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Wang L, Du ZX, Liu HL, Zhang Y, Wang SS, Hu YF, Li LQ, Zhu P, Zhong YD, Xiong QF, Yang YF. IAIH-PG consensus for histological criteria of AIH: Multicentre validation with focus on chronic liver diseases in China. Liver Int 2024; 44:2282-2292. [PMID: 38775078 DOI: 10.1111/liv.15971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 08/30/2024]
Abstract
BACKGROUND AND AIMS The International AIH Pathology Group (IAIH-PG) put forward the new histological criteria of autoimmune hepatitis (AIH) in 2022, which have not undergone adequate verification. In this study, we verified the applicability of the new histological criteria in the population of Chinese patients with chronic liver disease, comparing it with the simplified criteria. METHODS The gold standard for diagnosis in all patients was based on histological findings, combined with clinical manifestations and laboratory tests and determined after a follow-up period of at least 3 years. A total of 640 patients with various chronic liver diseases from multiple centres underwent scoring using the new histological criteria and the simplified criteria, comparing their diagnostic performance. RESULTS In this study, the new histological criteria showed a sensitivity of 73.6% and 100% for likely and possible AIH, with specificities of 100% and 69.0% respectively. The coincidence rates of possible AIH for the new histological criteria, simplified histological criteria and simplified score were 81.7%, 72.8% and 69.7% respectively. For likely AIH, the rates were 89.2%, 75.9% and 65.6% respectively. Based on the new histological criteria, all patients with AIH were correctly diagnosed. Specifically, 73.6% were diagnosed with likely AIH and 26.4% were possible AIH. Additionally, the simplified histological criteria achieved a diagnosis rate of 98.6% for AIH, while the simplified score could only diagnose 53.8% of AIH. CONCLUSIONS Compared with the simplified score and simplified histological criteria, the sensitivity and specificity of the new histological criteria for AIH were significantly improved. The results indicate that the new histological criteria exhibit high sensitivity and specificity for diagnosing AIH in China.
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Affiliation(s)
- Li Wang
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhi-Xiang Du
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | | | - Yu Zhang
- Southeast University, Nanjing, China
| | | | - Yi-Fan Hu
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Li-Qiu Li
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Ping Zhu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yan-Dan Zhong
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Qing-Fang Xiong
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Yong-Feng Yang
- Department of infectious disease and liver disease, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
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Ghiga G, Boca LO, Cojocaru E, Stârcea IM, Țarcă E, Scurtu AM, Mocanu MA, Ioniuc I, Tîrnovanu MC, Trandafir LM. Severe Liver Damage in an Obese Patient: Onset of Celiac Disease or Overlap Syndrome? Diagnostics (Basel) 2024; 14:1832. [PMID: 39202320 PMCID: PMC11353973 DOI: 10.3390/diagnostics14161832] [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: 07/31/2024] [Revised: 08/19/2024] [Accepted: 08/21/2024] [Indexed: 09/03/2024] Open
Abstract
Celiac disease (CeD) is an enteropathy caused by the complex interaction between genetic, environmental, and individual immunological factors. Besides the hallmark of intestinal mucosal damage, CeD is a systemic disorder extending beyond the gastrointestinal tract and impacting various other organs, causing extraintestinal and atypical symptoms. The association between CeD and liver damage has been classified into three main categories: mild and asymptomatic liver injury, autoimmune liver injury, and liver failure. We present a case of severe liver damage with cirrhotic evolution in an obese 12-year-old boy who had been admitted due to generalized jaundice and localized abdominal pain in the right hypochondrium. In the course of investigating the etiology of severe liver disease, toxic, infectious, metabolic, obstructive, and genetic causes were excluded. Despite the patient's obesity, a diagnosis of CeD was established, and in accordance with autoimmune hepatitis (AIH) criteria, the patient was diagnosed with autoantibody-negative AIH associated to CeD.
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Affiliation(s)
- Gabriela Ghiga
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Laura Otilia Boca
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Elena Cojocaru
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
- Department of Morphofunctional Sciences, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
| | - Iuliana Magdalena Stârcea
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Elena Țarcă
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
- Department of Pediatric Surgery, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
| | - Ana Maria Scurtu
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Maria Adriana Mocanu
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Ileana Ioniuc
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
| | - Mihaela Camelia Tîrnovanu
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Cuza Voda” Obstetrics-Gynecology Clinic Hospital, 700038 Iasi, Romania
| | - Laura Mihaela Trandafir
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (G.G.); (I.M.S.); (M.A.M.); (I.I.); (M.C.T.); (L.M.T.)
- “Saint Mary” Emergency Hospital for Children, 700309 Iasi, Romania; (E.C.); (E.Ț.); (A.M.S.)
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Costaguta GA, Álvarez F. B cell depletion for autoimmune liver diseases: A retrospective review of indications and outcomes. JPGN REPORTS 2024; 5:326-333. [PMID: 39149184 PMCID: PMC11322033 DOI: 10.1002/jpr3.12098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/08/2024] [Accepted: 05/19/2024] [Indexed: 08/17/2024]
Abstract
Objectives Pediatric autoimmune hepatitis has an incidence of 0.23/100.000 children in North America, with a bleak prognosis if left untreated. Steroids are the therapy of choice but are not always effective. B cell depletion is a safe and effective therapy that allows for a steroid-sparing protocol, especially in patients who do not tolerate side effects. Methods We retrospectively reviewed rituximab-treated patients between 2017 and 2022. Demographics, previous treatments, reasons for B cell depletion, response, and adverse effects were noted. Results Six patients with a mean age of 10.2 years were included. All patients had comorbidities that rendered treatment with steroids unsuccessful or undesirable. Rituximab was started at a mean follow-up of 8 months. After 6 months, the mean alanine transaminase and aspartate transaminase levels decreased from 575 IU/L and 342 IU/L, respectively, to 28 IU/L (p = 0.02) and 36 IU/L (p = 0.008), respectively. Mean γ-glutamyl transpeptidase decreased from 105 to 25 IU/L (p = 0.01). Immunoglobulin G levels were normalized in all patients (p = 0.01). No severe adverse events were observed. One patient had persistent hypogammaglobulinemia, and another had lymphopenia. Conclusion B-cell depletion is an effective and safe treatment for autoimmune liver diseases and should be included as an option, particularly for relapsing patients in whom steroids are undesirable or have shown nonadherence.
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Affiliation(s)
| | - Fernando Álvarez
- Gastroenterology, Hepatology and NutritionCHU Sainte‐JustineMontrealQuebecCanada
- Department of PediatricsUniversity of MontrealMontrealQuebecCanada
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Fawzy A, Sutton H, Vandriel SM, Sonnenberg M, Kamath BM. Outcomes and management in paediatric autoimmune hepatitis presenting as acute liver failure: Individual patient data meta-analysis. Liver Int 2024; 44:1797-1807. [PMID: 38700362 DOI: 10.1111/liv.15943] [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: 07/27/2023] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND AIMS Autoimmune hepatitis (AIH) in children presenting in acute liver failure (ALF) can be fatal and often requires liver transplantation (LTx). This individual patient data meta-analysis (IPD) aims to examine management and outcomes of this population, given the lack of large cohort studies on paediatric AIH first presenting as ALF (AIH-ALF). METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses of IPD statement using PubMed and Excerpta Medica dataBASE, and included English studies published between 2000 and 2020. The study included patients under 21 years of age, diagnosed with type 1 or 2 AIH and presenting with ALF. Data extracted included clinical and biochemical characteristics, interventions, and outcomes. RESULTS Three hundred and thirty eligible patients from 61 studies were identified, with an additional five patients from our institution. The majority were female (66.8%), with a median age of 10. Overall, 59.7% achieved native liver survival (NLS), 35% underwent LTx, and 5% died before LTx. The use of corticosteroids with non-steroid immunomodulators increased the likelihood of NLS by 2.5-fold compared to corticosteroids alone. AIH-1 was associated with 3.3-fold odds for NLS, compared to AIH-2. However, on multivariate analysis, only AIH-1 was identified as an independent predictor for NLS (OR 3.8 [95% CI 1.03-14.2], p = .04). CONCLUSION While corticosteroids and non-steroid immunomodulators treatment may offer enhanced probability of achieving NLS, treatment regimens for AIH-ALF may need to consider patient-specific factors, especially AIH type. This highlights the potential for NLS in AIH-ALF and suggest a need to identify biomarkers which predict the need for combination immunosuppression to avoid LTx.
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Affiliation(s)
- Aly Fawzy
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harry Sutton
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Shannon M Vandriel
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Mikayla Sonnenberg
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Engel B, Diestelhorst J, Hupa-Breier KL, Kirchner T, Henjes N, Loges S, Yuksel M, Janczyk W, Lalanne C, Zachou K, Oo YH, Gournay J, Pape S, Drenth JPH, Renand A, Dalekos GN, Muratori L, Socha P, Ma Y, Arikan C, Baumann U, Manns MP, Wedemeyer H, Junge N, Jaeckel E, Taubert R. Detection of polyreactive immunoglobulin G facilitates diagnosis in children with autoimmune hepatitis. Hepatol Int 2024; 18:1214-1226. [PMID: 38976227 PMCID: PMC11297808 DOI: 10.1007/s12072-024-10695-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/26/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE The detection of autoantibodies is essential to diagnose autoimmune hepatitis (AIH). Particularly in children, specificity of autoantibodies decreases due to lower titers being diagnostic and being present not only in AIH but also in other liver diseases. Recently, quantification of polyreactive IgG (pIgG) for detection of adult AIH showed the highest overall accuracy compared to antinuclear antibodies (ANA), anti-smooth muscle antibodies (anti-SMA), anti-liver kidney microsomal antibodies (anti-LKM) and anti-soluble liver antigen/liver pancreas antibodies (anti-SLA/LP). We aimed to evaluate the diagnostic value of pIgG for pediatric AIH. DESIGN pIgG, quantified using HIP1R/BSA coated ELISA, and immunofluorescence on rodent tissue sections were performed centrally. The diagnostic fidelity to diagnose AIH was compared to conventional autoantibodies of AIH in training and validation cohorts from a retrospective, European multi-center cohort from nine centers from eight European countries composed of existing biorepositories from expert centers (n = 285). RESULTS IgG from pediatric AIH patients exhibited increased polyreactivity to multiple protein and non-protein substrates compared to non-AIH liver diseases and healthy children. pIgG had an AUC of 0.900 to distinguish AIH from non-AIH liver diseases. pIgG had a 31-73% higher specificity than ANA and anti-SMA and comparable sensitivity that was 6-20 times higher than of anti-SLA/LP, anti-LC1 and anti-LKM. pIgG had a 21-34% higher accuracy than conventional autoantibodies, was positive in 43-75% of children with AIH and normal IgG and independent from treatment response. CONCLUSION Detecting pIgG improves the diagnostic evaluation of pediatric AIH compared to conventional autoantibodies, primarily owing to higher accuracy and specificity.
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Affiliation(s)
- Bastian Engel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany.
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.
| | - Jana Diestelhorst
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University Clinic for Haematology, UKRUB, University of Bochum, Minden, Germany
| | - Katharina Luise Hupa-Breier
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Theresa Kirchner
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Nicole Henjes
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Stephanie Loges
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Muhammed Yuksel
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College Hospital, King's College London, London, UK
- Koç University Research Centre for Translational Medicine (KUTTAM)-Liver Immunology Lab, Istanbul, Turkey
- Department of Biomedical Sciences, College of Liberal Arts and Life Sciences, University of Westminster, London, UK
| | - Wojciech Janczyk
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Claudine Lalanne
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Kalliopi Zachou
- Institute of Internal Medicine and Hepatology, Larissa, Greece
- l University Hospital of Larissa, Larissa, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Ye H Oo
- Centre for Liver and Gastro Research, National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, The Medical School, Birmingham, United Kingdom & Liver transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Jérôme Gournay
- Institut Des Maladies de L'Appareil Digestif (IMAD), Nantes Université, CHU Nantes, Hépato-Gastro-Entérologie, Inserm CIC 1413, 44000, Nantes, France
| | - Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Amédée Renand
- Center for Research in Transplantation and Translational Immunology, Nantes Université, UMR 1064, Inserm, 44000, Nantes, France
| | - George N Dalekos
- Institute of Internal Medicine and Hepatology, Larissa, Greece
- l University Hospital of Larissa, Larissa, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Luigi Muratori
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Piotr Socha
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Yun Ma
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College Hospital, King's College London, London, UK
| | - Cigdem Arikan
- Koç University Research Centre for Translational Medicine (KUTTAM)-Liver Immunology Lab, Istanbul, Turkey
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Koç University School of Medicine, Istanbul, 34010, Turkey
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Norman Junge
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Ajmera Transplant Center, Toronto General Hospital, United Health Network, University of Toronto, Toronto, Canada
| | - Richard Taubert
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, HepatologyHannover, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
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Jerregård Skarby A, Casswall T, Bergquist A, Lindström L. Good long-term outcomes of primary sclerosing cholangitis in childhood. JHEP Rep 2024; 6:101123. [PMID: 39139456 PMCID: PMC11321284 DOI: 10.1016/j.jhepr.2024.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 05/14/2024] [Accepted: 05/21/2024] [Indexed: 08/15/2024] Open
Abstract
Background & Aims Primary sclerosing cholangitis (PSC) is a rare progressive liver disease associated with inflammatory bowel disease (IBD). It is usually diagnosed in adults but can also present in children. Data on long-term outcomes of pediatric PSC are limited. Our aim was to study the natural history of pediatric PSC in Sweden. Methods This is a cohort study, including all children (<18 years), diagnosed with PSC between January 2000 and December 2015 at the Pediatric Liver Unit at Karolinska University Hospital, Stockholm. Patients were followed until liver transplantation, death or last date of follow-up (August 2021). Results We identified 124 children with a median age of 14 (1.9-17.8) years at PSC diagnosis. Sixty percent were boys, 93% had IBD. Median follow-up time was 13 years (5.7-21.6). Overall event-free survival in the cohort was 91% (95% CI 0.84-0.95) at 5 years and 77% (95% CI 0.68-0.84) at 10 years after diagnosis. Autoimmune hepatitis (AIH) was present in 31% (n = 39). Portal hypertension developed in 13% (n = 16), biliary complications in 24% (n = 30), cholangiocarcinoma (CCA) in 0.8% (n = 1), while 13% (n = 16) underwent liver transplantation and three patients died. Transplant-free survival was 91% after 10 years. Individuals with a high SCOPE index at diagnosis had a 2.3-fold increased risk of requiring liver transplantation (hazard ratio 2.35, 95% CI 1.18-4.66, c-statistics = 0.70). Patients with an additional diagnosis of autoimmune hepatitis had slightly higher risk of reaching transplantation during follow-up (hazard ratio 2.85, 95% CI 1.06-7.67, p = 0.038). Conclusions Children diagnosed with PSC have a good prognosis during the first decade after diagnosis. A high SCOPE index at diagnosis was associated with a less favorable outcome. Impact and implications Data on long-term outcome in pediatric primary sclerosing cholangitis bridging over to adulthood is limited. There is a great need among children with primary sclerosing cholangitis and their parents for more knowledge about the natural history of this disease and what they can expect from the future. We hope that the data presented in this study may help counsel health professionals, young individuals and families affected by this disease.
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Affiliation(s)
- Anna Jerregård Skarby
- Department of Medicine Huddinge, Karolinska Institutet, Department of Acute Geriatrics, Stroke and Palliative care, Nyköping Hospital Nyköping, Sweden
| | - Thomas Casswall
- Department of Clinical Science, Intervention and Technology (CLINTEC), Unit of Pediatrics, Karolinska Institutet, Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Bergquist
- Department of Medicine Huddinge, Karolinska Institutet, Department of Upper GI Disease, Division of Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Lindström
- Department of Medicine Huddinge, Karolinska Institutet, Department of Gastroenterology, Dermatovenereology and Rheumatology, Centre for Digestive Health, Karolinska University Hospital, Stockholm, Sweden
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Gardin A, Gaigne L, Magérus A, Rieux-Laucat F, Jacquemin E. PLCG2 Mutation in a Patient Presenting with Type 2 Autoimmune Hepatitis. J Clin Transl Hepatol 2024; 12:685-687. [PMID: 38993509 PMCID: PMC11233976 DOI: 10.14218/jcth.2024.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 07/13/2024] Open
Affiliation(s)
- Antoine Gardin
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Diseases of the Bile Ducts and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique–Hôpitaux de Paris, University Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR 1193, Hepatinov, Paris-Saclay University, Orsay, France
| | - Léa Gaigne
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Imagine Institute, Paris Cité University, Paris, France
| | - Aude Magérus
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Imagine Institute, Paris Cité University, Paris, France
| | - Frédéric Rieux-Laucat
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Imagine Institute, Paris Cité University, Paris, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Diseases of the Bile Ducts and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique–Hôpitaux de Paris, University Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR 1193, Hepatinov, Paris-Saclay University, Orsay, France
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8
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Yoon H, Kim J, Lim HJ, Lee MJ. Quantitative Liver Imaging in Children. Invest Radiol 2024:00004424-990000000-00238. [PMID: 39047265 DOI: 10.1097/rli.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
ABSTRACT In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.
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Affiliation(s)
- Haesung Yoon
- From the Department of Radiology, Gangnam Severance Hospital, Seoul, South Korea (H.Y.); Department of Radiology and Research Institute of Radiological Science, Yonsei University, College of Medicine, Seoul, South Korea (H.Y., J.K., H.J.L., M.-J.L.); and Department of Pediatric Radiology, Severance Children's Hospital, Seoul, South Korea (J.K., H.J.L., M.-J.L.)
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9
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King H, Tofias A, Greenhill A, Grimes A, Ng KF. Interpretation: use of autoantibodies in children. Arch Dis Child Educ Pract Ed 2024; 109:137-142. [PMID: 38503429 DOI: 10.1136/archdischild-2023-326327] [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] [Accepted: 01/15/2024] [Indexed: 03/21/2024]
Abstract
Judicious use of autoantibodies in paediatrics can be challenging. Autoimmune conditions can present with a wide range of signs and symptoms, many of which are non-specific. In combination with clinical features and laboratory findings, autoantibodies can facilitate diagnosis and in certain cases inform prognosis. Evidence for use of autoantibodies to guide and monitor treatment is limited. Caution is necessary when interpreting adult studies. We summarise the use of autoantibodies in paediatric practice with a guide on how they may be used.
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Affiliation(s)
- Hayley King
- Bristol Royal Hospital for Children, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Antonis Tofias
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | - Aidan Grimes
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Khuen Foong Ng
- Department of Paediatric Infectious Diseases and Immunology, Bristol Royal Hospital for Children, Bristol, UK
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10
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Mandato C, Colucci A, Vajro P. Letter to the editor in response to distinguishing autoimmune hepatitis from steatohepatitis in adolescents with obesity and positive screening alanine aminotransferase. JPGN REPORTS 2024; 5:238-239. [PMID: 38756137 PMCID: PMC11093892 DOI: 10.1002/jpr3.12050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/08/2023] [Indexed: 05/18/2024]
Affiliation(s)
- Claudia Mandato
- Section of Pediatrics, Department of MedicineSurgery and Dentistry “Scuola Medica Salernitana” University of SalernBaronissi (Salerno)Italy
| | - Angelo Colucci
- Section of Pediatrics, Department of MedicineSurgery and Dentistry “Scuola Medica Salernitana” University of SalernBaronissi (Salerno)Italy
| | - Pietro Vajro
- Section of Pediatrics, Department of MedicineSurgery and Dentistry “Scuola Medica Salernitana” University of SalernBaronissi (Salerno)Italy
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11
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Khan SA, Ali N, Farooq MA, Hasan S, Malik MI. Spectrum of Pediatric Autoimmune Hepatitis in a Cohort of Pakistani Children. Glob Pediatr Health 2024; 11:2333794X241251644. [PMID: 38694564 PMCID: PMC11062213 DOI: 10.1177/2333794x241251644] [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: 10/24/2023] [Revised: 03/26/2024] [Accepted: 04/12/2024] [Indexed: 05/04/2024] Open
Abstract
Background. Autoimmune hepatitis (AIH) is increasingly seen in children worldwide and it is more severe in children compared to adults. This study highlights the biochemical and clinical aspect, treatment given and outcome of the disease including pediatric liver transplantation. Study. Retrospective review (2012-2022) was done in Shifa International Hospital, Islamabad. Patients under 18 years diagnosed with AIH were included. Data related to age, gender, clinical features, laboratory investigations including liver function test, liver biopsy findings and imaging modalities were included. Results. Fifteen patients were included 7 (47%) were males and 8 (53%) females. AIH type 1 was the most common type seen in 7 (46%), AIH type 2 in 5 (33%) and seronegative in 3 (20%). Jaundice was the most common symptom. Liver biopsy showed findings characteristic of AIH. Liver transplant performed in 3 patients. Conclusion. The study highlights the varied clinical presentation of AIH in Pakistani children.
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Affiliation(s)
- Sabeen Abid Khan
- Shifa college of medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Naurin Ali
- Shifa college of medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | | | - Munir Iqbal Malik
- Shifa college of medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
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Joshi D, Nayagam J, Clay L, Yerlett J, Claridge L, Day J, Ferguson J, Mckie P, Vara R, Pargeter H, Lockyer R, Jones R, Heneghan M, Samyn M. UK guideline on the transition and management of childhood liver diseases in adulthood. Aliment Pharmacol Ther 2024; 59:812-842. [PMID: 38385884 DOI: 10.1111/apt.17904] [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] [Received: 08/31/2023] [Revised: 10/15/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Improved outcomes of liver disease in childhood and young adulthood have resulted in an increasing number of young adults (YA) entering adult liver services. The adult hepatologist therefore requires a working knowledge in diseases that arise almost exclusively in children and their complications in adulthood. AIMS To provide adult hepatologists with succinct guidelines on aspects of transitional care in YA relevant to key disease aetiologies encountered in clinical practice. METHODS A systematic literature search was undertaken using the Pubmed, Medline, Web of Knowledge and Cochrane database from 1980 to 2023. MeSH search terms relating to liver diseases ('cholestatic liver diseases', 'biliary atresia', 'metabolic', 'paediatric liver diseases', 'autoimmune liver diseases'), transition to adult care ('transition services', 'young adult services') and adolescent care were used. The quality of evidence and the grading of recommendations were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS These guidelines deal with the transition of YA and address key aetiologies for the adult hepatologist under the following headings: (1) Models and provision of care; (2) screening and management of mental health disorders; (3) aetiologies; (4) timing and role of liver transplantation; and (5) sexual health and fertility. CONCLUSIONS These are the first nationally developed guidelines on the transition and management of childhood liver diseases in adulthood. They provide a framework upon which to base clinical care, which we envisage will lead to improved outcomes for YA with chronic liver disease.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Jeremy Nayagam
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Lisa Clay
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Jenny Yerlett
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Lee Claridge
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Jemma Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Ferguson
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Paul Mckie
- Department of Social Work, King's College Hospital NHS Foundation Trust, London, UK
| | - Roshni Vara
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
- Evelina London Children's Hospital, London, UK
| | | | | | - Rebecca Jones
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Michael Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
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Ravindranath A, Yachha SK. An Approach to Investigations of Chronic Liver Disease. Indian J Pediatr 2024; 91:262-269. [PMID: 37702974 DOI: 10.1007/s12098-023-04751-1] [Citation(s) in RCA: 1] [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: 01/08/2023] [Accepted: 06/23/2023] [Indexed: 09/14/2023]
Abstract
Chronic liver disease (CLD) in children is more diverse compared to adults with respect to the etiology, progression and response to therapy. After history and clinical examination, the first step is to confirm the presence of CLD with basic blood investigations and ultrasonography. Markers of portal hypertension are splenomegaly, increased portal vein diameter, thrombocytopenia and presence of varices on endoscopy. The next step is to evaluate the etiology of CLD which will depend on the age of the child and needs targeted investigations as metabolic and inherited causes predominate in early childhood. CLD progression ought to be monitored regularly and several non-invasive markers are available but they have to be evaluated further in children. Since CLD progresses, complications have to be detected early not only to initiate appropriate treatment but also to prognosticate.
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Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Institute of Gastrointestinal Sciences, Apollo BGS Hospitals, Kuvempunagar, Mysore, Karnataka, 570023, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Sakra World Hospital, Bengaluru, Karnataka, 560103, India.
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Mercado LA, Gil-Lopez F, Chirila RM, Harnois DM. Autoimmune Hepatitis: A Diagnostic and Therapeutic Overview. Diagnostics (Basel) 2024; 14:382. [PMID: 38396421 PMCID: PMC10887775 DOI: 10.3390/diagnostics14040382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune hepatitis is an immune-mediated inflammatory condition of the liver of undetermined cause that affects both sexes, all ages, races, and ethnicities. Its clinical presentation can be very broad, from having an asymptomatic and silent course to presenting as acute hepatitis, cirrhosis, and acute liver failure potentially requiring liver transplantation. The diagnosis is based on histological abnormalities (interface hepatitis), characteristic clinical and laboratory findings (increased aspartate aminotransferase, alanine aminotransferase, and serum IgG concentration), and the presence of one or more characteristic autoantibodies. The large heterogeneity of these clinical, biochemical, and histological findings can sometimes make a timely and proper diagnosis a difficult task. Treatment seeks to achieve remission of the disease and prevent further progression of liver disease. First-line therapy includes high-dose corticosteroids, which are later tapered to decrease side effects, and azathioprine. In the presence of azathioprine intolerance or a poor response to the standard of care, second-line therapy needs to be considered, including mycophenolate mofetil. AIH remains a diagnostic and therapeutic challenge, and a further understanding of the pathophysiological pathways of the disease and the implementation of randomized controlled trials are needed.
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Affiliation(s)
- Lydia A. Mercado
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Fernando Gil-Lopez
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Razvan M. Chirila
- Department of General Internal Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
| | - Denise M. Harnois
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Altamimi E, Al Omari D, Obeidat H, Barham K. Retrospective, single-center analysis of autoimmune hepatitis in Jordanian children: clinical features, treatments, and outcomes. BMC Pediatr 2024; 24:102. [PMID: 38331749 PMCID: PMC10851525 DOI: 10.1186/s12887-024-04590-9] [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: 11/30/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES This study describes clinical, biochemical, and histological features and long-term outcomes in pediatric patients diagnosed with autoimmune hepatitis (AIH) at King Abdullah University Hospital, Jordan. DESIGN Retrospective, single-center study. SETTING King Abdullah University Hospital, Jordan. PARTICIPANTS Inclusion of all pediatric patients with AIH diagnosed at our hospital from 2015 to 2023. Exclusion criteria was patients aged over 18 at time of diagnosis and those diagnosed elsewhere. OUTCOME MEASURES Understanding clinical, biochemical, and histological AIH features in children, evaluating treatment responses, and reporting short- and long-term complications, including mortality. RESULTS Sixteen pediatric cases were diagnosed, with an average age of 9.84 ± 4.13 years. Females comprised 75% of patients, and 31.3% presented with acute liver failure. Jaundice was the most common symptom, and hepatosplenomegaly was observed in 18% of cases. Most patients had elevated transaminase levels, along with positive anti-smooth muscle antibody (ASMA) and antinuclear antibodies (ANA). Common hematological abnormalities included anemia (56.3%) and thrombocytopenia (37.5%). All patients underwent liver biopsy, with interface hepatitis present in 81.3% of cases. Treatment mainly involved prednisone and azathioprine. Three patients died, one discontinued therapy, two patients were lost to follow-up, and 10 remained on treatment. CONCLUSION Autoimmune hepatitis affects Jordanian children, primarily female children. Jaundice is the most common presenting symptoms. Only Type I AIH occurred in our cohort. Although of good response to conventional treatment with steroids and immunosuppression, mortality reached 18.8%.
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Affiliation(s)
- Eyad Altamimi
- Pediatric and Neonatology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
| | - Dana Al Omari
- Pediatric and Neonatology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hanadi Obeidat
- Pediatric and Neonatology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Kamleh Barham
- Pediatric and Neonatology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Warner S, Rajanayagam J, Russell E, Lloyd C, Ferguson J, Kelly DA, Hirschfield GM. Biliary disease progression in childhood onset autoimmune liver disease: A 30-year follow-up into adulthood. JHEP Rep 2024; 6:100901. [PMID: 38235169 PMCID: PMC10790098 DOI: 10.1016/j.jhepr.2023.100901] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/03/2023] [Accepted: 08/24/2023] [Indexed: 01/19/2024] Open
Abstract
Background & Aims Long-term follow-up studies of paediatric onset autoimmune liver disease (AILD) are invaluable in helping better understand the clinical course of disease. In day-to-day practice clinicians struggle with disease definitions whilst patients and parents lack clear prognostic information. Methods The clinical progression of 159 patients with childhood onset AILD between June 1990 and December 2013 was reviewed, capturing data up to adulthood (ending May 2021). Results Presentation with autoimmune hepatitis (AIH) was dominant (n = 119); biliary presentations accounted for 25%. During follow up, biliary disease progression confirmed by cholangiography and/or liver histology was observed frequently: 19.8% (20/101) patients with childhood onset AIH type 1 (AIH-1) developed biliary features by adulthood and of these 50% phenotypically transitioned to primary sclerosing cholangitis (PSC); the remaining transitioned to an overlap disease phenotype. No patients with AIH type 2 developed biliary progression. Two-thirds of patients with overlap features (14/21) in childhood had phenotypically progressed to PSC by adulthood. Approximately 43% (6/14) of AIH-1 patients requiring a liver transplant in adulthood had explant evidence of biliary disease compared with 11% (1/9) in childhood, whereas 35.7% (5/14) of patients had histology diagnostic of PSC in their explant liver and 7.1% (1/14) had overlap features. All patients with biliary phenotypes (PSC, autoimmune sclerosing cholangitis, overlap) who required a transplant (n = 18) were found to have explant histology consistent with PSC. Twelve of 14 patients with biliary progression developed ulcerative colitis during follow-up with 92% progressing to PSC. Conclusions Three decades of follow-up demonstrated how children presenting with AILD had a significant risk of clinical transformation to PSC. Biliary progression was significantly associated with the development of inflammatory bowel disease. Impact and implications Childhood onset autoimmune liver disease remains very impactful for patients and families. Disease nomenclature can however be confusing. Long-term follow up studies as children become adults is important to help understand how and why disease behaves over time. Understanding more about the long-term course of childhood autoimmune liver disease will help patients, families and doctors striving to improve care and reduce poor clinical outcomes. We followed over 150 patients with childhood onset autoimmune liver diseases into adulthood. We found that amongst patients with classical autoimmune hepatitis, 1 in 5 developed biliary disease over time, mostly consisting of primary sclerosing cholangitis. This was associated with developing inflammatory bowel disease. Our study design was retrospective and has relevant limitations. Defining phenotypes of autoimmune liver diseases is difficult and there is insufficient consensus, especially between adult and childhood physicians. Our data confirms the critical importance of careful long-term follow-up of patients, including safe transition to adult care, as well as robustly demonstrates, using real-world data, how disease nature can change over time. Our study affirms the need for investment in prospective cohort studies.
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Affiliation(s)
- Suz Warner
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Jeremy Rajanayagam
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Emily Russell
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Carla Lloyd
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - James Ferguson
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Deirdre A. Kelly
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - Gideon M. Hirschfield
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
- Toronto Centre for Liver Disease, Department of Medicine, University of Toronto, Toronto, Canada
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Nastasio S, Sciveres M, Francalanci P, Maggiore G. Pediatric Autoimmune Hepatitis. Pediatr Rep 2024; 16:110-113. [PMID: 38390999 PMCID: PMC10885090 DOI: 10.3390/pediatric16010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/11/2024] [Indexed: 02/24/2024] Open
Abstract
Pediatric autoimmune hepatitis (PAIH) is a rare necro-inflammatory disease of the liver of unknown etiology thought to derive from the dysregulation of the immune response upon exposure to environmental triggers in genetically predisposed individuals [...].
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy
| | - Paola Francalanci
- Division of Pathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Giuseppe Maggiore
- Division of Hepatogastroenterology, and Liver Transplant, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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Hadžić N, Deheragoda M, Worth A, Bansal S, Samyn M, Kusters M. JAK Inhibition in STAT1 Gain-of-Function-Mediated Treatment-Resistant Autoimmune Hepatitis. N Engl J Med 2024; 390:284-286. [PMID: 38231631 DOI: 10.1056/nejmc2311867] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
| | | | - Austen Worth
- Great Ormond Street Hospital, London, United Kingdom
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Kersten R, Trampert DC, Herta T, Hubers LM, Maillette de Buy Wenniger LJ, Verheij J, van de Graaf SFJ, Beuers U. IgG4-related cholangitis - a mimicker of fibrosing and malignant cholangiopathies. J Hepatol 2023; 79:1502-1523. [PMID: 37598939 DOI: 10.1016/j.jhep.2023.08.005] [Citation(s) in RCA: 1] [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: 04/12/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
IgG4-related cholangitis (IRC) is the major hepatobiliary manifestation of IgG4-related disease (IgG4-RD), a systemic fibroinflammatory disorder. The pathogenesis of IgG4-RD and IRC is currently viewed as multifactorial, as there is evidence of a genetic predisposition while environmental factors, such as blue-collar work, are major risk factors. Various autoantigens have been described in IgG4-RD, including annexin A11 and laminin 511-E8, proteins which may exert a partially protective function in cholangiocytes by enhancing secretion and barrier function, respectively. For the other recently described autoantigens, galectin-3 and prohibitin 1, a distinct role in cholangiocytes appears less apparent. In relation to these autoantigens, oligoclonal expansions of IgG4+ plasmablasts are present in patients with IRC and disappear upon successful treatment. More recently, specific T-cell subtypes including regulatory T cells, follicular T helper 2 cells, peripheral T helper cells and cytotoxic CD8+ and CD4+ SLAMF7+ T cells have been implicated in the pathogenesis of IgG4-RD. The clinical presentation of IRC often mimics other biliary diseases such as primary sclerosing cholangitis or cholangiocarcinoma, which may lead to inappropriate medical and potentially invalidating surgical interventions. As specific biomarkers are lacking, diagnosis is made according to the HISORt criteria comprising histopathology, imaging, serology, other organ manifestations and response to therapy. Treatment of IRC aims to prevent or alleviate organ damage and to improve symptoms and consists of (i) remission induction, (ii) remission maintenance and (iii) long-term management. Glucocorticosteroids are highly effective for remission induction, after which immunomodulators can be introduced for maintenance of remission as glucocorticosteroid-sparing alternatives. Increased insight into the pathogenesis of IRC will lead to improved diagnosis and novel therapeutic strategies in the future.
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Affiliation(s)
- Remco Kersten
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - David C Trampert
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Toni Herta
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Lowiek M Hubers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam University Medical Centers, the Netherlands
| | - Stan F J van de Graaf
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
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Riddell M, Novak C, Dinn S, Galante G. An Adolescent Female With Concurrent Presentation of Autoimmune Hepatitis and Secondary Syphilis. JPGN REPORTS 2023; 4:e382. [PMID: 38034433 PMCID: PMC10684115 DOI: 10.1097/pg9.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/09/2023] [Indexed: 12/02/2023]
Abstract
We describe concurrent diagnoses of autoimmune hepatitis (AIH) and secondary syphilis in a 17-year-old adolescent with jaundice, with possible syphilitic hepatitis (SH) excluded after a thorough investigation. Our patient presented with a several-day history of malaise, progressive jaundice, and vomiting. She disclosed being sexually active and requested testing for sexually transmitted infections. Her subsequent investigations demonstrated acute hepatitis with a positive antinuclear antibody and elevated IgG. She also tested positive for syphilis with a reactive rapid plasma regain and treponema pallidum particle agglutination assay. We considered 2 etiologies for her elevated liver enzymes: syphilitic hepatitis and AIH. AIH was confirmed on liver biopsy, establishing the first reported pediatric case of concurrent AIH and secondary syphilis. Syphilis is hypothesized to be an infectious trigger for AIH.
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Affiliation(s)
- Madison Riddell
- From the Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chris Novak
- From the Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Dinn
- From the Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gary Galante
- From the Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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21
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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22
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Ludz C, Stirnimann G, Semela D, Mertens J, Kremer AE, Filipowicz Sinnreich M, Sokollik C, Bernsmeier C, Bresson-Hadni S, McLin V, Rock N, Braegger C, Posovszky C, Müller P, Cremer M, De Gottardi A, Galante A, Furlano R, Righini-Grunder F, Becker B, Böhm S, Heyland K, Nydegger A, Limoni C, Vergani D, Mieli-Vergani G, Di Bartolomeo C, Cerny A, Terziroli Beretta-Piccoli B. Epidemiology, clinical features and management of autoimmune hepatitis in Switzerland: a retrospective and prospective cohort study. Swiss Med Wkly 2023; 153:40102. [PMID: 37769636 DOI: 10.57187/smw.2023.40102] [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: 10/03/2023] Open
Abstract
BACKGROUND AND AIMS The Swiss Autoimmune Hepatitis Cohort Study is a nationwide registry, initiated in 2017, that collects retrospective and prospective clinical data and biological samples from patients of all ages with autoimmune hepatitis treated at Swiss hepatology centres. Here, we report the analysis of the first 5 years of registry data. RESULTS A total of 291 patients with autoimmune hepatitis have been enrolled, 30 of whom were diagnosed before 18 years of age and composed the paediatric cohort. Paediatric cohort: median age at diagnosis 12.5 years (range 1-17, interquartile range (IQR) 8-15), 16 (53%) girls, 6 (32%) with type 2 autoimmune hepatitis, 8 (27%) with autoimmune sclerosing cholangitis, 1 with primary biliary cholangitis variant syndrome, 4 (15%) with inflammatory bowel disease and 10 (41%) with advanced liver fibrosis at diagnosis. Adult cohort: median age at diagnosis 54 years (range 42-64, IQR 18-81), 185 (71%) women, 51 (20%) with primary biliary cholangitis variant syndrome, 22 (8%) with primary sclerosing cholangitis variant syndrome, 9 (4%) with inflammatory bowel disease and 66 (32%) with advanced liver fibrosis at diagnosis. The median follow-up time for the entire cohort was 5.2 years (IQR 3-9.3 years). Treatment in children: 29 (97%) children were initially treated with corticosteroids, 28 of whom received combination treatment with azathioprine. Budesonide was used in four children, all in combination with azathioprine. Mycophenolate mofetil was used in five children, all of whom had previously received corticosteroids and thiopurine. Treatment in adults (data available for 228 patients): 219 (96%) were treated with corticosteroids, mostly in combination with azathioprine. Predniso(lo)ne was the corticosteroid used in three-quarters of patients; the other patients received budesonide. A total of 78 (33%) patients received mycophenolate mofetil, 62 of whom had previously been treated with azathioprine. Complete biochemical response was achieved in 13 of 19 (68%) children and 137 of 182 (75%) adults with available follow-up data. All children were alive at the last follow-up, and none had undergone liver transplantation. Five (2%) adults underwent liver transplantation, two of whom had a fulminant presentation. Four (2%) adults with autoimmune hepatitis died (two from liver-associated causes). CONCLUSION Patients with autoimmune hepatitis in Switzerland had clinical features similar to those in other cohorts. The proportion of patients diagnosed with primary biliary cholangitis variant syndrome was higher than expected. Autoimmune hepatitis was managed according to guidelines, except for the use of budesonide in a small proportion of paediatric patients. The outcomes were excellent, but the findings must be confirmed over a longer follow-up period.
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Affiliation(s)
- Christine Ludz
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Guido Stirnimann
- Universitätsklinik für Viszerale Chirurgie und Medizin, Inselspital Bern, Bern, Switzerland
| | - David Semela
- Klinik für Gastroenterologie und Hepatologie, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Andreas E Kremer
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Magdalena Filipowicz Sinnreich
- Clinic for Gastroenterology and Hepatology, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland
| | - Christiane Sokollik
- Departement Pädiatrische Gastroenterologie, Hepatologie und Ernährung, Kinderklinik Inselspital Bern, Bern Switzerland
| | - Christine Bernsmeier
- Gastroenterologie/Hepatologie, Universitäres Bauchzentrum Basel Clarunis, Basel, Switzerland
| | - Solange Bresson-Hadni
- Service de Gastroentérologie and Hépatologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Valérie McLin
- Département de l'Enfant et de l'Adolescent, Centre Suisse des Maladies du Foie de l'Enfant, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Nathalie Rock
- Département de l'Enfant et de l'Adolescent, Centre Suisse des Maladies du Foie de l'Enfant, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Christian Braegger
- Division of Pediatric Gastroenterology and Nutrition, University Children's Hospital Zurich, Zurich, Switzerland
| | - Carsten Posovszky
- Nutrition Research Unit, University Children's Hospital Zurich, Zurich, Switzerland
| | - Pascal Müller
- Departement pädiatrische Gastroenterologie und Hepatologie, Ostschweizer Kinderspital, St. Gallen, Switzerland
| | - Matthias Cremer
- Departement für Kinder- und Jugendmedizin, Kantonsspital Graubünden, Chur, Switzerland
| | - Andrea De Gottardi
- Servizio di Gastroenterologia, Ente Ospedaliero Cantonale Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Antonio Galante
- Servizio di Gastroenterologia, Ente Ospedaliero Cantonale Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Raoul Furlano
- University Children's Hospital Basel, Paediatric Gastroenterology and Nutrition, Basel, Switzerland
| | - Franziska Righini-Grunder
- Departement pädiatrische Gastroenterologie, Luzerner Kantonsspital/Kinderspital, Lucerne, Switzerland
| | - Björn Becker
- Departement Innere Medizin, Klinik für Gastroenterologie und Hepatologie, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Stephan Böhm
- Departement Gastroenterologie und Hepatologie, Klinik Innere Medizin, Spital Bülach, Bülach, Switzerland
| | - Klaas Heyland
- Departement Kindergastroenterologie, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Andreas Nydegger
- Département femme-mère-enfant, Centre hospitalier universitaire Vaudois, Lausanne, Switzerland
| | - Costanzo Limoni
- University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - Diego Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | - Giorgina Mieli-Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | | | | | - Benedetta Terziroli Beretta-Piccoli
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
- Epatocentro Ticino, Lugano, Switzerland
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Nastasio S, Mosca A, Alterio T, Sciveres M, Maggiore G. Juvenile Autoimmune Hepatitis: Recent Advances in Diagnosis, Management and Long-Term Outcome. Diagnostics (Basel) 2023; 13:2753. [PMID: 37685291 PMCID: PMC10486972 DOI: 10.3390/diagnostics13172753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023] Open
Abstract
Juvenile autoimmune hepatitis (JAIH) is severe immune-mediated necro-inflammatory disease of the liver with spontaneous progression to cirrhosis and liver failure if left untreated. The diagnosis is based on the combination of clinical, laboratory and histological findings. Prothrombin ratio is a useful prognostic factor to identify patients who will most likely require a liver transplant by adolescence or early adulthood. JAIH treatment consists of immune suppression and should be started promptly at diagnosis to halt inflammatory liver damage and ultimately prevent fibrosis and progression to end-stage liver disease. The risk of relapse is high especially in the setting of poor treatment compliance. Recent evidence however suggests that treatment discontinuation is possible after a prolonged period of normal aminotransferase activity without the need for liver biopsy prior to withdrawal.
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy;
| | - Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
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24
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Karemera M, Verce M, Roumain M, Muccioli GG, Cani PD, Everard A, Stephenne X, Sokal E. Pediatric Autoimmune or Primary Sclerosing Cholangitis: Metronidazole Effectiveness on Biochemical Data, Bile Acid Profile, and Gut Microbiota: A Pilot Study. JPGN REPORTS 2023; 4:e334. [PMID: 37600615 PMCID: PMC10435019 DOI: 10.1097/pg9.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/25/2023] [Indexed: 08/22/2023]
Abstract
Objectives Autoimmune hepatitis and primary sclerosing cholangitis (PSC) can both be present, resulting in autoimmune sclerosing cholangitis (ASC). PSC physiopathology could be based on the cross-talk between gut microbiota and bile acids (BAs); antibiotics are an innovative therapy. This pilot study assesses metronidazole (MTZ)'s effectiveness in ASC or PSC patients according to the stage of the disease, and its effects on biochemical parameters, BA profiles, and gut microbiota. Methods ASC or PSC patients from Cliniques universitaires Saint-Luc's pediatric hepato-gastroenterology division were enrolled retrospectively and prospectively; both datasets were merged. MTZ was administered over at least 14 days on top of standard treatment (ursodeoxycholic acid, azathioprine, and steroids). Fecal and blood samples were collected before (T0) and at MTZ day 14 (T14). Sustained biochemical remission was defined by the reduction of transaminases (AST and ALT), gamma-glutamyl transferase (GGT), and CRP until 12 months post-MTZ. Results A total of 18 patients (mean age, 13.2 ± 4.5 years) were enrolled (13 ASC and 5 PSC), and divided in remission or relapse patients. CRP, AST, ALT, and GGT levels decreased post-MTZ in both groups (excepting GGT in relapse patients), with decreases between T0 and T14 being significant for AST and ALT. Relapse patients were older (P = 0.0351) and in late-disease stage, with mainly large-duct PSC (P = 0.0466). In remission patients, the mean plasma relative abundance of hydrophilic BA increased by +6.3% (P = 0.0391) after MTZ. Neither at baseline nor T14, there were significant differences in gut microbiota recorded. Conclusion These data are likely indicative of long-term benefits following MTZ therapy at early-stage ASC or PSC, with increased hydrophilic BA abundance. Multicenter prospective studies are needed.
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Affiliation(s)
- Manon Karemera
- From the Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Marko Verce
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Walloon Excellence in Life Sciences and Biotechnology (WELBIO), UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Martin Roumain
- Bioanalysis and Pharmacology of Bioactive Lipids Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Giulio G. Muccioli
- Bioanalysis and Pharmacology of Bioactive Lipids Research Group, Louvain Drug Research Institute, UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Patrice D. Cani
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Walloon Excellence in Life Sciences and Biotechnology (WELBIO), UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Amandine Everard
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Walloon Excellence in Life Sciences and Biotechnology (WELBIO), UCLouvain, Université catholique de Louvain, Brussels, Belgium
| | - Xavier Stephenne
- From the Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- UCLouvain, Université catholique de Louvain, Institute of Experimental and Clinical Research - PEDI
| | - Etienne Sokal
- From the Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- UCLouvain, Université catholique de Louvain, Institute of Experimental and Clinical Research - PEDI
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25
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Walmsley M, Tornai D, Cazzagon N, Leburgue A, Mrzljak A, Lenzen H, Carbone M, Madaleno J, Lleo A, Junge N, Schramm C, Bergquist A. Patient-reported quality of care in primary sclerosing cholangitis. Liver Int 2023; 43:1654-1662. [PMID: 37312635 DOI: 10.1111/liv.15650] [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: 03/30/2023] [Revised: 05/23/2023] [Accepted: 06/04/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Management and follow-up strategies for primary sclerosing cholangitis (PSC) vary. The aim of the present study was to assess patient-reported quality of care to identify the most important areas for improvement. METHODS Data were collected via an online survey hosted on the EU Survey platform in 11 languages between October 2021 and January 2022. Questions were asked about the disease, symptoms, treatment, investigations and quality of care. RESULTS In total, 798 nontransplanted people with PSC from 33 countries responded. Eighty-six per cent of respondents reported having had at least one symptom. Twenty-four per cent had never undergone an elastography, and 8% had not had a colonoscopy. Nearly half (49%) had never undergone a bone density scan. Ursodeoxycholic acid (UDCA) was used in 90-93% in France, Netherlands and Germany, and 49-50% in the United Kingdom and Sweden. Itch was common (60%), and 50% of those had received any medication. Antihistamines were taken by 27%, cholestyramine by 21%, rifampicin by 13% and bezafibrate by 6.5%. Forty-one per cent had been offered participation in a clinical trial or research. The majority (91%) reported that they were confident with their care although half of the individuals reported the need for more information on disease prognosis and diet. CONCLUSION Symptom burden in PSC is high, and the most important areas of improvement are disease monitoring with more widespread use of elastography, bone density scan and appropriate treatment for itch. Personalised prognostic information should be offered to all individuals with PSC and include information on how they can improve their health.
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Affiliation(s)
- Martine Walmsley
- PSC Support, Oxford, UK
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Dávid Tornai
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nora Cazzagon
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Azienda Ospedale - Università Padova, Padova, Italy
| | - Angela Leburgue
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Albi, Association pour la Lutte contre les maladies inflammatoires du foie et des voies biliaires, Versailles, France
| | - Anna Mrzljak
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Department of Medicine, Merkur University Hospital, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Henrike Lenzen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marco Carbone
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Division of Gastroenterology, University of Milano-Bicocca, Milan, Italy
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - João Madaleno
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Liver Disease Unit, Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Lleo
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Norman Junge
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Division for Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Christoph Schramm
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- I. Medizinische Klinik und Poliklinik, and 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
| | - Annika Bergquist
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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26
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Yadav V, Irfan R, Safdar S, Sunkara V, Ekhator C, Pendyala PR, Devi M, Shahzed SMI, Das A, Affaf M, Bellegarde SB, Shrestha R, Naseem MA, Al Khalifa A. Advances in Understanding and Managing Autoimmune Hepatitis: A Narrative Review. Cureus 2023; 15:e43973. [PMID: 37622052 PMCID: PMC10446851 DOI: 10.7759/cureus.43973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 08/26/2023] Open
Abstract
Autoimmune hepatitis (AIH) is a chronic liver disease characterized by immune-mediated destruction of hepatocytes, leading to inflammation and fibrosis. In recent years, significant advances have been made in understanding the pathogenesis, epidemiology, diagnosis, and treatment of AIH. This comprehensive narrative review aims to provide an up-to-date overview of these advances. The review begins by outlining the historical background of AIH, dating back to its initial recognition in the 1940s, and highlights the evolution of diagnostic criteria and classification based on autoantibody profiles. The epidemiology of AIH is explored, discussing its varying prevalence across different regions and the role of genetic predisposition, viral infections, and drug exposure as risk factors. Furthermore, the review delves into the pathogenesis of AIH, focusing on the dysregulated immune response, involvement of T cells, and potential contribution of the gut microbiome. Clinical presentation, diagnostic criteria, and liver biopsy as crucial tools for diagnosis are also discussed. Regarding management, the review provides an in-depth analysis of the standard first-line treatments involving glucocorticoids and azathioprine, as well as alternative therapies for non-responsive cases. Additionally, emerging second and third-line treatment options are examined. In conclusion, this narrative review highlights the complexity of AIH and underscores the importance of early diagnosis and individualized treatment approaches to improve patient outcomes. Further research and clinical trials are needed to optimize AIH management and ensure a better long-term prognosis for affected individuals.
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Affiliation(s)
- Vikas Yadav
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | | | | | | | - Chukwuyem Ekhator
- Neuro-Oncology, New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, USA
| | - Praful R Pendyala
- Neurology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
| | | | | | - Archana Das
- Internal Medicine, North East Medical College and Hospital, Sylhet, BGD
| | - Maryam Affaf
- Medicine, Khyber Medical University, Peshawar, PAK
| | - Sophia B Bellegarde
- Pathology and Laboratory Medicine, American University of Antigua, St. John's, ATG
| | - Riya Shrestha
- Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, NPL
| | | | - Ahmed Al Khalifa
- Medical School, College of Medicine, Sulaiman Alrajhi University, Al Bukayriyah, SAU
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27
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KASL clinical practice guidelines for management of autoimmune hepatitis 2022. Clin Mol Hepatol 2023; 29:542-592. [PMID: 37137334 PMCID: PMC10366804 DOI: 10.3350/cmh.2023.0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
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28
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Bonroy C, Vercammen M, Fierz W, Andrade LEC, Van Hoovels L, Infantino M, Fritzler MJ, Bogdanos D, Kozmar A, Nespola B, Broeders S, Patel D, Herold M, Zheng B, Chan EYT, Uibo R, Haapala AM, Musset L, Sack U, Nagy G, Sundic T, Fischer K, Rego de Sousa MJ, Vargas ML, Eriksson C, Heijnen I, García-De La Torre I, Carballo OG, Satoh M, Kim KH, Chan EKL, Damoiseaux J, Lopez-Hoyos M, Bossuyt X. Detection of antinuclear antibodies: recommendations from EFLM, EASI and ICAP. Clin Chem Lab Med 2023; 61:1167-1198. [PMID: 36989417 DOI: 10.1515/cclm-2023-0209] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Antinuclear antibodies (ANA) are important for the diagnosis of various autoimmune diseases. ANA are usually detected by indirect immunofluorescence assay (IFA) using HEp-2 cells (HEp-2 IFA). There are many variables influencing HEp-2 IFA results, such as subjective visual reading, serum screening dilution, substrate manufacturing, microscope components and conjugate. Newer developments on ANA testing that offer novel features adopted by some clinical laboratories include automated computer-assisted diagnosis (CAD) systems and solid phase assays (SPA). METHODS A group of experts reviewed current literature and established recommendations on methodological aspects of ANA testing. This process was supported by a two round Delphi exercise. International expert groups that participated in this initiative included (i) the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group "Autoimmunity Testing"; (ii) the European Autoimmune Standardization Initiative (EASI); and (iii) the International Consensus on ANA Patterns (ICAP). RESULTS In total, 35 recommendations/statements related to (i) ANA testing and reporting by HEp-2 IFA; (ii) HEp-2 IFA methodological aspects including substrate/conjugate selection and the application of CAD systems; (iii) quality assurance; (iv) HEp-2 IFA validation/verification approaches and (v) SPA were formulated. Globally, 95% of all submitted scores in the final Delphi round were above 6 (moderately agree, agree or strongly agree) and 85% above 7 (agree and strongly agree), indicating strong international support for the proposed recommendations. CONCLUSIONS These recommendations are an important step to achieve high quality ANA testing.
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Affiliation(s)
- Carolien Bonroy
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Martine Vercammen
- Department of Laboratory Medicine, AZ Sint-Jan, Brugge, Belgium
- Research Group REIM, Vrije Universiteit Brussel, Brussels, Belgium
| | - Walter Fierz
- Schweizerischer Verband der Diagnostikindustrie (SVDI-ASID), Bern, Switzerland
| | - Luis E C Andrade
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
- Immunology Division, Fleury Medicine and Health Laboratories, Sao Paulo, Brazil
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maria Infantino
- Immunology and Allergology Laboratory, S. Giovanni di Dio Hospital, Florence, Italy
| | - Marvin J Fritzler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dimitrios Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University General Hospital of Larissa, Larissa, Greece
| | - Ana Kozmar
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Benoit Nespola
- Laboratory of Immunology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Dina Patel
- UK NEQAS Immunology, Immunochemistry & Allergy, Sheffield Teaching Hospitals, Sheffield, UK
| | - Manfred Herold
- Department of Internal Medicine II, Rheumatology Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - Bing Zheng
- Department of Laboratory Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Eric Y T Chan
- Department of Pathology, Queen Mary Hospital, Hong Kong, P.R. China
| | - Raivo Uibo
- Department of Immunology, Medical Faculty, University of Tartu, Tartu, Estonia
| | | | - Lucile Musset
- Department of Immunology, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Ulrich Sack
- Medical Faculty, Leipzig University, Leipzig, Germany
| | - Gabor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tatjana Sundic
- Department of Immunology and Transfusion Medicine, Haugesund Hospital, Helse Fonna, Haugesund, Norway
| | - Katarzyna Fischer
- Individual Laboratory for Rheumatologic Diagnostics, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Maria-José Rego de Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | | | - Catharina Eriksson
- Department of Clinical Microbiology Section of Infection and Immunology, Umeå University, Umeå, Sweden
| | - Ingmar Heijnen
- Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Ignacio García-De La Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente, Universidad de Guadalajara, Guadalajara, Mexico
| | - Orlando Gabriel Carballo
- Laboratory of Immunology, Hospital Carlos G. Durand, Buenos Aires, Argentina
- Department of Microbiology and Immunology, Instituto Universitario, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Minoru Satoh
- Department of Human, Information and Life Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
- Department of Medicine, Kitakyushu Yahata-Higashi Hospital, Kitakyushu, Japan
| | - Kyeong-Hee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Edward K L Chan
- Department of Oral Biology, University of Florida, Gainesville, FL, USA
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcos Lopez-Hoyos
- Immunology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Xavier Bossuyt
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
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Campos-Murguia A, Henjes N, Loges S, Wedemeyer H, Jaeckel E, Taubert R, Engel B. Evaluation of immunoserological detection of anti-liver kidney microsomal, anti-soluble liver antigen and anti-mitochondrial antibodies. Sci Rep 2023; 13:10038. [PMID: 37340049 DOI: 10.1038/s41598-023-37095-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/15/2023] [Indexed: 06/22/2023] Open
Abstract
Autoantibodies are the diagnostic hallmark of autoimmune liver diseases. Indirect immunofluorescence (IFT) is the reference method for the detection of anti-mitochondrial antibodies (AMA) and anti-liver kidney microsomal type-1 (anti-LKM1) antibodies, and inhibition ELISA (iELISA) for anti-soluble liver antigen (anti-SLA) antibodies. Given the complexity of these techniques, commercial ELISAs have emerged as a practical alternative, but without head-to-head validations. This study evaluated the agreement between three commercial ELISAs and the reference techniques and the impact of polyreactive immunoglobulin G (pIgG), a recently described phenomenon in autoimmune hepatitis, on commercial ELISAs. Inter-rater reliability was assessed using Cohen-Kappa coefficient (κ). Forty-eight, 46, and 66 samples were analyzed for AMA, anti-LKM1, and anti-SLA, respectively. For AMA, one commercial assay showed high agreement (κ = 0.91 (0.78-1.00)) with the reference method, while the other two showed weak or moderate agreement. For anti-LKM1, only one commercial assay showed high agreement (κ = 0.86 (0.71-1.0)). For anti-SLA antibodies only moderate agreement was achieved (κ up to 0.71 (0.52-0.89)). There was a trend towards higher pIgG levels in false-positives in the commercial ELISAs. Patients with high suspicion of autoimmune liver diseases should be referred to reference laboratories with the capacity of performing gold standard methods if the initial ELISA-based screening was performed.
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Affiliation(s)
- Alejandro Campos-Murguia
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Nicole Henjes
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Stephanie Loges
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Ajmera Transplant Center, Toronto General Hospital, United Health Network, University of Toronto, Toronto, Canada
| | - Richard Taubert
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Bastian Engel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
- Member of the European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.
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Islek A, Tumgor G. Seronegative autoimmune hepatitis in childhood. World J Clin Pediatr 2023; 12:77-85. [PMID: 37342447 PMCID: PMC10278082 DOI: 10.5409/wjcp.v12.i3.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 06/08/2023] Open
Abstract
Comprehensive guidelines on seropositive autoimmune hepatitis have been published for both adults and children, although these guidelines comprise only limited knowledge about seronegative autoimmune hepatitis. Autoimmune hepatitis presents as an acute or chronic progressive disease and poor outcomes are inevitable if left untreated. The absence of autoantibody positivity, hypergammaglobulinemia and lack of comprehensive algorithms makes seronegative autoimmune hepatitis a mysterious disease. In general, seronegative autoimmune hepatitis often presents with acute hepatitis, and its treatment and prognosis similar to seropositive autoimmune hepatitis. The present review focuses on the known characteristics of seronegative autoimmune hepatitis in childhood, and those of which current knowledge is vague.
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Affiliation(s)
- Ali Islek
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
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31
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Vimalesvaran S, Samyn M, Dhawan A. Liver disease in adolescents. Arch Dis Child 2023; 108:427-432. [PMID: 36167480 DOI: 10.1136/archdischild-2021-323647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 11/04/2022]
Abstract
In this article, we discuss common liver diseases in the adolescent population. We describe the initial evaluation of an adolescent presenting with new-onset liver enzyme abnormalities, based on the clinical history and physical examination. The management approach to the adolescent with liver disease is exemplified, including monitoring for adherence, risk-taking behaviours and focusing on psychosocial aspects of their care. Finally, we highlight the challenges of caring for the adolescent patient and the importance of addressing not only the liver disease but, more importantly, the holistic approach towards their management.
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Marianne Samyn
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anil Dhawan
- Paediatric Liver, Gastroenterology and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
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32
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Maggiore G, Bernard O, Mosca A, Ballot E, Johanet C, Jacquemin E. Long-term outcomes of patients with type 1 or 2 autoimmune hepatitis presenting in childhood. J Hepatol 2023; 78:979-988. [PMID: 36708813 DOI: 10.1016/j.jhep.2023.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/14/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS In children with autoimmune hepatitis, uncertainties include outcomes associated with type 2 hepatitis, the possibility of and criteria for attempting withdrawal of treatment, and long-term outcomes. We report our experience on these issues. METHODS From 1973 to 2002, 117 children with type 1 (n = 65) or type 2 (n = 52) hepatitis, excluding fulminant hepatitis, were treated, primarily with prednisone and azathioprine. Median follow-up was 20 years in survivors. RESULTS Normalisation of aminotransferases and prothrombin ratio were observed in 93% and 84% of children, respectively; sustained remission after treatment withdrawal was recorded in 24% of the entire population, with a median follow-up of 7 years. Sustained treatment-free remission was obtained in 11 of 24 children with follow-ups of 4-22 years based on durable normalisation of aminotransferases (without histological assessment). Gastrointestinal bleeding from varices and the emergence of extrahepatic autoimmune disorders occurred in 10 and 22 patients, respectively. Liver transplantation was performed in 23 patients at a median age of 21 years. The 30-year probabilities of overall and native liver survival were 81% and 61%, respectively. No differences were observed between type 1 and 2 hepatitis for any of the component parts of outcome. In the multivariate analysis, a persistent abnormal prothrombin ratio was associated with worse probabilities of overall and native liver survival. CONCLUSIONS In terms of liver outcome, type 2 hepatitis is not different from type 1. Withdrawal of treatment is possible without prior liver histology. A persistent abnormal prothrombin ratio identifies patients who will require liver transplantation in adolescence or early adulthood. IMPACT AND IMPLICATIONS In children with autoimmune hepatitis, there are conflicting reports on the differences in outcome between type 1 and type 2 hepatitis, and on the possibility of treatment withdrawal, before which liver histology is required; data concerning >10-year overall and native liver survival rates are limited. In this study, we found no differences in outcomes between type 1 and 2 hepatitis; a durable treatment-free state was achieved in 19% of all patients throughout childhood and early adulthood, and in 45% of children for whom treatment withdrawal was attempted without prior liver histology; prothrombin was found to be predictive of 30-year overall and native liver survival. The results allow for a less-strict approach to treatment withdrawal in children, avoiding the risks of a liver biopsy, and they provide a tool to help anticipate the need for liver transplantation before complications occur.
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Affiliation(s)
- Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Olivier Bernard
- Paediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Biliary Diseases and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicetre Hospital, APHP, University Paris-Saclay, Le Kremlin-Bicetre, France
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eric Ballot
- Laboratory of Autoimmunity, Department of Immunology, St Antoine Hospital, APHP, Sorbonne University, Paris, France
| | - Catherine Johanet
- Laboratory of Autoimmunity, Department of Immunology, St Antoine Hospital, APHP, Sorbonne University, Paris, France
| | - Emmanuel Jacquemin
- Paediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Biliary Diseases and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicetre Hospital, APHP, University Paris-Saclay, Le Kremlin-Bicetre, France; Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
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Maria A, Sood V, Khanna R, Lal BB, Trehanpati N, Alam S. Association of HLA DRB1 Allele Profile with Pediatric Autoimmune Liver Disease in India. J Clin Exp Hepatol 2023; 13:397-403. [PMID: 37250880 PMCID: PMC10213850 DOI: 10.1016/j.jceh.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/02/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives The aim of this study is to study the association of human leukocyte antigen (HLA) DRB1 alleles with treatment response in Indian children with autoimmune liver disease (AILD). Methods HLA DRB1 alleles of 71 Indian children with pediatric AILD (pAILD) were analyzed along with 25 genetically confirmed patients with Wilson disease as controls. After 1 year of therapy, all those who failed to normalize aspartate & alanine transferase (AST/ ALT) (below 1.5 times of upper limit of normal) and/or failed to normalize IgG levels, or who had >2 relapses (AST/ALT levels >1.5 times of upper limit of normal) while on treatment, were labeled as difficult to treat (DTT). Results HLA DRB1∗3 was found to be significantly associated with AIH type 1 (46.2% vs. 4% in controls; P corrected = 0.011). Majority of the patients [55 (77.5%)] had chronic liver disease at presentation, with 42 (59.2%) having portal hypertension and 17 (23.9%) having ascites. Out of the 71 with pAILD, 19 (26.8%) were DTT. HLA DRB1∗14 was found to be independently associated with DTT cases (36.8% vs. 9.6%, OR 5.87, 95% CI 1.07-32.09, P = 0.041). Other factors independently associated with DTT were presence of autoimmune sclerosing cholangitis (OR 8.57, P = 0.008) and high-risk varices (OR 7.55, P = 0.016), improving the correctness of classification of the model from 73.2% to 84.5%. Conclusion HLA DRB1∗14 is independently associated with treatment response in pAILD and HLA DRB1∗3 is associated with AIH type 1. HLA DRB1 alleles may thus provide supportive information for diagnosis and prognosis of AILD.
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Affiliation(s)
- Arjun Maria
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant B. Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nirupama Trehanpati
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Hildreth A, Shapiro WL, Lowenthal BM, Goyal A, Schwimmer JB. Distinguishing Autoimmune Hepatitis From Steatohepatitis in Adolescents With Obesity and Positive Screening Alanine Aminotransferase. JPGN REPORTS 2023; 4:e292. [PMID: 37200725 PMCID: PMC10187841 DOI: 10.1097/pg9.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/02/2022] [Indexed: 05/20/2023]
Abstract
Screening children with obesity for nonalcoholic fatty liver disease leads to identification of elevated alanine aminotransferase (ALT) and is a common cause for referral to pediatric gastroenterology. Guidelines recommend that children with positive screening ALT be evaluated for causes of ALT elevation beyond nonalcoholic fatty liver disease. One clinical challenge is that autoantibodies can be present in patients with obesity and thus may or may not represent autoimmune hepatitis. This case series highlights the importance of a comprehensive evaluation to reach an accurate diagnosis.
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Affiliation(s)
- Amber Hildreth
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California
| | - Warren L Shapiro
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California
- Department of Pediatrics, Kaiser Permanente Medical Center San Diego, San Diego, California
| | - Brett M Lowenthal
- Department of Pathology, Kaiser Permanente Medical Center San Diego, San Diego, California
| | - Anurag Goyal
- Department of Vascular and Interventional Radiology, Kaiser Permanente Medical Center San Diego, San Diego, California
| | - Jeffrey B Schwimmer
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California
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35
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Sîrbe C, Badii M, Crişan TO, Bența G, Grama A, Joosten LAB, Rednic S, Pop TL. Detection of Novel Biomarkers in Pediatric Autoimmune Hepatitis by Proteomic Profiling. Int J Mol Sci 2023; 24:ijms24087479. [PMID: 37108648 PMCID: PMC10141667 DOI: 10.3390/ijms24087479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
Autoimmune hepatitis (AIH) is characterized by immune-mediated hepatocyte injury resulting in the destruction of liver cells, causing inflammation, liver failure, and fibrosis. Pediatric (AIH) is an autoimmune inflammatory disease that usually requires immunosuppression for an extended period. Frequent relapses after treatment discontinuation demonstrate that current therapies do not control intrahepatic immune processes. This study describes targeted proteomic profiling data in patients with AIH and controls. A total of 92 inflammatory and 92 cardiometabolic plasma markers were assessed for (i) pediatric AIH versus controls, (ii) AIH type 1 versus type 2, (iii) AIH and AIH-autoimmune sclerosing cholangitis overlapping syndrome and (iv) correlations with circulating vitamin D levels in AIH. A total of 16 proteins showed a nominally significant differential abundance in pediatric patients with AIH compared to controls. No clustering of AIH subphenotypes based on all protein data was observed, and no significant correlation of vitamin D levels was observed for the identified proteins. The proteins that showed variable expression include CA1, CA3, GAS6, FCGR2A, 4E-BP1 and CCL19, which may serve as potential biomarkers for patients with AIH. CX3CL1, CXCL10, CCL23, CSF1 and CCL19 showed homology to one another and may be coexpressed in AIH. CXCL10 seems to be the central intermediary link for the listed proteins. These proteins were involved in relevant mechanistic pathways for liver diseases and immune processes in AIH pathogenesis. This is the first report on the proteomic profile of pediatric AIH. The identified markers could potentially lead to new diagnostic and therapeutic tools. Nevertheless, considering the complex pathogenesis of AIH, more extensive studies are warranted to replicate and validate the present study's findings.
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Affiliation(s)
- Claudia Sîrbe
- 2nd Pediatric Discipline, Department of Mother and Child, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Pediatric Clinic, Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Medeea Badii
- Department of Medical Genetics, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Department of Internal Medicine, Radboud University Medical Centre, 6525 XZ Nijmegen, The Netherlands
| | - Tania O Crişan
- Department of Medical Genetics, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Department of Internal Medicine, Radboud University Medical Centre, 6525 XZ Nijmegen, The Netherlands
| | - Gabriel Bența
- 2nd Pediatric Discipline, Department of Mother and Child, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Pediatric Clinic, Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Alina Grama
- 2nd Pediatric Discipline, Department of Mother and Child, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Pediatric Clinic, Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Leo A B Joosten
- Department of Internal Medicine, Radboud University Medical Centre, 6525 XZ Nijmegen, The Netherlands
| | - Simona Rednic
- Rheumatology Department, Emergency County Hospital Cluj, 400347 Cluj-Napoca, Romania
- Rheumatology Discipline, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Tudor Lucian Pop
- 2nd Pediatric Discipline, Department of Mother and Child, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Pediatric Clinic, Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
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Lopez RN, Leach ST, Bowcock N, Coker E, Shapiro AJ, Day AS, Lemberg DA. Differences in Gut Microbiome Profile between Healthy Children and Children with Inflammatory Bowel Disease and/or Autoimmune Liver Disease: A Case-Control Study. Pathogens 2023; 12:pathogens12040585. [PMID: 37111471 PMCID: PMC10145405 DOI: 10.3390/pathogens12040585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The role of gastrointestinal microbiome in health and disease is increasingly appreciated. A significant amount of evidence clearly points to a dysbiosis manifest in inflammatory bowel disease (IBD) when compared to healthy controls. Less understood is the microbiome profile in autoimmune liver disease (AILD). Both adult and paediatric data indicate a distinct microbial signature in patients with IBD and co-existent primary sclerosing cholangitis (PSC), which is unique and different compared to the microbial signature that exists in patients with IBD alone. However, there is limited information on the microbiome make-up of patients with parenchymal liver disease, with or without IBD. METHODS The present study sought to compare the microbiome of children with IBD, to those with IBD-AILD, those with AILD alone and those of healthy controls. RESULTS Results from this work indicate that children with AILD have a microbiome profile that mirrors healthy controls. CONCLUSION Those with IBD-AILD and IBD have similar microbiome profiles which are distinct from AILD alone and healthy controls. This suggests that the dysbiosis in these groups is primarily due to IBD rather than AILD.
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Affiliation(s)
- Robert N Lopez
- Department of Gastroenterology, Sydney Children's Hospital, Sydney 2031, Australia
| | - Steven T Leach
- Department of Paediatrics, School of Clinical Medicine, University of NSW, Sydney 2052, Australia
| | - Nerissa Bowcock
- Department of Paediatrics, School of Clinical Medicine, University of NSW, Sydney 2052, Australia
| | - Elise Coker
- Department of Gastroenterology, Sydney Children's Hospital, Sydney 2031, Australia
| | - Amanda J Shapiro
- Department of Paediatrics, School of Clinical Medicine, University of NSW, Sydney 2052, Australia
| | - Andrew S Day
- Department of Paediatrics, School of Clinical Medicine, University of NSW, Sydney 2052, Australia
- Department of Paediatrics, University of Otago Christchurch, Christchurch 8041, New Zealand
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital, Sydney 2031, Australia
- Department of Paediatrics, School of Clinical Medicine, University of NSW, Sydney 2052, Australia
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Costa JM, Pinto SM, Santos-Silva E, Moreira-Silva H. Incidental hypertransaminasemia in children-a stepwise approach in primary care. Eur J Pediatr 2023; 182:1601-1609. [PMID: 36697884 PMCID: PMC9877494 DOI: 10.1007/s00431-023-04825-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/27/2023]
Abstract
Children with elevated liver enzymes are occasionally discovered through laboratory work-up from different clinical scenarios. Although the majority will have transient and/or benign conditions, a subgroup will have underlying liver disorders. The differential diagnosis is broad and therefore, a systematic approach is of utmost importance. In this article, we reviewed the most recent and relevant literature to provide a comprehensive overview of the main disease processes that cause hypertransaminasemia in children. Ultimately, we propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes in asymptomatic children. The first step is to obtain a complete history along with a thorough physical examination to exclude red flags, which should dictate urgent consultation with a paediatric gastroenterologist or hepatologist. Conclusion: Hypertransaminasemia is a challenging scenario in the primary care setting. The aetiology can be broad, ranging from hepatic and extrahepatic to transient versus chronic liver disease. Timely referral to a specialised centre is of paramount importance for conducting targeted research and to not miss the chance of identifying a progressive, but still asymptomatic, treatable liver disease. What is Known: • Elevated liver enzyme is a challenging scenario in the primary care setting. • There are few studies guiding the evaluation of asymptomatic hypertransaminasemia in the paediatric population and a standardised approach is lacking. What is New: • We propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes.
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Affiliation(s)
- Joana Meneses Costa
- Valbom Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Sara Martins Pinto
- Nascente Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal
- Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, UCIBIO, Universidade do Porto, Porto, Portugal
| | - Helena Moreira-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal.
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Sakulsaengprapha V, Wasuwanich P, Naraparaju G, Korotkaya Y, Thawillarp S, Oshima K, Karwowski C, Scheimann AO, Karnsakul W. Applicability of International Autoimmune Hepatitis Group (IAIHG) Scoring System for Autoimmune Hepatitis in Pediatrics. BIOLOGY 2023; 12:479. [PMID: 36979170 PMCID: PMC10045027 DOI: 10.3390/biology12030479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Many hepatologic pathologies mimic autoimmune hepatitis (AIH). Researchers developed the International Autoimmune Hepatitis Group (IAIHG) scoring system to compensate for the lack of specific diagnostic tests for AIH. The scoring system was not designed with pediatric patients in mind, so there are limits to its pediatric use. Additionally, there is limited information on the value of a liver biopsy in conjunction with its use. METHODS In this retrospective study, we evaluated the effect of liver biopsy scores on the IAIHG scoring system in patients that were 0-18 years old with suspected AIH. We also analyzed demographic data and laboratory values associated with a final AIH diagnosis. RESULTS We found that interface hepatitis and predominant plasma cells found during the biopsy were significantly associated with a final AIH diagnosis. We also found that abnormal laboratory values were associated with an AIH diagnosis. We found that IAIHG scores calculated post-liver biopsy showed a greater area under the receiver operating characteristic curve (AUROC) of 0.95, which was compared to 0.88 for the scores calculated before a liver biopsy. Including biopsy metrics lowered the optimized cutoff score and test specificity. CONCLUSION Incorporating liver histopathological features improved the performance of the IAIHG scoring system. Further studies to identify other potential elements in liver histology may improve the performance metrics of the IAIHG test in the pediatric population.
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Affiliation(s)
- Vorada Sakulsaengprapha
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
| | - Paul Wasuwanich
- College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Gayathri Naraparaju
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
| | - Yelena Korotkaya
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
| | - Supharerk Thawillarp
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Kiyoko Oshima
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christine Karwowski
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
| | - Ann O. Scheimann
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (V.S.); (G.N.); (Y.K.); (C.K.); (A.O.S.)
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Lohse AW, Hørby Jørgensen M. Paediatric autoimmune hepatitis: Time to change the textbooks? J Hepatol 2023; 78:893-895. [PMID: 36841545 DOI: 10.1016/j.jhep.2023.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 02/27/2023]
Affiliation(s)
- Ansgar Wilhelm Lohse
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
| | - Marianne Hørby Jørgensen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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Jańczyk W, Bierła JB, Trojanowska I, Wierzbicka-Rucińska A, Cukrowska B, Socha P. Prevalence and Significance of Autoantibody Seropositivity in Children with Wilson's Disease. Diagnostics (Basel) 2023; 13:diagnostics13040768. [PMID: 36832258 PMCID: PMC9955693 DOI: 10.3390/diagnostics13040768] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/03/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Autoantibodies occur in healthy subjects as well as in children with Wilson's disease (WD), but their prevalence and significance are unknown. Thus, we aimed to assess the prevalence of autoantibodies and autoimmune markers, and their relationship to liver injury in WD children. The study included 74 WD and 75 healthy children as a control group. Patients with WD underwent transient elastography (TE) examinations, as well as determination of liver function tests, copper metabolism markers, and serum immunoglobulins (Ig). In the sera of the WD patients and controls, anti-nuclear (ANA), anti-smooth muscle, anti-mitochondrial, anti-parietal cell, anti-liver/kidney microsomal, anti-neutrophil cytoplasmic autoantibodies, and specific celiac antibodies were determined. Among the autoantibodies, only the prevalence of ANA in children with WD was higher than in the controls. There was no significant relationship between the presence of autoantibodies and liver steatosis or stiffness after TE. However, advanced liver stiffness (E > 8.2 kPa) was related to IgA, IgG, and gamma globulin production. The type of treatment did not influence the prevalence of autoantibodies. Our results suggest that autoimmune disturbances in WD might not be directly related to liver damage as expressed by steatosis and/or liver stiffness after TE.
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Affiliation(s)
- Wojciech Jańczyk
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-8151874
| | - Joanna B. Bierła
- Department of Pathomorphology, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Ilona Trojanowska
- Department of Pathomorphology, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Aldona Wierzbicka-Rucińska
- Department of Biochemistry, Radioimmunology and Experimental Medicine, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Bożena Cukrowska
- Department of Pathomorphology, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Piotr Socha
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
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Abstract
Autoimmune hepatitis is an inflammatory disease of the liver of unknown cause that may progress to liver cirrhosis and end stage liver failure if diagnosis is overlooked and treatment delayed. The clinical presentation is often that of acute hepatitis, sometimes very severe; less frequently, it can be insidious or completely asymptomatic. The disease can affect people of any age and is more common in women; its incidence and prevalence seem to be on the rise worldwide. An abnormal immune response targeting liver autoantigens and inducing persistent and self-perpetuating liver inflammation is the pathogenic mechanism of the disease. A specific set of autoantibodies, increased IgG concentrations, and histological demonstration of interface hepatitis and periportal necrosis are the diagnostic hallmarks of autoimmune hepatitis. Prompt response to treatment with corticosteroids and other immunomodulatory drugs is almost universal and supports the diagnosis. The aims of treatment are to induce and maintain long term remission of liver inflammation. Treatment can often even reverse liver fibrosis, thus preventing progression to advanced cirrhosis and its complications. Most patients need lifelong maintenance therapy, and repeated follow-up in experienced hands improves the quality of care and quality of life for affected patients.
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Affiliation(s)
- Luigi Muratori
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Marco Lenzi
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
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Nayagam JS, Joshi D, Thompson RJ, Dhawan A, Hadzic N, Mestre-Alagarda C, Deheragoda M, Samyn M. Hepatic Dry Copper Weight in Pediatric Autoimmune Liver Disease. J Pediatr Gastroenterol Nutr 2023; 76:e21-e26. [PMID: 36332083 DOI: 10.1097/mpg.0000000000003654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Elevated hepatic dry copper weight is recognized in adults with autoimmune liver disease (AILD) and chronic cholestasis. We aim to review hepatic dry copper weight in pediatric AILD. METHODS Retrospective review of pediatric AILD managed at our institution from 1999 to 2018, and 104 patients with hepatic dry copper weight assessment were included. RESULTS Median age at presentation was 13.4 years (interquartile range, IQR, 11.7-14.9), 60% female, 54% autoimmune hepatitis, 42% autoimmune sclerosing cholangitis, and 4% primary sclerosing cholangitis. Histological features of advanced liver fibrosis in 68%. Median hepatic dry copper weight was 51.1 µg/g dry weight (IQR, 28.0-103.8). Elevated hepatic dry copper weight (>50 µg/g dry weight) was present in 51%, and was not associated with AILD subtype ( P = 0.83), age at presentation ( P = 0.68), or advanced fibrosis ( P = 0.53). Liver transplantation (LT) was performed in 10%, who had higher hepatic dry copper weight (148.5 µg/g dry weight [IQR, 39.5-257.3] vs 47.5 [IQR, 27.8-91.5], P = 0.04); however this was not associated with LT on multivariate analysis (hazard ratio 1.002, 95% CI 0.999-1.005, P = 0.23). In 8 (7.7%) patients ATP7B was sequenced and potentially disease causing variants were identified in 2 patients, both who required LT. CONCLUSIONS Elevations in hepatic dry copper weight are common in pediatric AILD. Unlike in adults, it is not associated with AILD subtypes with cholestasis. Higher dry copper weight was detected in patients who required LT. While further work is needed to identify the significance of copper deposition in pediatric AILD, we recommend close monitoring of patients with elevated levels for progressive liver disease.
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Affiliation(s)
- Jeremy S Nayagam
- From Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
- Institute of Liver Studies, King's College London, London, UK
| | - Deepak Joshi
- From Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
| | - Richard J Thompson
- From Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
- Institute of Liver Studies, King's College London, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Nedim Hadzic
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | | | - Maesha Deheragoda
- From Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
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Dalekos GN, Gatselis NK. Autoimmune serology testing in clinical practice: An updated roadmap for the diagnosis of autoimmune hepatitis. Eur J Intern Med 2023; 108:9-17. [PMID: 36400668 DOI: 10.1016/j.ejim.2022.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/18/2022]
Abstract
Diagnosis of autoimmune hepatitis (AIH) is in most cases challenging for clinicians as there is not a single specific laboratory or histological marker to diagnose or exclude the presence of the disease. The clinical spectrum of AIH varies from completely asymptomatic to acute-severe or even rarely fulminant hepatic failure, while everybody can be affected irrespective of age, gender, and ethnicity. The old revised and the newer simplified diagnostic scores have been established by the International Autoimmune Hepatitis Group (IAIHG) in 1999 and 2008, respectively, which are based on several clinical, laboratory and histological parameters. Additionally, a thorough differential diagnosis from other diseases mimicking AIH is absolutely indicated. In this context, autoantibodies detection in patients with suspected AIH is mandatory -even though not pathognomonic- not only for AIH diagnosis but furthermore, for AIH classification (AIH-type 1 and AIH-type 2). Although autoimmune serology can be supportive of AIH diagnosis in ≥95% of cases if testing has been performed according to the IAIHG guidelines, this is not the case under real-life circumstances in routine clinical laboratories. Clinicians should be careful both for the importance of the required testing and how to interpret the results and therefore, they should communicate and discuss with the laboratory personnel to achieve the maximum benefit for the patient. Herein, a detailed and updated review of the diagnostic work-up for AIH diagnosis under real-life conditions is given to minimize the underestimation and misdiagnosis of AIH which can result in progression of the disease and unfavourable outcomes.
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Affiliation(s)
- George N Dalekos
- 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; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece.
| | - 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; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
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Yuksel M, Nazmi F, Wardat D, Akgül S, Polat E, Akyildiz M, Arikan Ç. Standard immunosuppressive treatment reduces regulatory B cells in children with autoimmune liver disease. Front Immunol 2023; 13:1053216. [PMID: 36685568 PMCID: PMC9849683 DOI: 10.3389/fimmu.2022.1053216] [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: 09/25/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Autoimmune hepatitis (AIH) is a chronic liver disease caused by a perturbed immune system. The scarcity of short- and long-term immune monitoring of AIH hampered us to comprehend the interaction between immunosuppressive medication and immune homeostasis. Methods and patients We recruited children with AIH at the time of diagnosis and at the 1st, 3rd, 6th, 12th, 18th, and 24th months of immunosuppression (IS). We also enrolled children with AIH being on IS for >2 years. Children with drug-induced liver injury (DILI), and those receiving tacrolimus after liver transplantation (LT), were enrolled as disease/IS control subjects. Healthy children (HC) were also recruited. Peripheral blood mononuclear cells (PBMCs) were isolated from all participants. Healthy liver tissue from adult donors and from livers without inflammation were obtained from children with hepatoblastoma. By using flow cytometry, we performed multi-parametric immune profiling of PBMCs and intrahepatic lymphocytes. Additionally, after IS with prednisolone, tacrolimus, rapamycin, or 6-mercaptopurine, we carried out an in vitro cytokine stimulation assay. Finally, a Lifecodes SSO typing kit was used to type HLA-DRB1 and Luminex was used to analyze the results. Results Untreated AIH patients had lower total CD8 T-cell frequencies than HC, but these cells were more naïve. While the percentage of naïve regulatory T cells (Tregs) (CD4+FOXP3lowCD45RA+) and regulatory B cells (Bregs, CD20+CD24+CD38+) was similar, AIH patients had fewer activated Tregs (CD4+FOXP3highCD45RA - ) compared to HC. Mucosal-associated-invariant-T-cells (MAIT) were also lower in these patients. Following the initiation of IS, the immune profiles demonstrated fluctuations. Bregs frequency decreased substantially at 1 month and did not recover anymore. Additionally, the frequency of intrahepatic Bregs in treated AIH patients was lower, compared to control livers, DILI, and LT patients. Following in vitro IS drugs incubation, only the frequency of IL-10-producing total B-cells increased with tacrolimus and 6MP. Lastly, 70% of AIH patients possessed HLA-DR11, whereas HLA-DR03/DR07/DR13 was present in only some patients. Conclusion HLA-DR11 was prominent in our AIH cohort. Activated Tregs and MAIT cell frequencies were lower before IS. Importantly, we discovered a previously unrecognized and long-lasting Bregs scarcity in AIH patients after IS. Tacrolimus and 6MP increased IL-10+ B-cells in vitro.
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Affiliation(s)
- Muhammed Yuksel
- Paediatric Gastroenterology-Hepatology, Koç University Hospital, Istanbul, Türkiye,Liver Immunology Lab, Koç University Research Centre for Translational Medicine (KUTTAM), Istanbul, Türkiye
| | - Farinaz Nazmi
- Paediatric Gastroenterology-Hepatology, Koç University Hospital, Istanbul, Türkiye,Liver Immunology Lab, Koç University Research Centre for Translational Medicine (KUTTAM), Istanbul, Türkiye
| | - Dima Wardat
- Liver Immunology Lab, Koç University Research Centre for Translational Medicine (KUTTAM), Istanbul, Türkiye
| | - Sebahat Akgül
- Transplant Immunology Research Centre of Excellence (TIREX) Tissue Typing Lab, Koç University Hospital, Istanbul, Türkiye
| | - Esra Polat
- Paediatric Gastroenterology and Hepatology, Sancaktepe Education and Research Hospital, Istanbul, Türkiye
| | - Murat Akyildiz
- Adult Gastroenterology-Hepatology, Koç University Hospital, Istanbul, Türkiye
| | - Çigdem Arikan
- Paediatric Gastroenterology-Hepatology, Koç University Hospital, Istanbul, Türkiye,Liver Immunology Lab, Koç University Research Centre for Translational Medicine (KUTTAM), Istanbul, Türkiye,*Correspondence: Çigdem Arikan,
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Snijders RJALM, Stoelinga AEC, Gevers TJG, Pape S, Biewenga M, Verdonk RC, de Jonge HJM, Vrolijk JM, Bakker SF, Vanwolleghem T, de Boer YS, Pronk MAMCB, Beuers UHW, van der Meer AJ, van Gerven NMF, Sijtsma MGM, Verwer BJ, Gisbertz IAM, Bartelink M, van den Brand FF, Sebib Korkmaz K, van den Berg AP, Guichelaar MMJ, Soufidi K, Levens AD, van Hoek B, Drenth JPH. Assessing the efficacy and safety of mycophenolate mofetil versus azathioprine in patients with autoimmune hepatitis (CAMARO trial): study protocol for a randomised controlled trial. Trials 2022; 23:1012. [PMID: 36514163 PMCID: PMC9745715 DOI: 10.1186/s13063-022-06890-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Currently, the standard therapy for autoimmune hepatitis (AIH) consists of a combination of prednisolone and azathioprine. However, 15% of patients are intolerant to azathioprine which necessitates cessation of azathioprine or changes in therapy. In addition, not all patients achieve complete biochemical response (CR). Uncontrolled data indicate that mycophenolate mofetil (MMF) can induce CR in a majority of patients. Better understanding of first-line treatment and robust evidence from randomised clinical trials are needed. The aim of this study was to explore the potential benefits of MMF as compared to azathioprine, both combined with prednisolone, as induction therapy in a randomised controlled trial in patients with treatment-naive AIH. METHODS CAMARO is a randomised (1:1), open-label, parallel-group, multicentre superiority trial. All patients with AIH are screened for eligibility. Seventy adult patients with AIH from fourteen centres in the Netherlands and Belgium will be randomised to receive MMF or azathioprine. Both treatment arms will start with prednisolone as induction therapy. The primary outcome is biochemical remission, defined as serum levels of alanine aminotransferase and immunoglobulin G below the upper limit of normal. Secondary outcomes include safety and tolerability of MMF and azathioprine, time to remission, changes in Model For End-Stage Liver Disease (MELD)-score, adverse events, and aspects of quality of life. The study period will last for 24 weeks. DISCUSSION The CAMARO trial investigates whether treatment with MMF and prednisolone increases the proportion of patients in remission compared with azathioprine and prednisolone as the current standard treatment strategy. In addition, we reflect on the challenges of conducting a randomized trial in rare diseases. TRIAL REGISTRATION EudraCT 2016-001038-91 . Prospectively registered on 18 April 2016.
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Affiliation(s)
- Romée J. A. L. M. Snijders
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
| | - Anna E. C. Stoelinga
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom J. G. Gevers
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany ,grid.412966.e0000 0004 0480 1382Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Simon Pape
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
| | - Maaike Biewenga
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert C. Verdonk
- grid.415960.f0000 0004 0622 1269Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Hendrik J. M. de Jonge
- grid.413508.b0000 0004 0501 9798Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, ‘s Hertogenbosch, The Netherlands
| | - Jan Maarten Vrolijk
- grid.415930.aDepartment of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sjoerd F. Bakker
- grid.416373.40000 0004 0472 8381Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Thomas Vanwolleghem
- grid.411414.50000 0004 0626 3418Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Ynto S. de Boer
- European Reference Network RARE-LIVER, Hamburg, Germany ,grid.509540.d0000 0004 6880 3010Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Martine A. M. C. Baven Pronk
- grid.413370.20000 0004 0405 8883Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Ulrich H. W. Beuers
- European Reference Network RARE-LIVER, Hamburg, Germany ,grid.509540.d0000 0004 6880 3010Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Adriaan J. van der Meer
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole M. F. van Gerven
- Department of Gastroenterology and Hepatology, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Marijn G. M. Sijtsma
- Department of Gastroenterology and Hepatology, St. Jansdal Hospital, Harderwijk, The Netherlands
| | - Bart J. Verwer
- grid.416219.90000 0004 0568 6419Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Ingrid A. M. Gisbertz
- Department of Gastroenterology and Hepatology, Hospital Bernhoven, Uden, The Netherlands
| | - Maartje Bartelink
- grid.413649.d0000 0004 0396 5908Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Floris F. van den Brand
- grid.440209.b0000 0004 0501 8269Department of Gastroenterology and Hepatology, OLVG Oost, Amsterdam, The Netherlands
| | - Kerem Sebib Korkmaz
- Department of Gastroenterology and Hepatology, IJselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Aad P. van den Berg
- grid.4494.d0000 0000 9558 4598Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Maureen M. J. Guichelaar
- grid.415214.70000 0004 0399 8347Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Khalida Soufidi
- grid.416905.fDepartment of Gastroenterology and Hepatology, Zuyderland, Heerlen, The Netherlands
| | - Amar D. Levens
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart van Hoek
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost P. H. Drenth
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
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Limdi JK. Editorial commentary on the Indian Journal of Gastroenterology-November-December 2022. Indian J Gastroenterol 2022; 41:527-532. [PMID: 36494578 DOI: 10.1007/s12664-022-01317-5] [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: 02/03/2023]
Affiliation(s)
- Jimmy K Limdi
- Section of Inflammatory Bowel Diseases, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, UK. .,University of Manchester, Manchester, UK. .,Manchester Metropolitan University, Manchester, UK.
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Gong K, Xu X, Yao J, Ye S, Yu X, Tu H, Lan Y, Fan YC, Shi Y. Acute hepatitis of unknown origin in children: A combination of factors. Front Pharmacol 2022; 13:1056385. [PMID: 36438816 PMCID: PMC9698116 DOI: 10.3389/fphar.2022.1056385] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/31/2022] [Indexed: 08/16/2023] Open
Abstract
On 5 April 2022, the World Health Organization was notified of 10 cases of severe acute hepatitis of unknown etiology in children under 10 years of age in the United Kingdom. Although the exact cause of a proportion of pediatric acute hepatitis and acute liver failure cases was unclear, the above event has caused widespread concern worldwide. As of 14 September 2022, approximately 1,296 probable cases of acute hepatitis of unknown etiology have been reported from 37 countries/regions, of which approximately 55 required or received liver transplantation and 29 died. Although the etiology of acute hepatitis of unknown origin in children remains unclear, many hypotheses have been proposed about the disease. Instead of individual factors such as "adenovirus infection," "SARS-CoV-2 related," and "Adeno-associated virus 2 with helper virus coinfection," it is more likely due to a combination of factors. Accordingly, there is an urgent need for more data and research to clarify the disease etiology. This review aims to provide a historical perspective of acute hepatitis of unknown etiology in children in the past decades and summarize the current hypothesis and evidence on this emerging disease.
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Affiliation(s)
- Kai Gong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xianbin Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Junjie Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shaoheng Ye
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xia Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huilan Tu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yan Lan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu-chen Fan
- Department of Hepatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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48
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Hepatitis-associated Aplastic Anemia. J Pediatr Gastroenterol Nutr 2022; 75:553-555. [PMID: 36070526 DOI: 10.1097/mpg.0000000000003603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hepatitis-associated aplastic anemia (HAAA) accounts for 4% of autoimmune hepatitis in children. An episode of seronegative autoimmune hepatitis is followed a few days or months later by aplastic anemia or full aplasia. This autoimmune disease could be due to a regulation defect in the immune response to a viral trigger, in a genetically predisposed individual. Other causes of hepatitis or aplastic anemia have to be ruled out. Steroids and azathioprine usually control the liver damage but do not prevent the development of aplastic anemia. Aplastic anemia is treated with either hematopoietic stem cell transplantation in patients with a sibling donor or anti-thymocyte globulins and cyclosporine. We propose guidelines to explore and treat this rare disease. We emphasize on the necessary close collaboration between hepatologists and hematologists.
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Nassar R, Waisbourd‐Zinman O. Autoimmune liver disease in gastrointestinal conditions. Clin Liver Dis (Hoboken) 2022; 20:108-110. [PMID: 36245679 PMCID: PMC9549311 DOI: 10.1002/cld.1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Raouf Nassar
- Institute of Gastroenterology, Nutrition and Liver DiseasesSchneider Children's Medical CenterPetach TikvaIsrael
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Faculty of Health SciencesBen‐Gurion UniversityBe'er‐ShevaIsrael
| | - Orith Waisbourd‐Zinman
- Institute of Gastroenterology, Nutrition and Liver DiseasesSchneider Children's Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
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50
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Whitehead B, Kriegermeier A. Natural history and management of refractory autoimmune hepatitis. Clin Liver Dis (Hoboken) 2022; 20:120-123. [PMID: 36245680 PMCID: PMC9549313 DOI: 10.1002/cld.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Bridget Whitehead
- Division of Gastroenterology, Hepatology and NutritionNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
| | - Alyssa Kriegermeier
- Division of Gastroenterology, Hepatology and NutritionNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
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