Autoimmune hepatitis

Aging liver and hepatitis

Chronic liver disease and cirrhosis are the tenth leading causes of death in the United States and results in approximately 25,000 deaths annually. As life expectancy in developed countries has increased, so has the number of elderly patients who have liver disease. With an aging population and chronic liver disease becoming an increasingly significant cause of morbidity and mortality, the various causes for hepatitis will need to be evaluated and available treatments considered, even in elderly population. Common causes for hepatitis in elderly individuals include viral, autoimmune, and drug-induced hepatitis, but evidence for treatment of this population is limited. This article reviews the likely causes of hepatitis in elderly individuals and discusses evidence for treating this population.

Autoimmune hepatitis (AIH) in the elderly: a systematic retrospective analysis of a large group of consecutive patients with definite AIH followed at a tertiary referral centre

BACKGROUND/AIMS

A few reports have suggested that AIH may be less severe in the elderly and may be underdiagnosed, but there is a paucity of data.

METHODS

We have undertaken a systematic analysis of 164 consecutive patients (36 males, 128 females) with definite AIH (median score 23, range 18-28) attending our clinics, comparing those presenting at age >60 years (Group 1, n=43) with those presenting at <60 years (Group 2, n=121).

RESULTS

Median (range) duration of follow-up was 9 years (1-28) in Group 1 and 14 years (1-33) in Group 2. Median ages (ranges) at presentation were: Group 1=65 (60-79) and Group 2=41 (6-59). Group 1 patients had a significantly increased incidence of ascites at presentation (p<0.001) and a lower incidence of relapse (42% vs. 70%, p=0.002), but there were no significant differences between the groups with respect to mode of onset (acute, insidious, asymptomatic), other clinical signs at presentation, biochemical parameters, types or titres of autoantibodies, incidence of histological cirrhosis, response to therapy or related side effects. There were also no significant differences in liver-related deaths or transplantation, or the frequencies of HLA DR3 or DR4 - although there was an increased frequency of the A1-B8-DR3/4 haplotype in Group 2 (40% vs. 22%, p=0.138).

CONCLUSIONS

These findings suggest that AIH often presents in older patients, who frequently have severe disease. Active management in these patients can lead to a normal life expectancy.

Cost-effectiveness of pharmacotherapy for autoimmune hepatitis

In > 80% of patients with autoimmune hepatitis, steroid therapy alone or in combination with azathioprine results in disease remission. Treatment response results in reversal of fibrosis and excellent long-term survival in many patients, whereas untreated patients may expect a 10-year survival of < 30%. The use of azathioprine monotherapy (2 mg/kg/day) has gained widespread acceptance in maintaining remission in clinical practice. Although all patients with autoimmune hepatitis may not need treatment, particularly those with mild disease, alternative strategies are required in patients who have failed to achieve remission on standard therapy of steroids with or without azathioprine, or patients with azathioprine-induced drug toxicity. In such circumstances, the use of salvage therapy in the form of ciclosporin, tacrolimus or mycophenolate mofetil may be warranted. Liver transplantation is the treatment of choice for patients who present with subacute liver failure or decompensated cirrhosis. Salvage therapy results in an exponential rise in cost with each increment in therapeutic escalation. As an alternative to standard therapy, it has also been suggested that novel therapies such as ciclosporin, tacrolimus or mycophenolate mofetil be initiated to achieve remission. However, a > 10-fold cost differential exists between the charges associated with more potent immunosuppression and standard therapy. Therefore, in evaluating novel immunosuppression in autoimmune hepatitis, it behoves clinicians not only to consider end points pertaining to efficacy, but also end points pertaining to cost-effectiveness. Moreover, the exact role of pharmacogenomics and genotyping of thiopurine methyltransferase in patients with autoimmune hepatitis needs to be fully defined.

[Elevated aminotransferse levels--diagnostic approach]

INTRODUCTION

Aminotransferase levels are a sensitive indicator of liver cell injury and is frequently used to identify patients with liver diseases such as hepatitis. Both aminotransferases are normally present in serum at low levels, usually less than 30 U per liter. Although these enzymes are present in tissues throughout the body, they are most often elevated in patients with liver diseases and may reflect liver injury. Raised aminotransferase levels of unknown origin are common problem in clinical practice. Serum alanine aminotransferase (ALT) activity, the variable most commonly measured to assess hepatic disease, fails to identify many patients with hepatic injury. On the other hand, elevated ALT level doesn't always confirm liver disease. The aim of this study was to show the most common reasons for elevated aminotransferase levels.

MATERIAL AND METHODS

The study included 27 patients with elevated ALT. All of them were followed-up for six months before liver biopsy was performed. All patients underwent routine laboratory tests and ultrasound of the abdomen.

RESULTS

We found that four patients had a nonalcoholic steatohepatitis (NASH), four patients had chronic hepatitis of unknown etiology, two of them had autoimmune hepatitis, four had mild lobular hepatitis (three of them unresolved acute hepatitis, one of them had nodular regenerative hyperplasia), six patients had normal results, and three had no specific changes.

CONCLUSION

Elevated ALT level doesn't always mean that there is a liver disease. If aminotransferase levels are persistently more than twice the normal value, a biopsy is recommended. Although results of biopsy are unlikely to lead to a diagnosis or to changes in management, they often provide reassurance to the patient and the physician to exclude serious pathology.

[A histologic variant of autoimmune hepatitis with zonal necrosis]

Autoimmune hepatitis type 1 in a 8-year old girl is described. The diagnosis was established using International Autoimmune hepatitis group scoring system. In addition to characteristic histologic features of autoimmune hepatitis (periportal hepatitis, piecemeal necrosis and rozettes) prominent centrilobular necrosis was discovered. As an isolate finding in autoimmune hepatitis, this type was described only in five cases. In our unique case centrilobular necrosis is a very important parallel finding previously not detected in autoimmune hepatitis. Some experimental studies suggest that cytocins present in inflammatory cell infiltrate in the liver play a pathologic role in autoimmune liver cell damage.

Current and novel immunosuppressive therapy for autoimmune hepatitis

Corticosteroids alone or in conjunction with azathioprine is the treatment of choice in patients with autoimmune hepatitis (AIH) and results in remission induction in over 80% of patients. Sustained response to therapy may result in substantial regression of fibrosis even in advanced cases. The outcome of rapid withdrawal of immunosuppression is disease relapse in many patients. Consequently, the use of 2 mg/kg/d of azathioprine as a sole agent to maintain remission has been widely accepted in clinical practice. Persistent severe laboratory abnormalities or histologic abnormalities such as bridging necrosis or multilobular necrosis are absolute indications for treatment based on controlled clinical trials, but debate exists as to whether all patients with AIH need treatment. Examination of liver tissue remains the best method of evaluating both treatment response and need for treatment in patients who have little biochemical activity. Alternative strategies in patients who have failed to achieve remission on "standard therapy" of corticosteroids with or without azathioprine or patients with drug toxicity include the use of cyclosporine, tacrolimus, or mycophenolate mofetil. Liver transplantation is the treatment of choice in managing decompensated disease. In this review we examine current management strategies of AIH, and evaluate available data pertaining to the use of novel immunosuppressive agents in this condition.