Autoimmune liver disease

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

INTRODUCTION AND AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

A serum metabolomic analysis for diagnosis and biomarker discovery of primary biliary cirrhosis and autoimmune hepatitis

BACKGROUND

Because of the diversity of the clinical and laboratory manifestations, the diagnosis of autoimmune liver disease (AILD) remains a challenge in clinical practice. The value of metabolomics has been studied in the diagnosis of many diseases. The present study aimed to determine whether the metabolic profiles, based on ultraperformance liquid chromatography-mass spectrometry (UPLC-MS), differed between autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC), to identify specific metabolomic markers, and to establish a model for the diagnosis of AIH and PBC.

METHODS

Serum samples were collected from 20 patients with PBC, 19 patients with AIH, and 25 healthy individuals. UPLC-MS data of the samples were analyzed using principal component analysis, partial least squares discrimination analysis and orthogonal partial least squares discrimination analysis.

RESULTS

The partial least squares discrimination analysis model (R2Y=0.991, Q2=0.943) was established between the AIH and PBC groups and exhibited both sensitivity and specificity of 100%. Five groups of biomarkers were identified, including bile acids, free fatty acids, phosphatidylcholines, lysolecithins and sphingomyelin. Bile acids significantly increased in the AIH and PBC groups compared with the healthy control group. The other biomarkers decreased in the AIH and PBC groups compared with those in the healthy control group. In addition, the biomarkers were downregulated in the AIH group compared with the PBC group.

CONCLUSIONS

The biomarkers identified revealed the pathophysiological changes in AILD and helped to discriminate between AIH and PBC. The predictability of this method suggests its potential application in the diagnosis of AILD.

Tumour necrosis factor alpha (TNF-α) genetic polymorphisms and the risk of autoimmune liver disease: a meta-analysis

Epidemiological studies have evaluated the association between tumour necrosis factor alpha (TNF-α)- 308G/A and (TNF-α)- 238G/A polymorphisms, and the risk of autoimmune liver disease (AILD), yet the results are conflicting. To derive a more precise estimation of the relationship, we performed this meta-analysis. A systematic review was conducted to identify all eligible studies of TNF-α polymorphisms and AILD risk. We used odds ratios (ORs) with 95% confidence intervals (CIs) to assess the strength of the association between the two TNF-α polymorphisms and AILD risk. A total of 15 eligible studies were identified. Overall, positive associations of -308G/A polymorphism with AILD risk were found (A vs G allele: OR =1.45, 95%CI = 1.13- 1.86; AA vs GG: OR = 2.74, 95%CI = 1.51- 4.96; GA vs GG: OR = 1.46, 95%CI = 1.11- 1.92;dominant model: OR = 1.57, 95%CI = 1.18- 2.10; recessive model: OR = 2.22, 95%CI = 1.31- 3.76). In subgroup analysis by ethnicity, a significantly higher risk was found in Caucasians. In subgroup analysis by AILD category, significant association was observed in autoimmune hepatitis and primary sclerosing cholangitis, especially in Caucasians. Patients carrying TNF-α-238A allele had a slightly decreased risk of developing AILD (OR = 0.65, 95%CI = 0.48- 0.87). However, we found both TNF-α polymorphisms were not associated with primary biliary cirrhosis risk, even in subgroup analysis. Our meta-analysis suggests that the TNF-α-308G/A and -238G/A polymorphisms may contribute to AILD susceptibility in Caucasians,especially for autoimmune hepatitis and primary sclerosing cholangitis. Nevertheless, we found both TNF-α polymorphisms were unlikely to be associated with the risk of primary biliary cirrhosis

Plasma cell hepatitis (de-novo autoimmune hepatitis) developing post liver transplantation

PURPOSE OF REVIEW

Cases of de-novo autoimmune hepatitis/plasma cell hepatitis (PCH) are increasingly being diagnosed by liver transplant centers. Its pathogenesis is poorly understood but this entity appears to be a variant of rejection. Herein, we review recent clinical reports of patients developing PCH.

RECENT FINDINGS

Histologically, PCH is a challenging diagnosis, especially in the setting of recurrent hepatitis C and, in some cases, can be mistaken for acute cellular rejection. Recent case reports and case-control studies have shown that interferon appears to trigger PCH in hepatitis C posttransplant patients. Optimization of the immunosuppression regimen was found to prevent the development of PCH. In the nonhepatitis C posttransplant patient, tacrolimus-based immunosuppression appears to have some protective effect from PCH development. A combination therapy of cyclosporine and everolimus has also been shown to be effective in treating PCH.

SUMMARY

PCH is a variant of rejection and is a cause of late graft loss post liver transplantation, especially in patients with hepatitis C. It should be part of the differential diagnosis of abnormal liver enzyme tests occurring in the post-liver transplant setting.

Impact of pretransplant antinuclear antibody and antismooth muscle antibody titers on disease recurrence and graft survival following liver transplantation in autoimmune hepatitis patients

BACKGROUND AND AIMS

Disease recurrence following transplantation occurs in 20-45% of patients with autoimmune hepatitis (AIH). Factors associated with an increased risk of recurrence include human leukocyte antigen (HLA) DR3 and HLA DR4 positivity, inadequate immunosuppression, and severity of inflammation in the native liver. Titers of several autoantibodies can be elevated in patients with AIH, including antinuclear antibody (ANA) and antismooth muscle antibody (SMA); however, it is unclear whether or not the degree of elevation influences the risk of disease recurrence following transplantation.

METHODS

We conducted a retrospective study to evaluate the potential impact of pretransplant titers on post-transplant outcomes for patients with AIH. Sixty-three patients with AIH who underwent 72 liver transplants between 1 January 1989 and 1 January 2009 were included, with a median follow up of 10 months. Patients were divided into group A (ANA or SMA ≥ 1:160) and group B (titers ≤ 1:160).

RESULTS

There was no significant difference in the recurrence rates or death between patients in groups A and B, respectively. Only race appeared to impact outcomes, with African American patients having a higher incidence of death and recurrent disease post-transplant compared to other ethnicities.

CONCLUSIONS

  Based on our findings, pretransplant ANA and SMA levels do not appear to impact recurrence rates or outcomes following liver transplantation for AIH.

Low incidence of positive smooth muscle antibody and high incidence of isolated IgM elevation in Chinese patients with autoimmune hepatitis and primary biliary cirrhosis overlap syndrome: a retrospective study

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BACKGROUND

Up to now, few data are available regarding the clinical characteristics of autoimmune hepatitis and primary biliary cirrhosis overlap syndrome. The study was to investigate and analyze the prevalent and clinical features of Chinese patients with this disease.

METHODS

Clinical data on patients diagnosed as autoimmune hepatitis and primary biliary cirrhosis overlap syndrome in our hospital from January 2001 to December 2006 were collected and analyzed.

RESULTS

Overlap syndrome of autoimmune hepatitis and primary biliary cirrhosis accounted for 10.33% of patients with autoimmune liver diseases during the past six years. For these patients with overlap syndrome, xanthochromia, lethargy and anorexia were the predominant complaints; a low incidence (14/146) of smooth muscle antibody positivity and a high incidence (37/89) of isolated IgM elevation were the main serological characteristics.

CONCLUSIONS

Overlap syndrome of autoimmune hepatitis and primary biliary cirrhosis was not rare in Chinese patients with clinical manifests of autoimmune liver diseases. Overlap of the diseases should not be disregarded when isolated IgM elevation was exhibited, and smooth muscle antibody might have little diagnostic significance in the overlap syndrome. If it was difficult to make a definite diagnosis, liver biopsy was necessary.

Autoimmune hepatitis induced by syngeneic liver cytosolic proteins biotransformed by alcohol metabolites

BACKGROUND AND AIMS

Aldehydes that are produced following the breakdown of ethanol (acetaldehyde) and lipid peroxidation of membranes (malondialdehyde) have been shown to bind (adduct) proteins. Additionally, these two aldehydes can combine (MAA) on nonsyngeneic and syngeneic proteins to initiate numerous immune responses to the unmodified part of the protein in the absence of an adjuvant. Therefore, these studies provide a potential mechanism for the development of antigen-specific immune responses resulting in liver damage should syngeneic liver proteins be adducted with MAA.

METHODS

This study sought to test whether MAA-modified syngeneic liver cytosolic proteins administered daily in the absence of adjuvant into C57BL/6 mice abrogates tolerance to initiate a MAA-induced autoimmune-like hepatitis.

RESULTS

In mice immunized with MAA-modified cytosols, there was an increase in liver damage as assessed by aspartate aminotransferase/alanine aminotransferase levels that correlated with liver pathology scores and the presence of the pro-fibrotic factors, smooth muscle actin, TGF-β, and collagen. IgG antibodies and T-cell proliferative responses specific for cytosolic proteins were also detected. Pro-inflammatory cytokines were produced in the livers of animals exposed to MAA-modified cytosols. Finally, transfer of immunized T cells to naïve animals caused biochemical and histological evidence of liver damage.

CONCLUSIONS

These data demonstrate that a disease with an autoimmune-like pathophysiology can be generated in this animal model using soluble MAA-modified syngeneic liver cytosols as the immunogen. These studies provide insight into potential mechanism(s) that the metabolites of alcohol may play in contributing to the onset of an autoimmune-like disease in patients with alcoholic liver disease.

Complement mediated hepatocytes injury in a model of autoantibody induced hepatitis

Despite multiple reports on autoantibody-initiated complement activation in autoimmune hepatitis (AIH), how does the humoral immunity contribute to the pathogenesis of AIH remained unclear. In this report, by adoptively transferring a polyclonal rabbit anti-OVA antibody into Hep-OVA Tg mice in which OVA is selectively expressed on the surface of hepatocytes, we found that excessive complement activation initiated by the autoantibody overwhelmed the protection of intrinsic cell surface complement regulators, and induced hepatocytes injury both in vitro and in vivo. The anti-OVA antibody induced hepatic injury in Hep-OVA Tg but not WT C57BL/6 mice as assessed by serum ALT levels and liver histopathology. Immunohistochemical analyses showed that after the antibody administration, there was massive complement activation on anti-OVA IgG coated hepatocytes in Hep-OVA Tg mice, but not in WT mice. Consistent with these results, depleting complement by cobra venom factor (CVF) prior to antibody injections protected Hep-OVA Tg mice from anti-OVA IgG induced hepatic injury. In addition, treating Hep-OVA Tg mice with recombinant mouse decay accelerating factor, a native complement inhibitor, protected them from autoantibody induced hepatitis. These results suggest that complement could play a pivotal role in liver specific autoantibody mediated hepatocyte injury in AIH, and that complement inhibitors could be, in principle, developed as novel therapeutics against AIH.

Chronically inflamed livers up-regulate expression of inhibitory B7 family members

Hepatitis B virus, hepatitis C virus, autoimmune hepatitis, and nonalcoholic fatty liver disease can induce chronic liver disease. The Programmed Death-1 (PD-1) inhibitory pathway assists in T cell response regulation during acute and chronic inflammation and participates in the progression of inflammatory liver disease. To examine whether PD-1 and its ligands, B7-H1 and B7-DC, are modulated during chronic necroinflammatory liver disease, we investigated expression profiles in normal patients and patients with the aforementioned conditions. Relative to liver biopsies from normal individuals, those from patients with chronic necroinflammatory liver diseases (hepatitis B virus, hepatitis C virus, and autoimmune hepatitis) contain increased numbers of PD-1-expressing lymphocytes. Kupffer cells, liver sinusoidal endothelial cells, and leukocytes express PD-1 ligands. We also detect PD-1 ligands on hepatocytes within biopsies and on isolated cells. All forms of chronic necroinflammatory liver disease examined correlate with increased B7-H1 and B7-DC expression on Kupffer cells, liver sinusoidal epithelial cells, and leukocytes. The degree of necroinflammation correlates with expression levels of PD-1 family members.

CONCLUSION

These results demonstrate that expression of PD-1/PD-1 ligands links more directly with the degree of inflammation than with the underlying etiology of liver damage. The PD-1 pathway may assist the liver in protecting itself from immune-mediated destruction.

IL-21 induces the secretion of proinflammatory cytokines in patients with autoimmune hepatitis

AIM: To detect the expression of IL-21 receptor (IL-21R) in peripheral blood mononuclear cells (PBMCs) from patients with autoimmune hepatitis (AIH) and analyze the secretion of proinflammatory cytokines (e.g., TNF-α, IFN-γ and IL-2) in cultured PBMCs stimulated with IL-21.

METHODS: Peripheral blood samples were collected from 21 AIH patients and 25 healthy controls, respectively. The expression of IL-21Rin CD4⁺ and CD8⁺ T cells was examined by flow cytometry. After cultured PBMCs were stimulated with IL-21 and anti-CD3, the secretion of cytokines was examined by ELISA.

RESULTS: IL-21R was significantly upregulated in CD4⁺ and CD8⁺ T cells (7.66% ± 2.37% vs 3.12% ± 0.76% and 9.42% ± 2.48% vs 4.02% ± 0.89%, respectively; both P < 0.05). After stimulation with IL-21 and anti-CD3, the levels of secreted TNF-α, IFN-γ and IL-2 in PBMCs from AIH patients were significantly higher than those in PBMCs from healthy controls (P < 0.05).

CONCLUSION: IL-21R is highly expressed in T cells from AIH patients, and IL-21 is able to induce the secretion of proinflammatory cytokines, suggesting that IL-21 is involved in the process of tissue injury in AIH.

Diagnosis and epidemiology of cirrhosis

Cirrhosis is defined histologically as an advanced form of progressive hepatic fibrosis with distortion of the hepatic architecture and regenerative nodule formation. It may be due to a variety of causes. It can be diagnosed incidentally on liver biopsy or hepatic imaging studies, or patients may present clinically with one or more features of hepatic failure. This article gives the reader a broad overview of the epidemiology, diagnosis, and natural history of cirrhosis; laying the foundation for subsequent articles, which will discuss the diagnosis and management of each of the specific cirrhosis-related complications.

Autoimmune hepatitis: CT and MR imaging features with histopathological correlation

BACKGROUND

To describe the CT and MRI features of autoimmune hepatitis (AIH) and correlate them with histological grade and stage. Observed changes associated with treatment are also described.

METHODS

A retrospective analysis of the initial CT scans (n = 22) and MRI exams (n = 12) of 27 patients with pathologically-proven AIH was conducted. Multiple objective and subjective imaging features were evaluated. Correlation of imaging features with histological inflammatory grade and fibrotic stage was performed using the Fisher exact test and Spearman's rank correlation coefficient. In eight patients serial CT and MR imaging during treatment was used to describe the changes associated with treatment.

RESULTS

The presence of ascites, expanded gallbladder fossa, spleen size, and enlarged preportal space had significant positive correlations with fibrotic stage. No significant positive correlations existed between imaging features and portal or lobular inflammatory grade. Seven patients (25.9%) were normal. The most common abnormal finding was surface nodularity: CT (n = 11 [50%]) and MRI (n = 8 [66.7%]). There was a wide variability in imaging appearances of patients who had serial scans on treatment.

CONCLUSIONS

There is a wide spectrum of CT and MR imaging features in patients with AIH. Several MRI features demonstrate a significant positive correlation with fibrotic stage.