated using Cox proportional hazards models. Results During the median follow-up period of 5.3 years, 1,227 patients died (including 789 from liver-related causes) and 113 underwent LT. ALBI score and ALBI grade were significantly associated with Scheuer's classification (both p <0.0001). ALBI grade 2 or 3 had significant associations with all-cause mortality or need for LT as well as liver-related mortality or need for LT according to Cox proportional hazards regression analysis (hazard ratio 3.453, 95% CI 2.942-4.052 and hazard ratio 4.242, 95% CI 3.421-5.260, respectively; both p <0.0001). Cumulative LT-free survival rates at 5 years in the ALBI grade 1, 2, and 3 groups were 97.2%, 82.4%, and 38.8%, respectively, while respective non-liver-related survival rates were 98.1%, 86.0%, and 42.0% (both p <0.0001, log-rank test). Conclusions This large nationwide study of patients with PBC suggested that baseline measurements of ALBI grade were a simple non-invasive predictor of prognosis in PBC. Impact and implications Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by progressive destruction of intrahepatic bile ducts. This study examined the ability of albumin-bilirubin (ALBI) score/grade to estimate histological findings and disease progression in PBC by means of a large-scale nationwide cohort in Japan. ALBI score/grade were significantly associated with Scheuer's classification stage. Baseline ALBI grade measurements may be a simple non-invasive predictor of prognosis in PBC.
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Key Words
- ALBI, albumin-bilirubin
- ALP, alkaline phosphatase
- AMA, anti-mitochondrial autoantibody
- AUC, area under the ROC curve
- BZF, bezafibrate
- HR, hazard ratio
- LSM, liver stiffness measurement
- LT, liver transplantation
- M2BPGi, Mac-2-binding protein glycosylation isomer
- PBC, primary biliary cholangitis
- Prognosis
- ROC, receiver-operating characteristic
- Transplantation
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- Ursodeoxycholic acid
- pc, corrected p
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Affiliation(s)
- Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan.,Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
| | - Takefumi Kimura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Junko Hirohara
- The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Toshiaki Nakano
- The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Atsumasa Komori
- Clinical Research Center, National Hospital Organization (NHO) Nagasaki Medical Center, Nagasaki, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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14
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Hussain N, Trivedi PJ. The Inconvenient Truth of Primary Biliary Cholangitis/Autoimmune Hepatitis Overlap Syndrome. Clin Liver Dis 2022; 26:657-680. [PMID: 36270722 DOI: 10.1016/j.cld.2022.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The term 'PBC/AIH-overlap' has been applied when features of autoimmune hepatitis (AIH), be they biochemical, serological or histological, coexist with primary biliary cholangitis (PBC), either at first presentation or sequentially during disease course. Several treatment paradigms have been proposed, extrapolated from those of the primary conditions. However, there are no randomised studies showing improved survival with combination therapy compared to bile acid monotherapy. In the absence of high-quality evidence, multidisciplinary patient-specific approaches must be used to individualise treatment pathways, with appreciation that disease phenotypes are not always static, differ in treatment responses, and have the potential to evolve over time.
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Affiliation(s)
- Nasir Hussain
- NIHR Birmingham BRC, Institute of Immunology and Immunotherapy, Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham B15 2TT, United Kingdom; Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, United Kingdom
| | - Palak J Trivedi
- NIHR Birmingham BRC, Institute of Immunology and Immunotherapy, Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham B15 2TT, United Kingdom; Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
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15
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Liu CH, Bowlus CL. Treatment of Primary Biliary Cholangitis: First-Line and Second-Line Therapies. Clin Liver Dis 2022; 26:705-726. [PMID: 36270725 DOI: 10.1016/j.cld.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune disease of the interlobular bile ducts leading to secondary damage of hepatocytes and may progress to cirrhosis and liver failure. The first-line treatment is ursodeoxycholic acid; up to 40% of patients do not have an adequate response and remain at risk of disease progression. Obeticholic acid has been conditionally approved for the treatment of PBC as add-on therapy and bezafibrate has shown similar efficacy in this group of patients. Several new therapies are in development and may further add to the treatment options available to patients with PBC.
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Affiliation(s)
- Chung-Heng Liu
- Drexel University College of Medicine, 2900 W Queen Ln, Philadelphia, PA 19129 USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA 95817, USA.
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16
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Schramm C, Wedemeyer H, Mason A, Hirschfield GM, Levy C, Kowdley KV, Milkiewicz P, Janczewska E, Malova ES, Sanni J, Koo P, Chen J, Choudhury S, Klickstein LB, Badman MK, Jones D. Farnesoid X receptor agonist tropifexor attenuates cholestasis in a randomised trial in patients with primary biliary cholangitis. JHEP Rep 2022; 4:100544. [PMID: 36267872 PMCID: PMC9576902 DOI: 10.1016/j.jhepr.2022.100544] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background & Aims The safety, tolerability, and efficacy of the non-bile acid farnesoid X receptor agonist tropifexor were evaluated in a phase II, double-blind, placebo-controlled study as potential second-line therapy for patients with primary biliary cholangitis (PBC) with an inadequate ursodeoxycholic acid response. Methods Patients were randomised (2:1) to receive tropifexor (30, 60, 90, or 150 μg) or matched placebo orally once daily for 28 days, with follow-up on Days 56 and 84. Primary endpoints were safety and tolerability of tropifexor and reduction in levels of γ-glutamyl transferase (GGT) and other liver biomarkers. Other objectives included patient-reported outcome measures using the PBC-40 quality-of-life (QoL) and visual analogue scale scores and tropifexor pharmacokinetics. Results Of 61 enrolled patients, 11, 9, 12, and 8 received 30-, 60-, 90-, and 150-μg tropifexor, respectively, and 21 received placebo; 3 patients discontinued treatment because of adverse events (AEs) in the 150-μg tropifexor group. Pruritus was the most frequent AE in the study (52.5% [tropifexor] vs. 28.6% [placebo]), with most events of mild to moderate severity. Decreases seen in LDL-, HDL-, and total-cholesterol levels at 60-, 90-, and 150 μg doses stabilised after treatment discontinuation. By Day 28, tropifexor caused 26-72% reduction in GGT from baseline at 30- to 150-μg doses (p <0.001 at 60-, 90-, and 150-μg tropifexor vs. placebo). Day 28 QoL scores were comparable between the placebo and tropifexor groups. A dose-dependent increase in plasma tropifexor concentration was observed, with 5- to 5.55-fold increases in AUC0-8h and Cmax between 30- and 150-μg doses. Conclusions Tropifexor showed improvement in cholestatic markers relative to placebo, predictable pharmacokinetics, and an acceptable safety-tolerability profile, thereby supporting its potential further clinical development for PBC. Lay summary The bile acid ursodeoxycholic acid (UDCA) is the standard-of-care therapy for primary biliary cholangitis (PBC), but approximately 40% of patients have an inadequate response to this therapy. Tropifexor is a highly potent non-bile acid agonist of the farnesoid X receptor that is under clinical development for various chronic liver diseases. In the current study, in patients with an inadequate response to UDCA, tropifexor was found to be safe and well tolerated, with improved levels of markers of bile duct injury at very low (microgram) doses. Itch of mild to moderate severity was observed in all groups including placebo but was more frequent at the highest tropifexor dose. Clinical Trials Registration This study is registered at ClinicalTrials.gov (NCT02516605).
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Key Words
- AE, adverse event
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AUC, area under the concentration–time curve
- C4, 7-alpha-hydroxy-4-cholesten-3-one
- CL/F,ss, the apparent systemic clearance following oral administration at steady state
- Cmax, maximum plasma concentration
- FGF19, fibroblast growth factor 19
- FXR, farnesoid X receptor
- Farnesoid X receptor
- GGT, γ-glutamyl transferase
- HDL, high-density lipoprotein
- LDL, low-density lipoprotein
- NASH, non-alcoholic steatohepatitis
- OCA, obeticholic acid
- PBC, primary biliary cholangitis
- PD, pharmacodynamic
- PRO, patient-reported outcome
- Primary biliary cholangitis
- Proof of concept
- Pruritus
- QoL, quality of life
- Racc, accumulation ratio
- SAE, serious adverse event
- Tmax, time to reach Cmax
- Tropifexor
- ULN, upper limit of normal
- VAS, visual analogue scale
- pBAD, primary bile acid diarrhoea
- qd, once daily
- γ-Glutamyl transferase
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Affiliation(s)
- Christoph Schramm
- Medizinische Klinik und Poliklinik Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center of Translational Immunology, Hamburg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Andrew Mason
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Levy
- University of Miami, Schiff Center for Liver Diseases, Miami, FL, USA
| | - Kris V Kowdley
- Liver Institute Northwest, Washington State University, Seattle, WA, USA
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Janczewska
- ID Clinic, Myslowice Poland.,Department of Basic Medical Sciences, School of Health Sciences in Bytom, Medical University of Silesia, Bytom, Poland
| | | | - Johanne Sanni
- Novartis Institutes for Biomedical Research, Basel, Switzerland.,Sannity Consulting Ltd, Worthing, UK
| | - Phillip Koo
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Jin Chen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | | | - David Jones
- The Newcastle Upon Tyne Hospitals, NHS Foundation Trust, Royal Victoria Infirmary, Newcastle, UK
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17
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Ding D, Guo G, Liu Y, Zheng L, Jia G, Deng J, Sun R, Wang X, Guo C, Shang Y, Han Y. Efficacy and safety of fenofibrate addition therapy in patients with cirrhotic primary biliary cholangitis with incomplete response to ursodeoxycholic acid. Hepatol Commun 2022; 6:3487-3495. [PMID: 36213941 PMCID: PMC9701475 DOI: 10.1002/hep4.2103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/15/2022] [Accepted: 09/01/2022] [Indexed: 01/21/2023] Open
Abstract
Fenofibrate (FF) has shown potential benefits in patients with primary biliary cholangitis (PBC) who have an incomplete response to ursodeoxycholic acid (UDCA). However, the efficacy and safety of FF in patients with cirrhosis remain unclear. To evaluate the efficacy and safety of additional FF therapy in patients with PBC-related cirrhosis with an incomplete response to UDCA, we conducted a retrospective analysis comparing the clinical results of additional FF therapy and continued UDCA monotherapy. A total of 59 patients were included; 27 cases underwent UDCA monotherapy and 32 cases underwent UDCA combined with FF therapy. A significant difference in alkaline phosphatase (ALP) normalization was achieved in the FF group compared to the UDCA group (37% vs. 11%, respectively; p = 0.020). Additional FF therapy was an independent risk factor for ALP normalization (hazard ratio, 7.679; 95% confidence interval, 2.059-28.633; p = 0.003). Hepatic deterioration was experienced by 40% versus 48% (p = 0.562) while 11% vs. 37% (p = 0.111) experienced liver-related mortality or liver transplantation in the FF and UDCA groups, respectively. Compared to UDCA monotherapy, additional FF therapy was associated with lower United Kingdom (UK)-PBC risk score and surrogate serum indices of liver fibrosis. After 12 months of add-on FF therapy, median ALP level and UK-PBC risk score decreased 35% and 52% from baseline (p = 0.001 and 0.210, respectively). Serum aminotransferase, triglyceride, and cholesterol decreased progressively, while total bilirubin, serum creatinine, blood urea, estimated glomerular filtration rate, aspartate aminotransferase-to-platelet ratio index, and fibrosis-4 index remained stable in FF-treated cirrhotic cases during follow-up. No significant adverse effects associated with additional FF therapy were observed in our cohort. Conclusion: Additional FF therapy was associated with higher ALP normalization rates and lower UK-PBC risk scores in patients with cirrhotic PBC with an incomplete response to UDCA. In addition, FF therapy seemed safe and well tolerated with a low frequency of adverse effects in patients with cirrhosis.
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Affiliation(s)
- Dawei Ding
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Guanya Guo
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Yansheng Liu
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Linhua Zheng
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Gui Jia
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Juan Deng
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Ruiqing Sun
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Xiufang Wang
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Changcun Guo
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Yulong Shang
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Ying Han
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
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18
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Gu J, Wu Q, Zhang Q, You Q, Wang L. A decade of approved first-in-class small molecule orphan drugs: Achievements, challenges and perspectives. Eur J Med Chem 2022; 243:114742. [PMID: 36155354 DOI: 10.1016/j.ejmech.2022.114742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022]
Abstract
In the past decade (2011-2020), there was a growing interest in the discovery and development of orphan drugs for the treatment of rare diseases. However, rare diseases only account for a population of 0.65‰-1‰ which usually occur with previously unknown biological mechanisms and lack of specific therapeutics, thus to increase the demands for the first-in-class (FIC) drugs with new biological targets or mechanisms. Considering the achievements in the past 10 years, a total of 410 drugs were approved by U.S. Food and Drug Administration (FDA), which contained 151 FIC drugs and 184 orphan drugs, contributing to make up significant numbers of the approvals. Notably, more than 50% of FIC drugs are developed as orphan drugs and some of them have already been milestones in drug development. In this review, we aim to discuss the FIC small molecules for the development of orphan drugs case by case and highlight the R&D strategy with novel targets and scientific breakthroughs.
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Affiliation(s)
- Jinying Gu
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Design and Optimization, China Pharmaceutical University, Nanjing, 210009, China; Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Qiuyu Wu
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Design and Optimization, China Pharmaceutical University, Nanjing, 210009, China; Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Qiuyue Zhang
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Design and Optimization, China Pharmaceutical University, Nanjing, 210009, China; Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Qidong You
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Design and Optimization, China Pharmaceutical University, Nanjing, 210009, China; Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Lei Wang
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Design and Optimization, China Pharmaceutical University, Nanjing, 210009, China; Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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19
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Kimura M, Nishikawa K, Osawa Y, Imamura J, Yamaji K, Harada K, Yatsuhashi H, Murata K, Miura K, Tanaka A, Kanto T, Kohara M, Kamisawa T, Kimura K. Inhibition of CBP/β-catenin signaling ameliorated fibrosis in cholestatic liver disease. Hepatol Commun 2022; 6:2732-2747. [PMID: 35855613 PMCID: PMC9512479 DOI: 10.1002/hep4.2043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/02/2022] [Accepted: 06/25/2022] [Indexed: 11/11/2022] Open
Abstract
Chronic cholestatic liver diseases are characterized by injury of the bile ducts and hepatocytes caused by accumulated bile acids (BAs) and inflammation. Wnt/β-catenin signaling is implicated in organ fibrosis; however, its role in cholestatic liver fibrosis remains unclear. Therefore, we explored the effect of a selective cAMP response element-binding protein-binding protein (CBP)/β-catenin inhibitor, PRI-724, on murine cholestatic liver fibrosis. PRI-724 suppressed liver fibrosis induced by multidrug resistance protein 2 knockout (KO), bile duct ligation, or a 3.5-diethoxycarbonyl-1.4-dihydrocollidine (DDC) diet; it also suppressed BA synthesis and macrophage infiltration. The expression of early growth response-1 (Egr-1), which plays a key role in BA synthesis, was increased in the hepatocytes of patients with cholestatic liver disease. PRI-724 inhibited Egr-1 expression induced by cholestasis, and adenoviral shEgr-1-mediated Egr-1 knockdown suppressed BA synthesis and fibrosis in DDC diet-fed mice, suggesting that PRI-724 exerts its effects, at least in part, by suppressing Egr-1 expression in hepatocytes. Hepatocyte-specific CBP KO in mice suppressed BA synthesis, liver injury, and fibrosis, whereas hepatocyte-specific KO of P300, a CBP homolog, exacerbated DDC-induced fibrosis. Intrahepatic Egr-1 expression was also decreased in hepatocyte-specific CBP-KO mice and increased in P300-KO mice, indicating that Egr-1 is located downstream of CBP/β-catenin signaling. Conclusion: PRI-724 inhibits cholestatic liver injury and fibrosis by inhibiting BA synthesis in hepatocytes. These results highlight the therapeutic effect of CBP/β-catenin inhibition in cholestatic liver diseases.
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Affiliation(s)
- Masamichi Kimura
- Department of Hepatology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koji Nishikawa
- Department of Hepatology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yosuke Osawa
- Department of Gastroenterology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Jun Imamura
- Department of Hepatology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kenzaburo Yamaji
- Department of Microbiology and Cell Biology, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Hiroshi Yatsuhashi
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Omura, Japan
| | - Kazumoto Murata
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kouichi Miura
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Tatsuya Kanto
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Japan
| | - Michinori Kohara
- Department of Microbiology and Cell Biology, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Terumi Kamisawa
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kiminori Kimura
- Department of Hepatology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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20
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Nguyen HH, Fritzler MJ, Swain MG. A Review on Biomarkers for the Evaluation of Autoimmune Cholestatic Liver Diseases and Their Overlap Syndromes. FRONTIERS IN MOLECULAR MEDICINE 2022; 2:914505. [PMID: 39086971 PMCID: PMC11285550 DOI: 10.3389/fmmed.2022.914505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/30/2022] [Indexed: 08/02/2024]
Abstract
Autoimmune cholestatic liver disease includes both Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC). Both conditions result in impairment of hepatic bile flow ultimately leading to chronic liver injury, liver fibrosis and eventually end stage cirrhosis. Early and accurate diagnosis are important for the risk stratification, follow up and management of these patients. The underlying pathogenesis of these conditions have not been completely resolved and poses a barrier for the development of new diagnostic and prognostics tools. Current research work suggests that the pathogenesis of autoimmune cholestatic liver disease results from environmental, genetic, and a large component of underlying immune dysfunction. While the current available serum biomarkers and imaging modalities showcases progression in precision medicine for the management of autoimmune cholestatic liver disease, development of new biomarkers are still an area of need in this field. In this review, we will discuss the current and emerging biomarkers in patients with PBC, PSC, and a special population that exhibit overlap syndrome with autoimmune hepatitis (AIH). The use of these biomarkers for diagnosis and prognosis of these patients will be reviewed through the lens of the current understanding of the complex immune pathophysiology of these conditions.
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Affiliation(s)
- Henry H. Nguyen
- University of Calgary Liver Unit, Department of Medicine & Department of Microbiology, Immunology and Infectious Diseases, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marvin J. Fritzler
- Department of Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark G. Swain
- University of Calgary Liver Unit, Department of Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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21
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Garrido I, Liberal R, Cardoso MJ, Macedo G. The impact of undiagnosed primary biliary cholangitis. Eur J Gastroenterol Hepatol 2021; 33:e1027-e1031. [PMID: 34402472 DOI: 10.1097/meg.0000000000002268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary biliary cholangitis (PBC) is a chronic autoimmune disease characterized by symptoms with a major impact on the quality of life. The aim of this study was to identify patients with undiagnosed PBC who are not under hepatology follow-up and to assess the clinical impact of lack of adequate treatment and surveillance. METHODS Adult patients with a positive antimitochondrial antibodies (AMA) titer were identified from local biochemistry records. Patients with probable PBC who were not known by the hepatology services were invited to accurately stage their disease and optimize medical management. RESULTS A total of 214 AMA-positive patients were identified, 148 of whom had diagnostic criteria for PBC. Twenty-three patients were not known by the hepatology services, most of them followed by specialties other than gastroenterology. These patients had significantly higher liver stiffness compared to those followed by the hepatology services (14.3 kPa vs. 6.2 kPa; P = 0.009). A large percentage of untreated individuals reported fatigue (72.7%) and pruritus (27.3%). CONCLUSIONS A substantial number of patients with PBC are not known to have hepatology services with a significant long-term impact from a lack of follow-up and therapy. Strategies must be established to identify these patients and reduce the disease's progressive nature.
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Affiliation(s)
- Isabel Garrido
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de São João.,World Gastroenterology Organization (WGO) Porto Training Center
| | - Rodrigo Liberal
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de São João.,World Gastroenterology Organization (WGO) Porto Training Center
| | - Maria João Cardoso
- Clinical Pathology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de São João.,World Gastroenterology Organization (WGO) Porto Training Center
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22
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Patel R, Portone G, Lambert JA, Mak S, Alrubaiy L. Disease-modifying therapies and symptomatic management for primary biliary cholangitis. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34817254 DOI: 10.12968/hmed.2021.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary biliary cholangitis is a chronic condition characterised by autoimmune destruction of intralobular bile ducts. Publications have shown widespread gaps in the care of patients with primary biliary cholangitis. This article reviews the literature regarding currently licensed first- and second-line therapies and evaluates therapeutic options for symptomatic management of primary biliary cholangitis. Ursodeoxycholic acid is recommended for all patients with primary biliary cholangitis, with obeticholic acid available as second-line therapy, both having demonstrated safety and efficacy. Potential disease-modifying therapies, such as fibrates and budesonide, require further investigation before licensing. Cholestyramine is first-line therapy for pruritus, albeit with limited evidence and common side-effects. There is no licensed therapy for primary biliary cholangitis-related fatigue; treating underlying causes where applicable is recommended. Disease-modifying and symptomatic therapies must be considered in tandem when managing patients with primary biliary cholangitis. Emerging therapies show initial promise but further randomised trials with long-term follow up are required to evaluate their efficacy as single or combination therapies.
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Affiliation(s)
- Roshni Patel
- Faculty of Medicine, Imperial College London, UK
| | | | | | - Sau Mak
- Faculty of Medicine, Imperial College London, UK
| | - Laith Alrubaiy
- Faculty of Medicine, Imperial College London, UK.,Department of Gastroenterology, St. Mark's Hospital, London, UK
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23
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Sorda JA, González Ballerga E, Barreyro FJ, Avagnina A, Carballo P, Paes de Lima A, Daruich J. Bezafibrate therapy in primary biliary cholangitis refractory to ursodeoxycholic acid: a longitudinal study of paired liver biopsies at 5 years of follow up. Aliment Pharmacol Ther 2021; 54:1202-1212. [PMID: 34587309 DOI: 10.1111/apt.16618] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/16/2020] [Accepted: 09/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) is the first-line therapy for primary biliary cholangitis (PBC). However, nearly 40% of patients have an incomplete response to UDCA. The addition of bezafibrate has shown biochemical benefit in this group of patients. AIM To evaluate the long-term effects of UDCA in combination with bezafibrate on histological outcomes in patients with UDCA-refractory PBC. METHODS Fifty-nine patients refractory to UDCA were included. Clinical parameters were monitored and paired liver biopsy (PLB) was performed after 5 years of follow-up. RESULTS Of the total cohort, 49 subjects were analysed and 31 had PLB at 5 years. Values for serum ALP, AST, ALT and GGT significantly improved with UDCA-bezafibrate. This beneficial effect was observed at 12 months where 86% achieved ALP at normal levels. Analyses of PLB showed a significant decrease in liver damage as reflected by Ludwig (baseline 2.29 ± 1.2, to 1.84 ± 1 at year 5, P = 0.0242) and Ishak (baseline 6.19 ± 2.2 to 4.77 ± 2.2 at year 5, P = 0.0008) scores. Overall, regression of fibrosis was attained in 48% of patients. Furthermore, we observed a significant reduction in the proportion with cirrhosis from 19% at baseline to 3% at 5 years (P < 0.001). These beneficial effects were associated with better predictive risk scores using the GLOBE and UK-PBC prognosis models. CONCLUSIONS Adding bezafibrate to UDCA in patients with UDCA-refractory PBC showed a significant decrease in fibrosis and inflammatory histological scores at 5 years. These beneficial effects warrant further evaluation in long-term cohort studies and controlled trials.
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Affiliation(s)
- Juan Antonio Sorda
- Department of Gastroenterology and Hepatology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Esteban González Ballerga
- Department of Gastroenterology and Hepatology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Javier Barreyro
- Biotechnology Institute of Misiones (INBIOMIS), National University of Misiones, National Scientific and Technical Research Council (CONICET), Posadas, Argentina
| | - Alejandra Avagnina
- Department of Pathology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Pilar Carballo
- Department of Pathology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Andrea Paes de Lima
- Department of Pathology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Jorge Daruich
- Department of Gastroenterology and Hepatology, University Hospital "José de San Martín", Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
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24
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Kolaric TO, Nincevic V, Kuna L, Duspara K, Bojanic K, Vukadin S, Raguz-Lucic N, Wu GY, Smolic M. Drug-induced Fatty Liver Disease: Pathogenesis and Treatment. J Clin Transl Hepatol 2021; 9:731-737. [PMID: 34722188 PMCID: PMC8516847 DOI: 10.14218/jcth.2020.00091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/08/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022] Open
Abstract
Metabolic dysfunction-associated fatty liver disease (commonly known as MAFLD) impacts global health in epidemic proportions, and the resulting morbidity, mortality and economic burden is enormous. While much attention has been given to metabolic syndrome and obesity as offending factors, a growing incidence of polypharmacy, especially in the elderly, has greatly increased the risk of drug-induced liver injury (DILI) in general, and drug-induced fatty liver disease (DIFLD) in particular. This review focuses on the contribution of DIFLD to DILI in terms of epidemiology, pathophysiology, the most common drugs associated with DIFLD, and treatment strategies.
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Affiliation(s)
- Tea Omanovic Kolaric
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Vjera Nincevic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Lucija Kuna
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | | | - Kristina Bojanic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
- Health Center Osijek, Osijek, Croatia
| | - Sonja Vukadin
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Nikola Raguz-Lucic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - George Y Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Martina Smolic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
- Correspondence to: Martina Smolic, University of Osijek, Faculty of Medicine, Department of Pharmacology; Faculty of Dental Medicine and Health, Department of Pharmacology and Biochemistry, J. Huttlera 4, Osijek 31000, Croatia. ORCID: https://orcid.org/0000-0002-6867-826X. Tel: + 385-31-512-800, Fax: +385-31-512-833, E-mail:
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25
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Usami J. Primary Biliary Cholangitis-associated Palmar Keratosis. Intern Med 2021; 60:2877. [PMID: 33746168 PMCID: PMC8479214 DOI: 10.2169/internalmedicine.6919-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jun Usami
- General Medicine, Aichi Medical University, Japan
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26
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Johnson AM, Akpan EJ, Kale S, Patel A. A Rare Case Presentation: Diagnosing Primary Biliary Cholangitis in a Male Patient With Concomitant Type 1 Diabetes. Cureus 2021; 13:e16109. [PMID: 34367753 PMCID: PMC8330503 DOI: 10.7759/cureus.16109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 12/03/2022] Open
Abstract
Primary biliary cholangitis (PBC) is characterized as an autoimmune disease that involves the destruction of intrahepatic bile ducts, characteristically leading to a cholestatic liver. The presence of disease-specific antimitochondrial antibodies (AMA) is the gold standard to diagnose PBC. Typically, PBC is known to affect female populations exceedingly over their male counterparts. Associated autoimmune diseases include Sjogren’s and Raynaud’s syndrome, which are also more prevalent in women. The low incidence rates of men affected with PBC, especially with a concomitant type 1 diabetes diagnosis, have resulted in little being known about the clinical course of the disease in this particular population group. Current research suggests no significant histological, serological, or biochemical differences between PBC in males and females. However, some symptoms and clinical associations may be different. This case report presents the rare case of a male patient with type 1 diabetes recently diagnosed with PBC.
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Affiliation(s)
| | - Ezekiel J Akpan
- Medicine, All Saints University College of Medicine, Kingstown, VCT
| | - Supriya Kale
- School of Medicine, Windsor University, Canyon, KNA
| | - Anna Patel
- Gastroenterology and Hepatology, Community First Medical Center, Chicago, USA
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27
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Mulinacci G, Palermo A, Invernizzi P, Carbone M. Old and novel prognostic biomarkers in primary biliary cholangitis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1927700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- G Mulinacci
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - A Palermo
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
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28
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Wu H, Chen C, Ziani S, Nelson LJ, Ávila MA, Nevzorova YA, Cubero FJ. Fibrotic Events in the Progression of Cholestatic Liver Disease. Cells 2021; 10:cells10051107. [PMID: 34062960 PMCID: PMC8147992 DOI: 10.3390/cells10051107] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Cholestatic liver diseases including primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are associated with active hepatic fibrogenesis, which can ultimately lead to the development of cirrhosis. However, the exact relationship between the development of liver fibrosis and the progression of cholestatic liver disease remains elusive. Periductular fibroblasts located around the bile ducts seem biologically different from hepatic stellate cells (HSCs). The fibrotic events in these clinical conditions appear to be related to complex crosstalk between immune/inflammatory mechanisms, cytokine signalling, and perturbed homeostasis between cholangiocytes and mesenchymal cells. Several animal models including bile duct ligation (BDL) and the Mdr2-knockout mice have improved our understanding of mechanisms underlying chronic cholestasis. In the present review, we aim to elucidate the mechanisms of fibrosis in order to help to identify potential diagnostic and therapeutic targets.
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Affiliation(s)
- Hanghang Wu
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (H.W.); (C.C.); (S.Z.); (Y.A.N.)
| | - Chaobo Chen
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (H.W.); (C.C.); (S.Z.); (Y.A.N.)
- Health Research Institute Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Department of General Surgery, Wuxi Xishan People’s Hospital, Wuxi 214000, China
| | - Siham Ziani
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (H.W.); (C.C.); (S.Z.); (Y.A.N.)
| | - Leonard J. Nelson
- Institute for Bioengineering (IBioE), School of Engineering, Faraday Building, The University of Edinburgh, Edinburgh EH9 3 JL, Scotland, UK;
- Institute of Biological Chemistry, Biophysics and Bioengineering (IB3), School of Engineering and Physical Sciences (EPS), Heriot-Watt University, Edinburgh EH14 4AS, Scotland, UK
| | - Matías A. Ávila
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain;
- Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Instituto de Investigaciones Sanitarias de Navarra IdiSNA, 31008 Pamplona, Spain
| | - Yulia A. Nevzorova
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (H.W.); (C.C.); (S.Z.); (Y.A.N.)
- Health Research Institute Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Department of Internal Medicine III, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (H.W.); (C.C.); (S.Z.); (Y.A.N.)
- Health Research Institute Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-91-394-1385; Fax: +34-91-394-1641
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Abstract
PURPOSE OF REVIEW Primary biliary cholangitis (PBC) is characterized by autoimmune damage of intrahepatic bile ducts associated with a loss of tolerance to mitochondrial antigens. PBC etiopathogenesis is intriguing because of different perplexing features, namely: a) although mitochondria are present in all cell types and tissues, the damage is mainly restricted to biliary epithelial cells (BECs); b) despite being an autoimmune disorder, it does not respond to immunosuppressive drugs but rather to ursodeoxycholic acid, a bile salt that induces HCO3- rich choleresis; c) the overwhelming female preponderance of the disease remains unexplained. Here we present an etiopathogenic view of PBC which sheds light on these puzzling facts of the disease. RECENT FINDINGS PBC develops in patients with genetic predisposition to autoimmunity in whom epigenetic mechanisms silence the Cl-/HCO3- exchanger AE2 in both cholangiocytes and lymphoid cells. Defective AE2 function can produce BECs damage as a result of decreased biliary HCO3- secretion with disruption of the protective alkaline umbrella that normally prevents the penetration of toxic apolar bile salts into cholangiocytes. AE2 dysfunction also causes increased intracellular pH (pHi) in cholangiocytes, leading to the activation of soluble adenylyl cyclase, which sensitizes BECs to bile salt-induced apoptosis. Recently, mitophagy was found to be inhibited by cytosolic alkalization and stimulated by acidification. Accordingly, we propose that AE2 deficiency may disturb mitophagy in BECs, thus, promoting the accumulation of defective mitochondria, oxidative stress and presentation of mitochondrial antigens to the immune cells. As women possess a more acidic endolysosomal milieu than men, mitophagy might be more affected in women in an AE2-defective background. Apart from affecting BECs function, AE2 downregulation in lymphocytes may also contribute to alter immunoregulation facilitating autoreactive T-cell responses. SUMMARY PBC can be considered as a disorder of Cl-/HCO3- exchange in individuals with genetic predisposition to autoimmunity.
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Affiliation(s)
- Jesús Prieto
- Center for Applied Medical Research (Centro de Investigación Médica Aplicada, CIMA), University of Navarra, Pamplona
| | - Jesus M. Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute – Donostia University Hospital – University of the Basque Country (UPV/EHU), San Sebastian
- National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd, ‘Instituto de Salud Carlos III’)
- IKERBASQUE, Basque Foundation for Science, Bilbao
| | - Juan F. Medina
- Unit of Medical Training, School of Medicine, University of Navarra, Pamplona, Spain
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Abstract
Biliary atresia (BA) is a fibro-obliterative condition of the biliary tree, presenting in infancy. The bilioenteric conduit formed at Kasai portoenterostomy (KPE), achieves restoration of bile flow in approximately 60% of infants. Even if the operation is successful, cirrhosis and its associated complications are, however, common. BA remains the leading cause for liver transplantation (LT) in children. Antibiotic, choleretic, and steroid therapy post-KPE have not convincingly reduced LT rates. Advances in molecular technology have enabled characterisation of the encoded genes of the gut microbiota (gut microbiome). The gut microbiome plays an important role in host metabolism, nutrition, and immune function, with alterations in its diversity and/or composition, known as dysbiosis, being described in disease states, including liver disease. Liver-gut microbiome exploration in adulthood largely focuses on nonalcoholic liver disease, cirrhosis (mainly alcohol- or viral-based aetiology) and cholestatic liver diseases (eg, primary sclerosing cholangitis), with microbial signatures correlating to disease severity. Investigation of the gut microbiota in BA had been limited to culture-based methodology, but molecular studies are emerging, and although in their infancy, highlight a potential pathogenic role for Enterobacteriaceae and Streptococcus, and a potential beneficial role for Bifidobacteria. Bacterial translocation, and the production of gut microbiome-derived metabolites, are key host-microbiome-mechanistic pathways in liver disease pathogenesis. Microbiome-targeted therapeutics for liver disease are in development, with faecal microbiota transplantation showing promise in cirrhosis. Could the gut microbiome be a novel modifiable risk factor in BA, reducing the need for LT?
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Real-world experience with obeticholic acid in patients with primary biliary cholangitis. JHEP Rep 2021; 3:100248. [PMID: 33681748 PMCID: PMC7930359 DOI: 10.1016/j.jhepr.2021.100248] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/23/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
Background & aims Obeticholic acid (OCA) is the second-line treatment approved for patients with primary biliary cholangitis (PBC) and an inadequate response or intolerance to ursodeoxycholic acid. We aimed to evaluate the effectiveness and safety of OCA under real-world conditions. Methods Patients were recruited into the Italian PBC Registry, a multicentre, observational cohort study that monitors patients with PBC at national level. The primary endpoint was the biochemical response according to Poise criteria; the secondary endpoint was the biochemical response according to normal range criteria, defined as normal levels of bilirubin, alkaline phosphatase (ALP), and alanine aminotransferase (ALT) at 12 months. Safety and tolerability were also assessed. Results We analysed 191 patients until at least 12 months of follow-up. Median age was 57 years, 94% female, 61 (32%) had cirrhosis, 28 (15%) had histologically proven overlap with autoimmune hepatitis (PBC-AIH). At 12 months, significant median reductions of ALP (-32.3%), ALT (-31.4%), and bilirubin (-11.2%) were observed. Response rates were 42.9% according to Poise criteria, and 11% by normal range criteria. Patients with cirrhosis had lower response than patients without cirrhosis (29.5% vs. 49.2%, p = 0.01), owing to a higher rate of OCA discontinuation (30% vs. 12%, p = 0.004), although with similar ALP reduction (29.4% vs. 34%, p = 0.53). Overlap PBC-AIH had a similar response to pure PBC (46.4% vs. 42.3%, p = 0.68), with higher ALT reduction at 6 months (-38% vs. -29%, p = 0.04). Thirty-three patients (17%) prematurely discontinued OCA because of adverse events, of whom 11 experienced serious adverse events. Treatment-induced pruritus was the leading cause of OCA discontinuation (67%). Conclusions Effectiveness and safety of OCA under real-world conditions mirror those in the Poise trial. Patients with cirrhosis had lower tolerability. Overlap PBC-AIH showed higher ALT reduction at 6 months compared with patients with pure PBC. Lay summary Obeticholic acid (OCA) was shown to be effective in more than one-third of patients not responding to ursodeoxycholic acid in a real-world context in Italy. Patients with cirrhosis had more side effects with OCA, and this led to suspension of the drug in one-third of patients. OCA was also effective in patients who had overlap between autoimmune hepatitis and primary biliary cholangitis.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine transferase
- AMA, antimitochondrial antibodies
- ANA, antinuclear antibodies
- AST, aspartate transferase
- Autoimmunity
- CRFs, case record forms
- Cholestasis
- Cirrhosis
- EDC, electronic data capture
- GGT, gamma-glutamyl transferase
- OC, Overall cohort
- OCA, obeticholic acid
- Overlap PBC-AIH
- PBC, primary biliary cholangitis
- QC, quality control
- RCT, randomised controlled trial
- RR, risk ratio
- TCC, Treatment Completer Cohort
- TIPS, transjugular intrahepatic portosystemic shunt
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- aRR, adjusted risk ratio
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Xiang X, Yang X, Shen M, Huang C, Liu Y, Fan X, Yang L. Ursodeoxycholic Acid at 18-22 mg/kg/d Showed a Promising Capacity for Treating Refractory Primary Biliary Cholangitis. Can J Gastroenterol Hepatol 2021; 2021:6691425. [PMID: 33542908 PMCID: PMC7843178 DOI: 10.1155/2021/6691425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 02/05/2023] Open
Abstract
Aim To compare the response between the current recommended dosage 13-15 mg/kg/d and 20 mg/kg/d dose of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) patients who do not respond completely to a standard dose of UDCA. Methods We included 73 patients with poor response and randomized them into two groups to investigate whether increasing the dosage of UDCA was beneficial to nonresponders. Patients assigned to the 13-15 mg/kg/d group continued with standard therapy, and participants in the 18-22 mg/kg/d group switched to the higher dosage (18-22 mg/kg/d), with a follow-up of 12 months for both groups. The primary endpoints were the rate of response at 6 months and drug side effects. Results According to the Paris 2 criteria, patients receiving 18-22 mg/kg/d UDCA achieved a response rate of 59.4% compared with 36.1% in the standard dosage group (P=0.046) at 6 months, respectively. At 12 months, the high-UDCA-dosage group achieved a response rate of 59.4% compared with 47.2% in the standard dosage group (P=0.295), respectively. Additionally, the risk score predicted by the UK-PBC model was lower in high-dosage UDCA-treated patients than in the standard dosage group (all P < 0.05). Side effects include diarrhea, nausea and vomiting, rash, and newly developed high blood pressure, which were mild and tolerated. Conclusions Patients treated with the high UDCA dosage showed some advantages over those who continued the standard dosage in terms of biochemical remission and disease progression, indicating that standard therapy with UDCA for 6 months and then another 1 year with high UDCA dosage for nonresponders could be a treatment option before second-line therapy is recommended.
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Affiliation(s)
- Xinyu Xiang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoli Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Mengyi Shen
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Huang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Yifeng Liu
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoli Fan
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
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Gochanour EM, Kowdley KV. Investigational drugs in early phase development for primary biliary cholangitis. Expert Opin Investig Drugs 2020; 30:131-141. [PMID: 33249947 DOI: 10.1080/13543784.2021.1857364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: With a large percentage of patients having an incomplete response or intolerance to current FDA approved medications, new therapies for the treatment of primary biliary cholangitis are in great demand. Areas covered: In this review, we assess currently available drugs as well as promising new therapies for the treatment of primary biliary cholangitis. A literature search was performed with the following search terms: 'PBC treatment,' 'PBC therapeutics,' 'PBC clinical trials,' and included original articles, meta-analyses, and systematic reviews from 1 January 1981, to 1 January 2020. ClinicalTrials.gov was accessed for data from ongoing trials. Expert opinion: Targeted drug therapies offer an alternative for patients who are unable to meet their therapeutic goals with either of the two currently approved treatment options. Specifically, new drugs targeting bile-acid regulation, immune-modulation, and fibrogenic pathways are currently in development with multiple agents showing encouraging early results with the ultimate goal of developing therapies that will achieve high rates of biochemical remission, will be well tolerated, and improve symptoms and quality of life in patients with primary biliary cholangitis. Based on a review of the current literature, PPAR agonists appear to be promising agents, along with FGF19 analogs and FXR agonists.
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34
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Fairfield B, Schnabl B. Gut dysbiosis as a driver in alcohol-induced liver injury. JHEP Rep 2020; 3:100220. [PMID: 33598648 PMCID: PMC7868813 DOI: 10.1016/j.jhepr.2020.100220] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022] Open
Abstract
Alcohol-related liver disease characterises a broad spectrum of hepatic diseases that result from heavy alcohol use, and include alcohol-related steatosis, steatohepatitis, fibrosis, cirrhosis, and alcoholic hepatitis. Amongst heavy drinkers, progression to more severe forms of alcohol-related liver disease is not universal, with only 20% developing cirrhosis and up to one-third developing alcoholic hepatitis. Non-alcohol-related triggers for severe disease are not well understood, but the intestinal microbiome is thought to be a contributing factor. This review examines the role of the microbiome in mild alcohol-related liver disease, cirrhosis, and alcoholic hepatitis. While most of the literature discusses bacterial dysbiosis, we also discuss the available evidence on fungal (mycobiome) and virome alterations in patients with alcohol-related liver disease. Additionally, we explore the mechanisms by which the microbiome contributes to the pathogenesis of alcohol-related liver disease, including effects on intestinal permeability, bile acid dysregulation, and production of hepatotoxic virulence factors.
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Key Words
- AH, alcoholic hepatitis
- ALD, Alcohol-related liver disease
- AUD, alcohol use disorder
- Alcohol
- Bile acids
- CDR, cirrhosis dysbiosis ratio
- Cirrhosis
- FGF19, fibroblast growth factor 19
- FXR, farnesoid X receptor
- Hepatitis
- LPS, lipopolysaccharide
- MELD, model for end-stage liver disease
- Microbiome
- Mycobiome
- PAMPs, pathogen-associated molecular patterns
- PPI, proton pump inhibitor
- SCFA, short-chain fatty acid
- Virome
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Affiliation(s)
- Bradley Fairfield
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
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Chen X, Ma X, Wang R, Wang L, Li J, Liu H, He T, Wei S, Li H, Wang M, Zhao Y. Treatment of primary biliary cirrhosis with ursodeoxycholic acid combined with traditional Chinese medicine: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e23107. [PMID: 33181677 PMCID: PMC7668450 DOI: 10.1097/md.0000000000023107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Ursodeoxycholic acid is the priority drug of primary biliary cirrhosis (PBC) and is usually combined with traditional Chinese medicine. This study aimed to systematically evaluate the benefits of integrated Chinese and western interventions for PBC. METHODS Searched the randomized controlled trials in PubMed, Web of Science, CNKI, CBM, Wanfang, VIP databases. The Cochrane risk of bias tool was used for methodological quality assessment and all data analysis was performed using Revman5.3 and Stata14.2 software. RESULT 30 randomized controlled trials involving 10 interventions with a total of 1948 participants were included. Identified the direct and indirect evidence of trials, and used network meta analyses ranked the benefits of different interventions based on pairwise meta analysis. The primary outcom was clinical efficacy rate. Secondary outcome was liver function, including alkaline phosphataseand total bilirubin. CONCLUSION The conclusion of this systematic review provide credible evidence - based for the relative advantages of integrated Chinese and western interventions for PBC.
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Affiliation(s)
- Xing Chen
- Department of Pharmacy, Chinese PLA General Hospital, Beijing
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Xiao Ma
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Ruilin Wang
- Integrative Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lifu Wang
- Integrative Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jianyu Li
- Integrative Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Honghong Liu
- Integrative Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tingting He
- Integrative Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Shizhang Wei
- Department of Pharmacy, Chinese PLA General Hospital, Beijing
| | - Haotian Li
- Department of Pharmacy, Chinese PLA General Hospital, Beijing
| | - Min Wang
- Department of Pharmacy, Chinese PLA General Hospital, Beijing
| | - Yanling Zhao
- Department of Pharmacy, Chinese PLA General Hospital, Beijing
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Alvaro D, Carpino G, Craxi A, Floreani A, Moschetta A, Invernizzi P. Primary biliary cholangitis management: controversies, perspectives and daily practice implications from an expert panel. Liver Int 2020; 40:2590-2601. [PMID: 32757367 DOI: 10.1111/liv.14627] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 02/13/2023]
Abstract
Primary biliary cholangitis (PBC) is a rare progressive immune-mediated liver disease that, if not adequately treated, may culminate in end-stage disease and need for transplantation. According to current guidelines, PBC is diagnosed in the presence of antimitochondrial antibodies (AMA) or specific antinuclear antibodies, and of a cholestatic biochemical profile, while biopsy is recommended only in selected cases. All patients receive ursodeoxycholic acid (UDCA) in first line; the only registered second-line therapy is obeticholic acid (OCA) for UDCA-inadequate responders. Despite the recent advances in understanding PBC pathogenesis and developing new treatments, many grey areas remain. Six Italian experts selected the following topics as the most urgent to address in PBC management: diagnosis and natural history of PBC: as a portion of the subjects with isolated AMA, normal alkaline phosphatase (ALP) levels and no symptoms of liver disease could have PBC by histology, defining how to manage and follow this population is crucial; role of liver biopsy: recent evidence suggests that biopsy may provide relevant information for risk stratification and prediction of UDCA response, possibly facilitating personalized approaches; risk stratification: the tools for risk stratification are well established, but some issues (eg bile acid dosage in routine practice) remain controversial; and therapy: those in more advanced stages of development are nuclear receptor modulators and fibrates, but more data are needed to plan personalized strategies. In this manuscript, for each topic, current evidence, controversies and future perspectives are summarized with the possible implications for clinical practice.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Guido Carpino
- Division of Health Sciences, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Antonio Craxi
- Gastroenterology and Liver Unit, PROMISE, University of Palermo, Palermo, Italy
| | - Annarosa Floreani
- Studioso Senior University of Padova and, Scientific Consultant IRCCS Negrar, Verona, Italy.,Scientific Consultant IRCCS Negrar, Verona, Italy
| | - Antonio Moschetta
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
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Neskorodov YB, Mardanly SG, Chuprov-Netochin RN. The Experience of Analyzing Biological Activity of Ursodeoxycholic Acid as Part of In Silico Prediction of the Gene Expression Profile. RUSS J GENET+ 2020. [DOI: 10.1134/s1022795420100099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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38
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Harms MH, de Veer RC, Lammers WJ, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Trivedi PJ, Hirschfield GM, Pares A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Hansen BE, Buuren HRV, van der Meer AJ. Number needed to treat with ursodeoxycholic acid therapy to prevent liver transplantation or death in primary biliary cholangitis. Gut 2020; 69:1502-1509. [PMID: 31843787 PMCID: PMC7398464 DOI: 10.1136/gutjnl-2019-319057] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/31/2019] [Accepted: 11/16/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The clinical benefit of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has never been reported in absolute measures. The aim of this study was to assess the number needed to treat (NNT) with UDCA to prevent liver transplantation (LT) or death among patients with PBC. METHODS The NNT was calculated based on the untreated LT-free survival and HR of UDCA with respect to LT or death as derived from inverse probability of treatment weighting-adjusted Cox proportional hazard analyses within the Global PBC Study Group database. RESULTS We included 3902 patients with a median follow-up of 7.8 (4.1-12.1) years. The overall HR of UDCA was 0.46 (95% CI 0.40 to 0.52) and the 5-year LT-free survival without UDCA was 81% (95% CI 79 to 82). The NNT to prevent one LT or death within 5 years (NNT5y) was 11 (95% CI 9 to 13). Although the HR of UDCA was similar for patients with and without cirrhosis (0.33 vs 0.31), the NNT5y was 4 (95% CI 3 to 5) and 20 (95% CI 14 to 34), respectively. Among patients with low alkaline phosphatase (ALP) (≤2× the upper limit of normal (ULN)), intermediate ALP (2-4× ULN) and high ALP (>4× ULN), the NNT5y to prevent one LT or death was 26 (95% CI 15 to 70), 11 (95% CI 8 to 17) and 5 (95% CI 4 to 8), respectively. CONCLUSION The absolute clinical efficacy of UDCA with respect to LT or death varied with baseline prognostic characteristics, but was high throughout. These findings strongly emphasise the incentive to promptly initiate UDCA treatment in all patients with PBC and may improve patient compliance.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rozanne C de Veer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Service d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Palak J Trivedi
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, Universita degli Studi di Padova, Padova, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology - location Academic Medical Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington, USA
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
The treatment of biliary atresia (BA) is predominantly surgical with firstly an attempt at restoration of bile flow from the native liver by wide excision of the obstructed, obliterated extrahepatic biliary tree to the level of the porta hepatis and a portoenterostomy using a long Roux loop-Kasai portoenterostomy (KPE). Liver transplantation is reserved for those that fail this and for those where surgery is considered futile for reasons of age or stage of disease. As the aetiology of BA remains ill-defined, so adjuvant treatment has been largely based on pragmatism, trial and error. Systematic analysis of the few randomized placebo-controlled trial data and less well-controlled cohort studies have suggested benefit from post-operative high-dose steroids and ursodeoxycholic acid (UDCA) while the benefit of long-term prophylactic antibiotics, bile acid sequestrants (e.g., colestyramine) or probiotics remains unproven. Newer modalities such as antiviral therapy (AVT), immunoglobulin, FXR agonists (e.g., obeticholic acid), ileal bile acid transporter (IBAT) antagonists (e.g., maralixibat) remain unproven. This article reviews the current evidence for the efficacy of adjuvant medical therapy in BA.
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Affiliation(s)
- Jessica Burns
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
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Zhang S, Yu M, Guo F, Yang X, Chen Y, Ma C, Li Q, Wei Z, Li X, Wang H, Hu H, Zhang Y, Kong D, Miao QR, Hu W, Hajjar DP, Zhu Y, Han J, Duan Y. Rosiglitazone alleviates intrahepatic cholestasis induced by α-naphthylisothiocyanate in mice: The role of circulating 15-deoxy-Δ 12,14 -PGJ 2 and Nogo. Br J Pharmacol 2020; 177:1041-1060. [PMID: 31658492 DOI: 10.1111/bph.14886] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/14/2019] [Accepted: 09/21/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Intrahepatic cholestasis is mainly caused by dysfunction of bile secretion and has limited effective treatment. Rosiglitazone is a synthetic agonist of PPARγ, whose endogenous agonist is 15-deoxy-Δ12,14 -PGJ2 (15d-PGJ2 ). Reticulon 4B (Nogo-B) is the detectable Nogo protein family member in the liver and secreted into circulation. Here, we determined if rosiglitazone can alleviate intrahepatic cholestasis in mice. EXPERIMENTAL APPROACH Wild-type, hepatocyte-specific PPARγ or Nogo-B knockout mice received intragastric administration of α-naphthylisothiocyanate (ANIT) and/or rosiglitazone, followed by determination of intrahepatic cholestasis and the involved mechanisms. Serum samples from primary biliary cholangitis (PBC) patients and non-PBC controls were analysed for cholestasis-related parameters. KEY RESULTS Rosiglitazone prevented wild type, but not hepatocyte-specific PPARγ deficient mice from developing ANIT-induced intrahepatic cholestasis by increasing expression of bile homeostatic proteins, reducing hepatic necrosis, and correcting abnormal serum parameters and enterohepatic circulation of bile. Nogo-B knockout provided protection similar to that of rosiglitazone treatment. ANIT-induced intrahepatic cholestasis decreased 15d-PGJ2 but increased Nogo-B in serum, and both were corrected by rosiglitazone. Nogo-B deficiency in the liver increased 15d-PGJ2 production, thereby activating expression of PPARγ and bile homeostatic proteins. Rosiglitazone and Nogo-B deficiency also alleviated cholestasis-associated dyslipidemia. In addition, rosiglitazone reduced symptoms of established intrahepatic cholestasis in mice. In serum from PBC patients, the decreased 15d-PGJ2 and increased Nogo-B levels were significantly correlated with classical cholestatic markers. CONCLUSIONS AND IMPLICATIONS Levels of 15d-PGJ2 and Nogo are important biomarkers for intrahepatic cholestasis. Synthetic agonists of PPARγ could be used for treatment of intrahepatic cholestasis and cholestasis-associated dyslipidemia.
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Affiliation(s)
- Shuang Zhang
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Miao Yu
- Institute for Cardiovascular Science and Department of Cardiovascular Surgery of the First Affiliated Hospital, Medical College of Soochow University, Suzhou, China
| | - Fangling Guo
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Xiaoxiao Yang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Yuanli Chen
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Chuanrui Ma
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Qi Li
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Zhuo Wei
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Xiaoju Li
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Hua Wang
- Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Huaqing Hu
- Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yujue Zhang
- Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Derun Kong
- Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qing Robert Miao
- Winthrop Hospital Diabetes and Obesity Research Center, New York University, New York, New York
| | - Wenquan Hu
- Winthrop Hospital Diabetes and Obesity Research Center, New York University, New York, New York
| | - David P Hajjar
- Weill Cornell Medicine, Cornell University, New York, New York
| | - Yan Zhu
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jihong Han
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China.,Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Yajun Duan
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
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Amano N, Ikeda Y, Hayashida S, Takahashi S, Sato S, Murata A, Tsuzura H, Sato S, Shimada Y, Iijima K, Wada R, Nagahara A, Genda T. Prognostic significance of serum tyrosine concentration in patients with primary biliary cholangitis under ursodeoxycholic acid therapy. Hepatol Res 2020; 50:214-223. [PMID: 31652380 DOI: 10.1111/hepr.13434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/23/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023]
Abstract
AIM Chronic liver insufficiency is often associated with alteration in amino acid metabolism. We evaluated the prognostic value of changes in serum amino acid concentrations in patients with primary biliary cholangitis. METHODS A total of 75 primary biliary cholangitis patients who started urusodeoxycholic acid therapy were retrospectively enrolled. Baseline serum concentrations of branched-chain amino acids and tyrosine, and branched-chain amino acid-to-tyrosine ratio were determined. The hazard ratios of factors associated with liver-related events were analyzed by Cox proportional hazard analysis. RESULTS Of the 75 patients enrolled, 12 showed a decrease in serum branched-chain amino acid levels, and 15 showed an increase in serum tyrosine levels. The branched-chain amino acid-to-tyrosine ratio decreased in 16 patients. During a median 5.6-year follow up, liver-related events occurred in 11 patients. Multivariate analysis showed that high serum tyrosine levels at baseline and high alkaline phosphatase levels 48 weeks after starting urusodeoxycholic acid therapy were independent risk factors for event occurrence. From the receiver operator characteristics curve analysis, serum tyrosine concentration >110 μmol/L was identified as a cut-off value with an adjusted hazard ratio of 20.9 (95% confidence interval 4.3-101.5, P < 0.001). Kaplan-Meier analysis showed that the 5-year cumulative incidences of event occurrence in patients with high and low serum tyrosine concentration were 56.5% and 5.5%, respectively (P < 0.001). The 10-year survival probabilities also showed significant differences between patients with high and low serum tyrosine concentration (44.9% vs. 92.0%, P < 0.001). CONCLUSION Elevation of serum tyrosine concentration indicates a high risk of liver-related events in primary biliary cholangitis patients receiving urusodeoxycholic acid therapy.
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Affiliation(s)
- Nozomi Amano
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Yuji Ikeda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Sho Hayashida
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Sho Takahashi
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Sho Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Ayato Murata
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Hironori Tsuzura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Shunsuke Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Yuji Shimada
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Katsuyori Iijima
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Ryo Wada
- Department of Pathology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
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Suri JS, Danford CJ, Patwardhan V, Bonder A. Mortality on the UNOS Waitlist for Patients with Autoimmune Liver Disease. J Clin Med 2020; 9:E319. [PMID: 31979326 PMCID: PMC7074547 DOI: 10.3390/jcm9020319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Outcomes on the liver transplant waitlist can vary by etiology. Our aim is to investigate differences in waitlist mortality of autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) using the United Network for Organ Sharing (UNOS) database. METHODS We identified patients who were listed for liver transplantation from 1987 to 2016 with a primary diagnosis of AIH, PBC, or PSC. We excluded patients with overlap syndromes, acute hepatic necrosis, missing data, and those who were children. The primary outcome was death or removal from the waitlist due to clinical deterioration. We compared waitlist survival using competing risk analysis. RESULTS Between 1987 and 2016, there were 7412 patients listed for liver transplant due to AIH, 8119 for PBC, and 10,901 for PSC. Patients with AIH were younger, more likely to be diabetic, and had higher listing model for end-stage liver disease (MELD) scores compared to PBC and PSC patients. Patients with PBC and AIH were more likely to be removed from the waitlist due to death or clinical deterioration. On competing risk analysis, AIH patients had a similar risk of being removed from the waitlist compared to those with PBC (subdistribution hazard ratio (SHR) 0.94, 95% CI 0.85-1.03) and higher risk of removal compared to those with PSC (SHR 0.8, 95% CI 0.72 to 0.89). CONCLUSION Autoimmune hepatitis carries a similar risk of waitlist removal to PBC and a higher risk than PSC. The etiology of this disparity is not entirely clear and deserves further investigation.
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Affiliation(s)
| | | | | | - Alan Bonder
- Liver Center, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Abstract
Though ursodeoxycholic acid (UDCA) remains the baseline treatment for most cholestatic liver diseases, UDCA treatment leaves approximately one-third of patients with primary biliary cholangitis (PBC) and all patients with primary sclerosing cholangitis (PSC) at risk for disease progression. New anticholestatic agents, including nuclear receptor agonists, choleretics, and bile acid synthesis suppressors, will likely increase response rates to therapy in PBC and PSC. Strategies that target early immune-mediated injury have so far been disappointing, hampered by the lack of biomarkers to detect early disease states, which then could profit from immunomodulatory therapy. Future concepts need to personalize treatments according to disease stage, progression, and phase, and to combine multiple drugs to target different pathogenic pathways.
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Affiliation(s)
- Martin Wagner
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
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44
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Yang SS, Oh JM, Chun S, Kim BS, Kim CS, Lee J. Tauroursodeoxycholic acid induces angiogenic activity in endothelial cells and accelerates bone regeneration. Bone 2020; 130:115073. [PMID: 31626993 DOI: 10.1016/j.bone.2019.115073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/08/2019] [Accepted: 09/17/2019] [Indexed: 12/31/2022]
Abstract
Angiogenesis is a crucial process during bone tissue regeneration. The aim of this study was to investigate the angiogenic activity and the potentiation of bone regeneration via angiogenesis using tauroursodeoxycholic acid (TUDCA) in vitro and in vivo. We investigated the effect of TUDCA on proliferation and angiogenic differentiation in human umbilical vein endothelial cells (HUVECs) and the associated signaling pathway. Proliferation was determined using crystal violet assay. Angiogenic effects were evaluated based on cell migration and tube formation. In order to explore TUDCA-signaling pathways, phosphorylation of mitogen activated protein kinase, protein kinase B (AKT), and endothelial nitric oxide synthase (eNOS) was determined using western blot. Furthermore, in vivo bone formation and angiogenesis were determined using a New Zealand outbred albino rabbit calvarial defect model, while angiogenesis and bone formation were evaluated using micro-CT and histological analysis. Our results show that TUDCA significantly increased cell proliferation. Moreover, TUDCA enhanced cell migration and tube formation in HUVECs. TUDCA increased the phosphorylation of AKT, ERK1/2, c-Jun N-terminal kinase, and eNOS. Specific inhibitors of ERK1/2 (PD98059), JNK (SP600125), and AKT (AKT1/2) inhibited the TUDCA-induced migration and tube formation, while the p38 inhibitor (SB203580) did not. The in vivo study used TUDCA to accelerate new blood vessel formation and promoted bone formation in rabbit calvarial defect model. These results indicate that TUDCA plays a critical role in enhancing the angiogenesis of endothelial cells and in vivo new bone regeneration. The use of TUDCA may contribute to the regeneration of bone tissue by improving angiogenesis.
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Affiliation(s)
- Sun-Sik Yang
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Wonkwang University 77 Dunsan-ro, Seo-gu, Daejeon 302-120, Republic of Korea
| | - Jung-Mi Oh
- Department of Physiology, Chonbuk National Medical School, Jeonju-si, Jeollabuk-do 54896, Republic of Korea
| | - Sungkun Chun
- Department of Physiology, Chonbuk National Medical School, Jeonju-si, Jeollabuk-do 54896, Republic of Korea
| | - Beom-Su Kim
- Carbon Nano Convergence Technology Center for Next Generation Engineers (CNN), Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju-si, Jeollabuk-do 54896, Republic of Korea.
| | - Cheol Sang Kim
- Department of Bionanosystem Engineering, Graduate School, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju-si, Jeollabuk-do 54896, Republic of Korea; Division of Mechanical Design Engineering, Chonbuk National University, Jeonju-si, Jeollabuk-do 54896, Republic of Korea.
| | - Jun Lee
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Wonkwang University 77 Dunsan-ro, Seo-gu, Daejeon 302-120, Republic of Korea.
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Palmer M, Regev A, Lindor K, Avigan MI, Dimick‐Santos L, Treem W, Marcinak JF, Lewis JH, Anania FA, Seekins D, Shneider BL, Chalasani N. Consensus guidelines: best practices for detection, assessment and management of suspected acute drug-induced liver injury occurring during clinical trials in adults with chronic cholestatic liver disease. Aliment Pharmacol Ther 2020; 51:90-109. [PMID: 31762074 PMCID: PMC6972572 DOI: 10.1111/apt.15579] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/03/2019] [Accepted: 10/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Improved knowledge of the molecular pathophysiology and immunopathogenesis of cholestatic liver diseases in recent years has led to an increased interest in developing novel therapies. Patients with cholestatic liver disease often require different approaches to assessment and management of suspected drug-induced liver injury (DILI) compared to those with healthy livers and those with parenchymal liver diseases. At present, there are no regulatory guidelines or society position papers, that systematically address best practices pertaining to detection of DILI in these patients. AIMS To outline best practices for detection, assessment and management of suspected acute DILI during clinical trials in adults with the cholestatic liver diseases - Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC). METHODS This is one of the several papers developed by the IQ DILI Initiative, which is comprised of members from 16 pharmaceutical companies, in collaboration with DILI experts from academia and regulatory agencies. The contents are the result of an extensive literature review, as well as in-depth discussions among industry, regulatory and academic DILI experts, to achieve consensus recommendations on DILI-related issues occurring during clinical trials for cholestatic liver diseases. RESULTS Recommended best practices are outlined pertaining to hepatic eligibility criteria, monitoring of liver tests, approach to a suspected DILI signal, and hepatic discontinuation rules. CONCLUSIONS This paper provides a framework for the approach to detection, assessment and management of suspected acute DILI occurring during clinical trials in adults with cholestatic liver disease.
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Goossens JF, Bailly C. Ursodeoxycholic acid and cancer: From chemoprevention to chemotherapy. Pharmacol Ther 2019; 203:107396. [DOI: 10.1016/j.pharmthera.2019.107396] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022]
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Moscoso CG, Steer CJ. "Let my liver rather heat with wine" - a review of hepatic fibrosis pathophysiology and emerging therapeutics. Hepat Med 2019; 11:109-129. [PMID: 31565001 PMCID: PMC6731525 DOI: 10.2147/hmer.s213397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/17/2019] [Indexed: 12/12/2022] Open
Abstract
Cirrhosis is characterized by extensive hepatic fibrosis, and it is the 14th leading cause of death worldwide. Numerous contributing conditions have been implicated in its development, including infectious etiologies, medication overdose or adverse effects, ingestible toxins, autoimmunity, hemochromatosis, Wilson’s disease and primary biliary cholangitis to list a few. It is associated with portal hypertension and its stigmata (varices, ascites, hepatic encephalopathy, combined coagulopathy and thrombophilia), and it is a major risk factor for hepatocellular carcinoma. Currently, orthotopic liver transplantation has been the only curative modality to treat cirrhosis, and the scarcity of donors results in many people waiting years for a transplant. Identification of novel targets for pharmacologic therapy through elucidation of key mechanistic components to induce fibrosis reversal is the subject of intense research. Development of robust models of hepatic fibrosis to faithfully characterize the interplay between activated hepatic stellate cells (the principal fibrogenic contributor to fibrosis initiation and perpetuation), hepatocytes and extracellular matrix components has the potential to identify critical components and mechanisms that can be exploited for targeted treatment. In this review, we will highlight key cellular pathways involved in the pathophysiology of fibrosis from extracellular ligands, effectors and receptors, to nuclear receptors, epigenetic mechanisms, energy homeostasis and cytokines. Further, molecular pathways of hepatic stellate cell deactivation are discussed, including apoptosis, senescence and reversal or transdifferentiation to an inactivated state resembling quiescence. Lastly, clinical evidence of fibrosis reversal induced by biologics and small molecules is summarized, current compounds under clinical trials are described and efforts for treatment of hepatic fibrosis with mesenchymal stem cells are highlighted. An enhanced understanding of the rich tapestry of cellular processes identified in the initiation, perpetuation and resolution of hepatic fibrosis, driven principally through phenotypic switching of hepatic stellate cells, should lead to a breakthrough in potential therapeutic modalities.
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Affiliation(s)
- Carlos G Moscoso
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
| | - Clifford J Steer
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition.,Department of Genetics, Cell Biology and Development, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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Prediction of Transplant-Free Survival through Albumin-Bilirubin Score in Primary Biliary Cholangitis. J Clin Med 2019; 8:jcm8081258. [PMID: 31430975 PMCID: PMC6723915 DOI: 10.3390/jcm8081258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/13/2019] [Accepted: 08/16/2019] [Indexed: 02/08/2023] Open
Abstract
Albumin–bilirubin (ALBI) grade is defined using the ALBI score, which is calculated based on total serum bilirubin and albumin. This study aimed to evaluate the diagnostic ability of the ALBI score for determining hepatic fibrosis stage and transplant-free survival in primary biliary cholangitis (PBC) patients. A total of 181 Japanese patients with biopsy-proven or serologically diagnosed PBC were enrolled. The pathological stage was assessed using the Scheuer classification. The ALBI score differentiated fibrosis in stage 4 from that of 3 in the biopsy-proven cohort (p < 0.05). With an ALBI score cut-off value of −1.679, the sensitivity and specificity were 100% and 91.1%, respectively, with a likelihood ratio of 12.3 to differentiate stage 4 from stages 1–3. The ALBI score at the beginning of ursodeoxycholic acid (UDCA) prescription correlated with the two prognostic scores calculated after 1-year UDCA treatment. Kaplan–Meier analysis showed that the baseline ALBI score differentiated liver transplant-free survival (p < 0.05). The ALBI score presented a greater hazard ratio for transplant-free survival than aspartate aminotransferase-to-platelet ratio index (APRI) in Cox proportional hazard model. In conclusion, ALBI score indicates pathological stage in Japanese PBC patients and scores before UDCA prescription predict better liver transplant-free survival, which correlated well with the two major prognostic scores. The prognosis-predicting ability of the ALBI score might surpass that of APRI.
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Corpechot C, Poupon R, Chazouillères O. New treatments/targets for primary biliary cholangitis. JHEP Rep 2019; 1:203-213. [PMID: 32039371 PMCID: PMC7001536 DOI: 10.1016/j.jhepr.2019.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/11/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune, cholestatic, chronic liver disease that ultimately progresses towards cirrhosis and liver failure if untreated. While ursodeoxycholic acid has been established as standard of care for PBC in the last few decades, significant advances in second-line treatment options have recently been made and new therapeutic developments are currently under evaluation. The purpose of this article is to provide the clinician with an overview of the current treatment options and future opportunities for patients with PBC.
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Affiliation(s)
- Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology Department, Saint-Antoine Hospital, Assistance Publique – Hôpitaux de Paris (APHP); INSERM UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
- Corresponding author. Address: Hepatology Department, Saint Antoine Hospital, 184 rue du Faubourg Saint Antoine, 75571 Paris Cedex 12, France.
| | - Raoul Poupon
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology Department, Saint-Antoine Hospital, Assistance Publique – Hôpitaux de Paris (APHP); INSERM UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Olivier Chazouillères
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology Department, Saint-Antoine Hospital, Assistance Publique – Hôpitaux de Paris (APHP); INSERM UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
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50
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Harms MH, van Buuren HR, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Hirschfield GM, Parés A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Lammers WJ, Hansen BE, van der Meer AJ. Ursodeoxycholic acid therapy and liver transplant-free survival in patients with primary biliary cholangitis. J Hepatol 2019; 71:357-365. [PMID: 30980847 DOI: 10.1016/j.jhep.2019.04.001] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The clinical efficacy of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) remains subject to debate as definitive randomized controlled trials are lacking. We aimed to determine whether UDCA prolongs liver transplant (LT)-free survival in patients with PBC. METHODS This international cohort study included patients from the Global PBC Study Group database, originating from 8 countries in Europe and North America. Both UDCA-treated and untreated patients were included. LT and death were assessed as a combined endpoint through Cox regression analyses, with inverse probability treatment weighting (IPTW). RESULTS In the 3,902 patients included, the mean (SD) age was 54.3 (11.9) years, 3,552 patients (94.0%) were female, 3,529 patients (90.4%) were treated with UDCA and 373 patients (9.6%) were not treated. The median (interquartile range) follow-up was 7.8 (4.1-12.1) years. In total, 721 UDCA-treated patients and 145 untreated patients died or underwent LT. After IPTW, the 10-year cumulative LT-free survival was 79.7% (95% CI 78.1-81.2) among UDCA-treated patients and 60.7% (95% CI 58.2-63.4) among untreated patients (p <0.001). UDCA was associated with a statistically significant reduced risk of LT or death (hazard ratio 0.46, 95% CI 0.40-0.52; p <0.001). The hazard ratio remained statistically significant in all stages of disease. Patients classified as inadequate biochemical responders after 1 year of UDCA had a lower risk of LT or death than patients who were not treated (adjusted hazard ratio 0.56; 95% CI 0.45-0.69; p <0.001). CONCLUSION The use of UDCA improves LT-free survival among patients with PBC, regardless of the disease stage and the observed biochemical response. These findings support UDCA as the current universal standard of care in PBC. LAY SUMMARY In this international multicenter study of 3,902 patients with primary biliary cholangitis, we found that treatment with ursodeoxycholic acid is associated with prolonged liver transplant-free survival. This association was significant, irrespective of sex, age, or disease stage. The survival benefit remained statistically significant in patients with an incomplete biochemical response to ursodeoxycholic acid therapy.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Keith D Lindor
- Arizona State University, College of Health Solutions, Phoenix, AZ, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada; Birmingham NIHR Biomedical Research Centre, and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, WA, USA
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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