Management of autoimmune hepatitis

Waitlist mortality in patients with autoimmune liver diseases

INTRODUCTION AND OBJECTIVES

Autoimmune liver diseases such as autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis are the primary indication for ∼24% of total liver transplants. The liver transplant allocation system is currently based upon the Model for End-Stage Liver Disease and it often underestimates the severity of autoimmune liver diseases. We aim to compare the rate of adverse waitlist removal among patients with all autoimmune liver diseases and other indications for liver transplant in the Model for End-Stage Liver -Na era.

MATERIALS AND METHODS

Using the United Network for Organ Sharing database, we identified all patients listed for liver transplant from 2016 to 2019. The outcome of interest was waitlist survival defined as the composite outcome of death or removal for clinical deterioration. Competing risk analysis was used to evaluate the waitlist survival.

RESULTS

Patients with autoimmune hepatitis had a higher risk of being removed from the waitlist for death or clinical deterioration (SHR 1.37, 95% CI 1.08-1.72; P<0.007), followed by primary biliary cholangitis (SHR 1.34, 95% CI 1.07-1.68; P<0.011).

CONCLUSIONS

High waitlist death or removal for clinical deterioration was observed in patients with PBC and AIH when compared to other etiologies. It may be useful to reassess the process of awarding MELD exception points to mitigate such disparity.

Evaluation of abnormal liver tests in the adult asymptomatic patient

PURPOSE OF REVIEW

Liver blood tests, including bilirubin, aminotransferases, and alkaline phosphatase, are among the most commonly encountered tests in medicine. With roles including the investigation of symptoms, medication monitoring, assessment of chronic disease, and routine assessment, these tests serve many purposes and result in abnormality in up to 40% of patients.

RECENT FINDINGS

The toll of liver disease continues to rise and abnormal liver tests offer an opportunity to identify hepatic disease early, when treatment is most effective and before patients suffer the potential downstream consequences of cirrhosis, portal hypertension, and hepatocellular carcinoma. By utilizing diagnostic strategies including detailed history gathering, alcohol use assessment, recognition of metabolic syndrome, and identifying patterns of liver test abnormalities, clinicians can develop a systematic approach to address abnormal liver tests. For these reasons, developing an evidence-based, systematic approach to handling abnormal liver tests is critically important.

SUMMARY

This review seeks to synthesize key elements of the best evidence, presently available guidelines, and expert opinion in drafting a strategy to aid clinicians and patients in the timely and accurate diagnosis of liver disease for the adult asymptomatic patient with abnormal liver tests.

Synergistic Effects of Jerusalem Artichoke in Combination with Pegylated Interferon Alfa-2a and Ribavirin Against Hepatic Fibrosis in Rats

BACKGROUND

Complementary and alternative medicine has been highly appreciated as a supportive regimen for classical treatment strategies. Here we offer a nutrition-based adjuvant therapy for liver fibrosis, a major risk factor for cirrhosis and hepatocellular carcinoma.

AIM OF THE STUDY

To evaluate the possible hepatoprotective effects of Jerusalem artichoke tubers (JAT) in combination with interferon and ribavirin.

MATERIALS AND METHODS

Twelve groups of rats were administered JAT, interferon and ribavirin either separately or in combination from day one of CCL4 administration until the end of the study. Animals were killed after 8 weeks of CCL4- induced hepatotoxicity.

RESULTS

Hepatocytes from rats treated with triple combination of interferon, ribavirin, and JAT showed more less normal architecture compared to CCL4- treated rats. We also detected significantly higher hepatic protein expression levels of p53, BAX and transforming growth factor-β (TGF-β) in the CCl4- intoxicated group compared to normal controls, as evidenced by immunohistochemical staining and western blotting analyses. Addition of JAT as a supportive regimen improved response to ribavirin and interferon and effectively participated in retaining normal histopathological and biochemical criteria and significantly lowered protein expression of p53, BAX, and TGF-β.

CONCLUSIONS

We suggest that addition of JAT as a supportive regimen to interferon and ribavirin effectively potentiates their anti-fibrotic effects.

Clinical usefulness of ursodeoxycholic acid for Japanese patients with autoimmune hepatitis

AIM

To evaluate the therapeutic effects of ursodeoxycholic acid (UDCA) on autoimmune hepatitis (AIH).

METHODS

A total 136 patients who were diagnosed with AIH were included in our study. All of the patients underwent a liver biopsy, and had at least a probable diagnosis on the basis of either the revised scoring system or the simplified scores. Initial treatment included UDCA monotherapy (Group U, n = 48) and prednisolone (PSL) monotherapy (Group P, n = 88). Group U was further classified into two subgroups according to the effect of UDCA: Patients who had achieved remission induction with UDCA monotherapy and showed no sign of relapse (Subgroup U1, n = 34) and patients who additionally received PSL during follow-up (Subgroup U2, n = 14). We compared the clinical and histological findings between each groups, and investigated factors contributing to the response to UDCA monotherapy.

RESULTS

In Group U, 34 patients (71%) achieved and maintained remission over 49 (range: 8-90) mo (Subgroup U1) and 14 patients (29%) additionally received PSL (Subgroup U2) during follow-up. Two patients in Subgroup U2 achieved remission induction once but additionally required PSL administration because of relapse (15 and 35 mo after the start of treatment). The remaining 12 patients in Subgroup U2 failed to achieve remission induction during follow-up, and PSL was added during 7 (range: 2-18) mo. Compared with Subgroup U2, Subgroup U1 had significantly lower alanine aminotransferase (ALT) levels at onset (124 IU/L vs 262 IU/L, P = 0.023) and a significantly higher proportion of patients with mild inflammation (A1) on histological examination (70.6% vs 35.7%, P = 0.025). When multivariate analysis was performed to identify factors contributing to the response to UDCA monotherapy, only a serum ALT level of 200 IU/L or lower was found to be associated with a significant difference (P = 0.013).

CONCLUSION

To prevent adverse events related to corticosteroids, UDCA monotherapy for AIH needs to be considered in patients with a serum ALT level of 200 IU/L or lower.

Comment on the British Society of Gastroenterology guidelines for management of autoimmune hepatitis (part 1)

The British Society of Gastroenterology guidelines for management of autoimmune hepatitis were recently published in Gut. The chapters concerning epidemiology, presentation and diagnosis are addressed here.

Autoimmune hepatitis: a review

Autoimmune hepatitis (AIH) is an inflammatory liver disease that predominantly affects females. The disease is characterized histologically by interface hepatitis, biochemically by increased aspartate and alanine aminotransferase levels, and serologically by the presence of autoantibodies and elevated levels of immunoglobulin G. AIH affects both adults and children, and is particularly aggressive in the latter group. It is a relatively rare but devastating disease, which progresses rapidly unless immunosuppressive treatment is started promptly. Treatment is often successful at inducing remission of disease, and this can lead to a normal life expectancy. However, progression to cirrhosis can and does occur in some. For those with advanced-stage disease and complications, consideration of liver transplantation is appropriate.

Diagnosis and treatment of autoimmune hepatitis

Autoimmune hepatitis is a chronic liver disease characterized by elevated aminotransferase levels, autoantibodies, increased γ-globulin or IgG levels and biopsy evidence of interface hepatitis. Recent advances include new practice guidelines that redefine criteria for remission to require complete biochemical and histological normalization on therapy; comparisons between the revised original and simplified diagnostic scoring systems; refined characterization of autoantibodies and their diagnostic performance parameters; proof of the safety and efficacy of combination budesonide and azathioprine therapy for non-cirrhotic patients; scrutiny of overlap syndromes; further analyses of the outcomes of orthotopic liver transplantation and the diagnosis and treatment of recurrent and de novo autoimmune hepatitis after transplantation. Anticipated consequences of the application of the new definition of therapeutic remission include a reduction in the proportion of patients achieving remission with conventional immunosuppression regimens and a corresponding increase in the need for alternative therapies.

Clinical features of autoimmune liver disease

AIM: To investigate the clinical features of autoimmune liver disease (ALD).

METHODS: A total of 91 patients with ALD were enrolled in this study, including 68 cases of autoimmune hepatitis (AIH) and 23 cases of primary biliary cirrhosis (PBC). Another 41 HBsAg-positive patients with cirrhosis were used as controls. Clinical manifestations, liver function parameters and serum immunoglobulins were compared among these patients.

RESULTS: The median onset age for patients with AIH and PBC was 51.2 ± 13.4 and 52.8 ± 10.3 years, respectively. Females were more likely to suffer from AIH and PBC than males. AIH patients had significantly higher levels of ALT, ALP, GGT, TP, and TBIL (all P < 0.05) than patients with chronic hepatitis B-related cirrhosis. Compared to patients with AIH, those with PBC had much higher levels of TBIL (P < 0.05) which were mainly caused by the increase in DBIL. All patients had decreased levels of ALB, especially those with chronic hepatitis B-related cirrhosis. Patients with AIH and those with PBC had nearly the same positive rate of autoantibodies (63.2% vs 78.3%), while all patients with chronic hepatitis B-related cirrhosis were negative for autoantibodies. Patients with AIH had higher positive rates of ANA and anti-dsDNA but a lower positive rate of AMA than patients with PBC (all P < 0.05). Autoantibody-negative AIH patients had significantly higher levels of ALT and AST, while autoantibody-negative PBC patients had lower levels of ALT, AST, ALP and GGT than autoantibody-positive ones.

CONCLUSION: ALD lacks typical clinical features. Perimenopausal women who display fatigue and jaundice and have elevated γ-globulin level and negative viral markers should be highly suspected of having ALD. The presence of autoantibodies may confirm the diagnosis. Patients with AIH often have abnormal transmainase levels, while high levels of transaminases activities (ALT, AST) and significantly increased biliary enzymes (ALP, GGT) and direct bilirubin levels may suggest PBC.