Chinese consensus on the diagnosis and management of autoimmune hepatitis (2015)

Exploring the Potential Mechanisms of Action of Gentiana Veitchiorum Hemsl. Extract in the Treatment of Cholestasis using UPLC-MS/MS, Systematic Network Pharmacology, and Molecular Docking

INTRODUCTION

Gentiana veitchiorum Hemsl. (GV) has a long history in Tibetan medicine for treating hepatobiliary disease cholestasis. However, the mechanisms mediating its efficacy in treating cholestasis have yet to be determined.

AIM

To elucidate the mechanisms of action of GV in the treatment of cholestasis, an integrated approach combining ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) analysis with network pharmacology was established.

MATERIALS AND METHODS

A comprehensive analysis of the chemical composition of GV was achieved by UPLC-MS/MS. Subsequently, a network pharmacology method that integrated target prediction, a protein-protein interaction (PPI) network, gene set enrichment analysis, and a component- target-pathway network was established, and finally, molecular docking and experiments in vitro were conducted to verify the predicted results.

RESULTS

Twenty compounds that were extracted from GV were identified by UPLC-MS/MS analysis. Core proteins such as AKT1, TNF, and IL6 were obtained through screening in the Network pharmacology PPI network. The Kyoto Encyclopedia of the Genome (KEGG) pathway predicted that GV could treat cholestasis by acting on signaling pathways such as TNF/IL-17 / PI3K-Akt. Network pharmacology suggested that GV might exert a therapeutic effect on cholestasis by regulating the expression levels of inflammatory mediators, and the results were further confirmed by the subsequent construction of an LPS-induced RAW 264.7 cell model.

CONCLUSIONS

In this study, UPLC-MS/MS analysis, network pharmacology, and experiment validation were used to explore potential mechanisms of action of GV in the treatment of cholestasis.

Metabolomic profiling for drug-induced liver injury with autoantibodies

BACKGROUNDS

Drug induced liver injury (DILI) is sometimes similar to autoimmune hepatitis (AIH) in serology and histology. Clinicians empirically screened DILI with significant autoimmune characteristics to implement clinical intervention. We tried to characterize DILI with autoantibodies by metabolomics.

METHODS

Untargeted metabolomics coupled with pattern recognition approaches were performed on sera samples including AIH (n = 59), DILI with autoantibodies (DILI^Ab+, n = 68), and DILI without autoantibodies (DILI^Ab-, n = 75). The differential metabolites and fingerprint metabolites between AIH and DILI^Ab- were screened by orthogonal partial least squares-discriminant analysis and hierarchical clustering respectively.

RESULTS

Of the 388 annotated differential metabolites between AIH and DILI^Ab-, 74 fingerprint metabolites were screened. The eigenmetabolite compressed from the fingerprint possessed high discrimination efficacy (AUC:0.891; 95 %CI, 0.838-0.944). In the fingerprint-based PCA model, AIH and DILI^Ab- were separated into three regions: the "pure region" of AIH (Region 1), the "pure region" of DILI^Ab- (Region 3), the mixture region of AIH and DILI^Ab- (Region 2). After incorporated into the PCA model, DILI^Ab+ samples were distributed into the three regions, indicating that DILI^Ab+ samples had different etiological tendencies. Moreover, the fingerprint-based radar model verified the results of PCA model characterizing DILI^Ab+. Notably, the antibody titers of DILI^Ab+ in the three regions did not differ significantly, while the response rates for glucocorticoids were obviously different. The metabolic difference among DILI^Ab+ in different regions mainly lies in energy metabolism.

CONCLUSIONS

In terms of metabolic signature, DILI^Ab+ may not be a community of same pathogenesis, including AIH-inclined parts. Which deserves further study.

Autoimmmune hepatitis

Autoimmune hepatitis (AIH) is a T-cell mediated, inflammatory liver disease affecting all ages and characterized by female preponderance, elevated serum transaminase and immunoglobulin G levels, positive circulating autoantibodies, and presence of interface hepatitis at liver histology. AIH type 1, affecting both adults and children, is defined by positive anti-nuclear and/or anti-smooth muscle antibodies, while type 2 AIH, affecting mostly children, is defined by positive anti-liver-kidney microsomal type 1 and/or anti-liver cytosol type 1 antibody. While the autoantigens of type 2 AIH are well defined, being the cytochrome P4502D6 (CYP2D6) and the formiminotransferase cyclodeaminase (FTCD), in type 1 AIH they remain to be identified. AIH-1 predisposition is conferred by possession of the MHC class II HLA DRB1*03 at all ages, while DRB1*04 predisposes to late onset disease; AIH-2 is associated with possession of DRB1*07 and DRB1*03. The majority of patients responds well to standard immunosuppressive treatment, based on steroid and azathioprine; second- and third-line drugs should be considered in case of intolerance or insufficient response. This review offers a comprehensive overview of pathophysiological and clinical aspects of AIH.

Type 3 progressive familial intrahepatic cholestasis combined with autoimmune hepatitis-primary biliary cirrhosis overlap syndrome: A case report

BACKGROUND

Autoimmune hepatitis-primary biliary cholangitis (AIH-PBC) overlap syndrome is not uncommon in autoimmune liver disease, but autoimmune liver disease combined with progressive familial intrahepatic cholestasis is relatively rare, which usually makes the diagnosis more complicated and difficult, and thus easily leads to a missed diagnosis and misdiagnosis.

CASE SUMMARY

A 32-year-old woman complained of "abnormal liver function and jaundice for 11 years", and was first admitted to our hospital in 2019. She visited different hospitals previously and could not achieve a clear diagnosis. During her first hospitalization in our hospital, a diagnosis of AIH-PBC overlap syndrome was made by the indicators of liver function enzymology, levels of IgG and IgM, autoantibodies related to liver disease, and the pathology of liver biopsy. The patient received the treatment of ursodeoxycholic acid plus glucocorticoid, and her liver function improved but the overall effects were suboptimal. Due to the patient's significantly enlarged spleen unexplained by AIH-PBC overlap syndrome, she was advised to undergo gene sequencing for the detection of potential genetic liver diseases. The findings showed heterozygous deletion mutations in the ABCB4 gene, suggesting that the patient had type 3 progressive familial intrahepatic cholestasis (PFIC3). In 2020 and 2021, the patient was twice admitted to our hospital because of upper gastrointestinal bleeding.

CONCLUSION

A clear diagnosis of AIH-PBC overlap syndrome was first made for the patient whose liver disease could not be clearly diagnosed for a long time. Due to the apparent splenomegaly not explained satisfactorily by AIH-PBC overlap syndrome, gene sequencing was permormed, which revealed the presence of ABCB4 gene mutations, resulting in a final diagnosis of PFIC3.

Chronic Drug-Induced Liver Injury: Updates and Future Challenges

Chronic drug-induced liver injury (DILI), defined as DILI with persistent liver injury more than one year after the first onset by the latest European guidelines, is a notable challenge globally with big issues of defining causality and establishing effective treatment. About 20% of patients with DILI develop into chronic DILI. Chronic DILI manifests as persistent or repeated inflammatory or diminishing bile ducts, even progresses to cirrhosis and needs liver transplantation eventually. However, research on chronic DILI over the last decades is still lacking, and the incidence, phenotypes, mechanisms, risk factors, and treatment have not been fully understood. In this paper, we reviewed the definition of chronic DILI, updated clinical studies in terms of incidence, special manifestations, and promising risk factors of chronic DILI, along with the recent progress and challenges in glucocorticoid therapy.

Association between positivity of serum autoantibodies and liver disease severity in patients with biopsy-proven NAFLD

BACKGROUND AND AIMS

Some previous studies reported serum autoantibody positivity in patients with nonalcoholic fatty liver disease (NAFLD). The clinical significance of these findings remains uncertain. We aimed to investigate the association between the presence of serum autoantibodies and liver disease severity in NAFLD.

METHODS AND RESULTS

A total of 388 consecutive patients with biopsy-proven NAFLD were included in the study. Various serum autoantibodies (including also anti-nuclear antibodies [ANA]) were detected by indirect immunofluorescent or immunoblotting assays. Overall, 84 (21.6%) patients with biopsy-confirmed NAFLD had positivity for at least one of the measured serum autoantibodies. ANA positivity was present in 50 (12.9%) patients, whereas anti-U1RNP or pANCA antibodies were detectable in 9 (2.3%) and 6 (1.5%) patients, respectively. Multivariate logistic regression analysis showed that ANA positivity (adjusted-odds ratio: 4.51, 95%CI: 1.77-11.5; P = 0.002) or positivity of any serum autoantibodies (adjusted-odds ratio: 3.14, 95%CI: 1.30-7.62; P = 0.01) were independently associated with advanced liver fibrosis (stages F3-F4). In serum autoantibody/ANA-positive patients, the proportion of those with advanced fibrosis was also greater among carriers of PNPLA3 rs738409 GG or CG than among those carrying PNPLA3 rs738409 CC genotype.

CONCLUSIONS

Serum autoantibody positivity was independently associated with advanced liver fibrosis in patients with biopsy-proven NAFLD. The presence of serum autoantibodies in patients with advanced fibrosis occurred more frequently amongst those carrying PNPLA3 rs738409 GG or CG genotypes.

Clinical characteristics and HLA genotypes in Chinese patients with anti-SLA/LP-positive autoimmune hepatitis

Background

Anti-soluble liver antigen/liver pancreas (anti-SLA/LP) is a highly specific serological marker for the diagnosis of autoimmune hepatitis (AIH). The aim of the present study was to define the clinical characteristics and human leucocyte antigen (HLA) genotypes of Chinese patients with anti-SLA/LP positive AIH.

Methods

Ninety-one AIH patients who were anti-SLA/LP positive were enrolled in this case control study. Clinical information was obtained through reviewing patients’ clinical notes. High-resolution genotyping of HLA-A, B, C, DRB1, and DQB1 alleles was performed by sequence-based typing polymerase chain reaction on 62 of the 91 patients. Data from 500 healthy patients were used as baseline controls.

Results

Anti-SLA/LP-positive AIH patients were characterized as follows: adults (age 20–80 years), female (88%), and frequent anti-nuclear antibody positivity (91%). Genetically, compared with the controls, HLA-B*35:01 and C*08:01 were significantly more frequent in patients. The frequencies of HLA-B*08:01, B*40:02, DRB1*04:01, DRB1*04:05, DRB1*14:01, and DRB1*16:02 increased, and the frequency in DRB1*15:01 decreased in patients, but did not reach significance after Bonferroni’s correction. Patients with other autoimmune diseases had a higher DRB1*04:05 and DQB1*04:01 allele carrier frequency than those without. DRB1*04:05 and DQB1*04:01 alleles were found at increased frequency in patients with decompensated liver disease than those with compensated liver disease.

Conclusions

Chinese anti-SLA/LP-positive AIH patients have some distinct clinical characteristics than other populations reported in the literature. The presence of certain specific HLA alleles could potentially increase the risk of developing anti-SLA/LP-positive AIH or other autoimmune disease and decompensated liver disease in the Chinese population.

Levels of serum IgG subclasses in patients with liver disease: A retrospective study

Viral and alcoholic liver disease, drug induced liver disease (DILD), primary biliary cirrhosis (PBC) and autoimmune hepatitis (AIH) are among the most common liver diseases observed in clinical practice. These diseases lack unique clinical characteristics at the beginning of pathogenesis, which renders specific diagnosis difficult. Immunoglobulin G (IgG) subclasses are the main isoform of antibodies that can be found in the serum that serve important protective roles in immunity. The present study aimed to investigate the serum IgG subclass distribution in patients with the five common liver diseases aforementioned. The present study retrospectively recorded and analyzed the serum IgG subclass levels of different patients, who were grouped according to their clinical diagnosis. Serum IgG subclass levels were measured using immunonephelometric assays. IgG3 levels were found to be significantly increased whereas IgG4 levels were significantly decreased in patients with PBC. In patients with AIH, IgG1 levels were significantly increased. By contrast, IgG1/IgG level ratios in patients with viral liver disease were significantly increased. No clear pattern in the distribution characteristics of IgG subclasses could be observed in cohorts with alcoholic liver disease and DILD in the present study. Additionally, model for end-stage liver disease scores regarding IgG1 in patients with AIH shared a synergistic relationship. Anti-mitochondrial antibody subtype M2 (AMA-M2) and IgG3 in patients with PBC demonstrated a synergistic relationship. These results suggested that IgG subclasses may be used as biomarkers to further the understanding of liver disease, which could allow for early diagnosis.

The efficacy and safety of different doses of glucocorticoid for autoimmune hepatitis: A systematic review and meta-analysis

BACKGROUND

Glucocorticoid as the standard treatment of autoimmune hepatitis has been recommended with different doses. The purpose of this study is to compare the efficacy and safety of high and low doses for clinical practice.

METHODS

Medline, Embase, and Cochrane Library were searched until January 16th, 2019 for cohort studies or randomized controlled trials in patients with autoimmune hepatitis. Glucocorticoid 60 mg/d or 1 mg/kg/d was defined as high dose and 40 to 50 mg/d or 0.5 mg/d as low dose. Outcome of interests includes the incidence of the biochemical remission, adverse event, and endpoint events. Double arcsine method with a random-effect model was used to combine the incidence. Potential heterogeneity was explored by meta-regression and subgroup analysis.

RESULTS

Overall, 25 studies (3305 patients) were included, with 10 studies in the high dose group and 15 in low dose group. The biochemical remission rate in the high and low dose group was 0.79 (95% confidence interval [CI] [0.72, 0.85]) and 0.72 (95% CI [0.65, 0.78]), respectively. The incidence of endpoint events and adverse event in the high were slightly higher (0.03, 95% CI [0.02, 0.04]; 0.42, 95% CI [0.30, 0.53]) than that of the low dose group (0.01, 95% CI [0.00, 0.01]; 0.39, 95% CI [0.15, 0.63]).

CONCLUSIONS

For autoimmune hepatitis patients, 60 mg/d or 1 mg/kg/d of glucocorticoid gives higher biochemical remission rate and higher incidence of endpoint events and adverse events.

Current epidemiology and clinical characteristics of autoimmune liver diseases in South Korea

Autoimmune liver diseases including autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) are rare diseases. The aim of this review is to examine the epidemiology and clinical characteristics of AIH and PBC in South Korea. There were 4,085 patients registered as AIH in the Rare Intractable Disease Registry of Korea between 2009-2013, with a median age of 56 years and female-to male ratio of 6.4. The age-adjusted incidence and prevalence of AIH were 1.07/100,000/year and 4.82/100,000 persons, respectively. Among the patients, 1.1% underwent liver transplantation, and case fatality was 2.18%. Liver cirrhosis at diagnosis was accompanied in 23%; liver biopsy was performed in 75.2%, and prednisolone therapy or prednisolone and azathioprine combination therapy was done in 73% with a remission rate of 86%. There were 2,824 patients with PBC (≥20 years) registered in Korea between 2009-2013 with a median age of 57 years and female-to male ratio of 6.2. The age-adjusted incidence and prevalence of PBC were 0.86/100,000/year and 4.75/100,000 persons, respectively. Among the patients, 2.5% underwent liver transplantation, and case fatality was 2.2% with a 5-year transplantation-free survival of 95.4%. Ursodeoxycholic acid (UDCA) was prescribed in 90% of the patients with a UDCA inadequate response rate of 30%. In conclusion, AIH and PBC are rare but mostly treatable diseases if diagnosed in the early stages. However, scarce data, low awareness, delayed diagnosis and non-availability of 2nd line therapeutics are important issues to be solved. Therefore, governmental support for research and drug development and nationwide cooperative studies are warranted.

Autoimmune hepatitis - update on clinical management in 2017

Autoimmune hepatitis (AIH) is a progressive immune mediated liver disease of unknown origin. Key diagnostic features include hypergammaglobulinemia/elevated serum-IgG, characteristic circulating autoantibodies, periportal hepatitis with interface activity on liver biopsy and the exclusion of hepatotropic viruses. However, the diagnosis is challenging in cholestatic and severe presentations. It can be difficult to differentiate AIH from drug-induced liver injury. Although many patients initially respond to standard immunosuppressive therapy, a significant proportion experiences intolerable side effects or insufficient treatment response. This underlines the need for effective alternative treatment options, which are still very limited and based on rather poor evidence. This review summarises core aspects of the clinical management of AIH with focus on recent achievements and unmet needs.

Clinical efficacy and safety of integrated traditional Chinese and Western medicine in elderly autoimmune liver disease patients with gastritis

AIM

To evaluate the clinical efficacy and safety of integrated traditional Chinese and Western medicine in elderly autoimmune liver disease patients with gastritis.

METHODS

From January 2010 to June 2016, 56 elderly autoimmune liver disease patients with gastritis were randomly divided into a control group (n = 28) and an observation group (n = 28). Both groups were treated by Western medicine symptomatic support, and the observation group was additionally given Chinese medicine decoction. The clinical efficacy and safety of the two groups were compared.

RESULTS

Before treatment, there was no significant difference in alanine transaminase (ALT) or glutamyl transpeptidase (GGT) between the two groups (P > 0.05). After treatment, ALT (45.31 IU/L ± 10.04 IU/L vs 68.42 IU/L ± 11.46 IU/L) and GGT (41.46 IU/L ± 10.24 IU/L vs 52.17 IU/L ± 11.25 IU/L) were significantly lower in the observation group than in the control group (P < 0.05). There was no significantly difference in the rate of adverse effects between the two groups (P > 0.05).

CONCLUSION

Traditional Chinese medicine decoction combined with Western medicine symptomatic support can improve the liver function of elderly autoimmune liver disease patients with gastritis, without increasing the rate of adverse effects.