Natural history of active chronic hepatitis. I. Clinical features, course, diagnostic criteria, morbidity, mortality and survival

Autoimmune hepatitis and pregnancy: considerations for the clinician

INTRODUCTION

Autoimmune hepatitis (AIH) is an immune mediated inflammatory disease of the liver which affects females of reproductive age. AIH poses unique challenges in pregnancy and historically was associated with adverse pregnancy outcomes.

AREAS COVERED

This report aims to review the current evidence for AIH pregnancy outcomes and the use of medical therapies in pregnancy. The disease course of AIH in pregnancy including loss of biochemical response (LOBR) and hepatic decompensation is also reviewed. The importance of preconception counselling and continued monitoring into the post-partum phase are reinforced.

EXPERT OPINION

The lack of prognostic markers and targeted immunosuppression are some of the areas for future development, as this will aid the move towards individualised risk stratification and personalised care.

Systematic review with meta-analysis: mycophenolate mofetil as a second-line therapy for autoimmune hepatitis

BACKGROUND

First-line treatment for autoimmune hepatitis (AIH) typically includes corticosteroids in combination with azathioprine. Mycophenolate mofetil (MMF) is often used as a rescue therapy in patients who are intolerant of, or nonresponsive to, standard therapy.

AIM

To systematically review studies and perform a meta-analysis on the efficacy and safety of MMF as a second-line therapy for AIH patients.

METHODS

MEDLINE, EMBASE and Cochrane Central were searched for studies that reported data on efficacy and safety of MMF as a second-line therapy in AIH. We calculated the pooled response rate, adverse events rate and discontinuation rate due to side effects, with their corresponding 95% confidence intervals.

RESULTS

Twelve studies comprising 397 patients, followed for a median of 34 months (range, 12-47 months), were included. MMF doses ranged from 0.5-4.0 g/d. Pooled response rate was 0.58 (95% CI 0.54-0.63). Pooled adverse events rate was 0.14 (95% CI 0.11-0.17), and pooled discontinuation rate due to side effects was 0.08 (95% CI 0.06-0.11). Five studies (n = 309) specified response rates according to reason for using MMF. Pooled response rate in the subgroup with intolerance to standard therapy was 0.82 (95% CI 0.77-0.87) and pooled response rate among nonresponders was 0.32 (95% CI 0.24-0.39).

CONCLUSIONS

The overall efficacy of MMF as second-line therapy in AIH was high. Response rate was greater in patients who started the medication due to intolerance to standard therapy as opposed to nonresponse. Overall, MMF was well tolerated, with a low discontinuation rate due to side effects.

Efficacy and Limitations of Budesonide as a Second-Line Treatment for Patients With Autoimmune Hepatitis

BACKGROUND & AIMS

Many patients with autoimmune hepatitis (AIH) develop steroid-specific side effects or require doses of steroids that are unacceptable for long-term treatment. We investigated the efficacy of budesonide as an alternative steroid for patients previously treated with prednisolone who developed side effects or were unable to reduce their dose of prednisolone below acceptable levels. We also report the effects of more than 12 months of budesonide treatment in a large cohort of patients with AIH.

METHODS

We performed a retrospective analysis of data from 60 patients (51 female) with AIH who were treated initially with prednisolone (mean time, 47 mo) but then switched to budesonide, managed at a single center in Germany from 2001 through June 2016. Patients were evaluated after 6 months, 12 months, 24 months, 36 months, and at the last follow-up evaluation; response to treatment with budesonide was assessed based on normal serum levels of aminotransferases and IgG (biochemical response).

RESULTS

Thirty patients were switched to budesonide therapy because of prednisolone-induced side effects and 30 patients switched because of prednisolone dependency. Overall, a biochemical response was detected in 55% of patients after 6 months of budesonide treatment, in 70% after 12 months, and in 67% after 24 months. At the last follow-up evaluation (mean time, 63 mo) 23 patients (38%) still were receiving budesonide treatment. Fifteen patients (25%) had switched back to prednisolone therapy because of insufficient response to budesonide or its side effects. Fifteen patients with osteopenia at the beginning of budesonide treatment were followed up and evaluated by dual-energy X-ray absorptiometry. After a median of 24 months of budesonide treatment, bone mineral density had improved in 6 patients, remained stable in 8 patients, and worsened in 1 patient.

CONCLUSIONS

We performed a retrospective analysis of patients with AIH that confirmed the therapeutic value of budesonide beyond 12 months of treatment in patients who are intolerant to or dependent on prednisolone. Although budesonide-induced side effects appear to be mild in real life, effectiveness was limited in a considerable proportion of patients; close monitoring is advised.

BMSCs-derived miR-223-containing exosomes contribute to liver protection in experimental autoimmune hepatitis

Autoimmune hepatitis is a chronic inflammatory disease in the liver with potential to the development of liver fibrosis. Recent evidences suggest that bone marrow derived mesenchymal stem cells (BMSCs) may exert its therapeutic activity through exosomes. Moreover, miR-223 is highly expressed in BMSCs and plays an important role in autoimmune diseases. Therefore, in this study, hepatoprotective role of BMSCs and miR-223 was investigated in both mice and hepatocytes. Liver antigen S100 was used to establish autoimmune hepatitis model in mice while LPS and ATP were used to establish cell injury model in hepatocyte. Before the experiments, BMSCs were infected with pre-miR-223 and transfected with miR-223 inhibitor respectively. Exosomes from bone marrow stem cells were isolated by ultracentrifugation. Liver injury was evaluated by serum levels of ALT and AST as well as liver histology. Inflammation and cell death were examined by inflammatory cytokines and lactase dehydrogenase respectively. Both BMSCs-exo and BMSCs-exo^miR-223(+) significantly reversed either S100 or LPS/ATP induced injury in mice and hepatocytes. Meanwhile, the expressions of cytokines, NLRP3 and caspase-1 were also downregulated by BMSCs-exo and BMSCs-exo^miR-223(+) at both protein and mRNA levels in mice and hepatocytes. Moreover, BMSCs-exo^miR-223(-) reverses the effects of BMSCs-exo and BMSCs-exo^miR-223(+) in mouse AIH and in hepatocytes. In conclusion, bone marrow stem cell derived exosomes can protect liver injury in an experimental model of autoimmune hepatitis and the mechanism could be related to exosomal miR-223 regulation of NLRP3 and caspase-1.

Liver Governs Tendon: A Theory from Traditional Chinese Medicine-Evidence from a Population-Based Matched Cohort Study in Taiwan for the Association of Chronic Liver Disease and Common Diseases in the Chiropractic Office

In traditional Chinese medicine (TCM) theory, the liver governs the tendons. This retrospective cohort study investigated the relationship between chronic liver disease and common orthopedic conditions by utilizing the National Health Insurance Research Database of Taiwan. The populations included within this study were chronic liver disease patients (International Classification of Diseases/ICD-9 code: 571) and a comparison group composed of patients with nonchronic liver disease. The medical event that was evaluated was internal derangement of joints (ICD-9 codes: 717-718). In comparison with the control group, patients with chronic liver disease were 1.29 times more likely to develop internal derangement of joints when major trauma had also occurred. We did not find the association of viral hepatitis with internal derangement of joints. Patients with chronic liver disease as well as anemia were 3.01 times more likely to develop joint derangements. Our study shows that patients with anemia in addition to chronic liver disease are more prone to develop joint derangements. This is the first documented research study that endorses “the liver governs the tendons which gives the body the ability to move” theory of TCM. The incidence rate of internal derangement of knee joints was higher in patients with chronic liver disease.

Mycophenolate mofetil as an alternative treatment for autoimmune hepatitis

Autoimmune hepatitis (AIH) is an immune-mediated chronic liver disease characterized by hepatocellular inflammation, necrosis, and fibrosis, which can progress to cirrhosis and fulminant hepatic failure. The standard treatment for AIH includes corticosteroids alone or in combination with azathioprine. Although most patients achieve remission using the standard regimen, some patients do not respond due to either drug intolerance or refractory disease; in such cases alternative immunosuppressive agents should be explored. The second-line therapies are cyclophilin inhibitors such as cyclosporine A or tacrolimus, and nowadays mycophenolate mofetil (MMF) is widely used if azathioprine-based therapies are not tolerated. Although these are recommended as an alternative to the first-line regimen, there is insufficient evidence for the efficacy of second-line therapies, with the evidence based mainly on expert opinion. Therefore, we report an AIH patient receiving the standard regimen in whom remission did not occur due to side effects to azathioprine, but was successfully treated with MMF in combination with corticosteroids as an alternative to the standard regimen.

Characteristics and outcome of autoimmune liver disease in Asian children

BACKGROUND

Little is known about autoimmune liver disease (AILD) in Asian children. We studied the clinical features and predictors of outcome in childhood AILD in an Asian population.

METHODS

Retrospective review of AILD [autoimmune hepatitis type 1 and 2 (AIH1, AIH2), primary sclerosing cholangitis (PSC) and autoimmune sclerosing cholangitis (ASC)] seen at two pediatric liver units in Malaysia.

RESULTS

At presentation, 17 (56%) of the 32 children [19 females, 59%; median (range) age 7.7 (1.8-15.5) years] with AILD (AIH1 = 18, AIH2 = 5, PSC = 0, ASC = 9) had liver cirrhosis. At final review [median (range) duration of follow-up 4.8 (0.4-12) years], 24 patients (75%) survived with a native liver. Twenty-one (66%) were in remission; 19 (AIH1 = 11; AIH2 = 4, ASC = 4) were on prednisolone and/or azathioprine, one on cyclosporine and another on mycophenolate mofetil. Three (AIH1 = 3) were in partial remission. Of the two who underwent liver transplantation (LT; 6.5%; both ASC), one died of primary graft failure after LT. Six patients (19%) died without LT (acute liver failure, n = 1; end-stage liver disease, n = 5). The overall survival rate (native liver and survival post-LT) was 78%. A delay in seeking treatment adversely affected the final outcome [survival with native liver vs. LT or death (duration between onset of disease and treatment; median ± standard error) = 2.5 ± 2.9 months vs. 24.0 ± 13.3 months; p = 0.012].

CONCLUSIONS

Although remission was achieved in the majority of patients with prednisolone and/or azathioprine therapy, delay in seeking diagnosis and treatment adversely affects the outcome of childhood AILD in Malaysia.

Current and prospective pharmacotherapy for autoimmune hepatitis

INTRODUCTION

Corticosteroids alone or in combination with azathioprine are the mainstay therapies of autoimmune hepatitis. Suboptimal responses (treatment failure, partial response, drug toxicity), frequent relapse after drug withdrawal, and the emergence of alternative immunosuppressive medications have fueled the pursuit of new treatments. The goals of this review are to present current management strategies and evolving interventions.

AREAS COVERED

PubMed searches from 1970 - 2014 provide the bases for this review. Corticosteroid regimens should be administered until resolution of symptoms, laboratory tests, and liver tissue abnormalities. Treatment failure warrants high doses of the original regimen, and relapse warrants re-treatment followed by long-term maintenance with azathioprine. The calcineurin inhibitors, budesonide, and mycophenolate mofetil are evolving as frontline therapies, and they may be considered as salvage therapies with the exception of budesonide. Rapamycin, rituximab, and infliximab have also rescued refractory patients but experiences are limited. Anti-oxidants, recombinant molecules, mAbs, and modulators of critical cell populations are key prospects.

EXPERT OPINION

Autoimmune hepatitis must be managed by multiple medications that supplement or supplant current regimens depending on the clinical situation. Rescue therapies will emerge as adjunctive interventions to minimize tissue damage (prevent fibrosis and hepatocyte apoptosis) and improve immune tolerance (regulatory T cell manipulations).

Review article: permanent drug withdrawal is desirable and achievable for autoimmune hepatitis

BACKGROUND

Autoimmune hepatitis can be rendered treatment-free, but the difficulty, frequency and risks associated with the pursuit of this outcome are unclear.

AIM

To describe the frequency that autoimmune hepatitis can be rendered treatment-free, identify the features that characterise these patients, examine the pathogenic pathways that may sustain or terminate the disease and indicate management protocols that can obtain this result.

METHODS

Studies cited in Pub Med from 1972-2014 for autoimmune hepatitis, treatment, relapse, remission and outcome were selected.

RESULTS

The frequency of a treatment-free state varies from 19% to 40% in patients observed for ≥3 years after drug withdrawal. Complete laboratory resolution and reversion to normal liver tissue prior to drug withdrawal favours this response. The development of cirrhosis during therapy may increase treatment-dependence. Persistent liver damage and the generation of neo-antigens during the apoptosis of hepatocytes may perpetuate the disease. Genetic and age-related effects on the vigour of the immune response may also contribute. Reversion to normal liver tissue is achieved in only 22% of patients during conventional corticosteroid therapy, and the emerging pharmacological and biological interventions may improve this frequency. A management strategy designed to achieve a treatment-free state accommodates all candidates for this outcome, and it can be modified to a long-term maintenance strategy as warranted by the clinical response.

CONCLUSIONS

Permanent drug withdrawal is a treatment outcome that is desirable and achievable in patients with autoimmune hepatitis. Normalisation of liver tests and liver tissue during treatment enhances this occurrence.

Review article: The prevention and reversal of hepatic fibrosis in autoimmune hepatitis

BACKGROUND

Immunosuppressive treatment of autoimmune hepatitis can prevent or reverse hepatic fibrosis, but these anti-fibrotic effects are inconsistent secondary gains.

AIM

To describe the anti-fibrotic effects of current therapies for autoimmune hepatitis, discuss the pathogenic mechanisms of hepatic fibrosis that might be targeted by anti-fibrotic interventions, indicate the non-invasive diagnostic tests of hepatic fibrosis that must be validated in autoimmune hepatitis and to suggest promising treatment opportunities.

METHODS

Studies cited in PubMed from 1972 to 2013 for autoimmune hepatitis, hepatic fibrosis, cirrhosis, anti-fibrotic therapy and non-invasive tests of hepatic fibrosis were selected.

RESULTS

Hepatic fibrosis improves in 53-57% of corticosteroid-treated patients with autoimmune hepatitis; progressive fibrosis slows or is prevented in 79%; and cirrhosis may be reversed. Progressive hepatic fibrosis is associated with liver inflammation, and the inability to fully suppress inflammatory activity within 12 months is associated with progression to cirrhosis (54%) and death or need for liver transplantation (15%). Liver tissue examination remains the gold standard for assessing hepatic fibrosis, but laboratory and radiological tests may be useful non-invasive methods to measure the fibrotic response. Severe liver inflammation can confound radiological assessments, and the preferred non-invasive test in autoimmune hepatitis is uncertain. Individualised treatment adjustments and adjunctive anti-fibrotic therapies are poised for study in this disease.

CONCLUSIONS

The prevention and reversal of hepatic fibrosis are achievable objectives in autoimmune hepatitis. Strategies that evaluate individualised therapies adjusted to the rapidity and completeness of the inflammatory response, and the use of adjunctive anti-fibrotic interventions, must be evaluated.

Autoimmune hepatitis in diverse ethnic populations and geographical regions

Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.

Epidemiology and treatment of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver that occurs worldwide with a low and probably underestimated prevalence. Although it typically affects young and middle-aged women, it can occur in both sexes and across all age groups. AIH runs a fluctuating course, but can present as severe and even fulminant hepatic failure or at a stage of advanced fibrosis or cirrhosis. Prognosis of severe AIH is poor if untreated. The pathogenesis is complex, combining environmental factors (external chemical or infectious triggers) and host genetic susceptibility. The diagnosis is based, after exclusion of other etiologies of chronic liver disease, on a combination of different elements, including the presence of elevated transaminases, elevated immunoglobulin G (IgG) levels, the presence and pattern of typical autoantibodies, and a liver biopsy showing interface hepatitis and other characteristic features. No single test can be used to make the diagnosis. Response to treatment can also help to establish the diagnosis. Simplified criteria can be used to make a bedside diagnosis with relatively high accuracy. Treatment consists of corticosteroids or other immunosuppressive regimens according to the severity of the disease, the response to the treatment, and the tolerance to therapy, with liver transplantation as an ultimate remedy in treatment-resistant cases with liver decompensation.

Efficacy of intravenous glycyrrhizin in the early stage of acute onset autoimmune hepatitis

BACKGROUND

Acute onset autoimmune hepatitis (AIH) shows acute presentation like acute hepatitis and does not have typical clinicopathological features of AIH. There is no gold standard for making the diagnosis. Therefore, losing the timing of starting immunosuppressive therapy, some of the cases develop into severe or fulminant form and have poor prognosis.

AIMS

Our aim was to elucidate the efficacy of intravenous glycyrrhizin in decreasing alanine aminotransferase (ALT) level in the early stage of acute onset AIH.

METHODS

Thirty-one patients were defined as acute onset AIH based on our uniform criteria, and were enrolled in this study. We prospectively treated 17 patients with sufficient doses (100 ml/day) of intravenous glycyrrhizin (SNMC) at an early stage (SNMC group), and treated 14 patients of severe disease with intravenous glycyrrhizin and corticosteroids (CS) (SNMC + CS group). We examined their clinical and biochemical features and treatment responses.

RESULTS

The ALT level could be controlled at an early stage using SNMC with no significant difference compared with SNMC + CS, and responsiveness to the therapy was determined by the disease severity at the time of starting therapy rather than the time duration from onset to therapy. Recovery rate was higher in the SNMC group than in the SNMC + CS group (P = 0.035).

CONCLUSIONS

The early introduction of sufficient doses of SNMC might prevent disease progression in patients with acute onset AIH. SNMC can be used safely and be useful for patients with difficult-to-diagnose acute liver disease as an 'initial' treatment tool to improve liver inflammation before starting disease-specific treatments.

Characteristics of autoimmune hepatitis in the Asia-Pacific Region: historical review

BACKGROUND

Autoimmune hepatitis (AIH) has been considered a relatively rare disease in Asia, including Japan, where there is a high frequency of infection with hepatitis viruses.

METHOD

We reviewd the ethnic differences of clinical features of autoimmume hepatitis by reported paper.

RESULT

Immunogenetic predisposition, especially differences in human leukocyte antigens (HLAs), has been pointed out as one of the factors for the occurrence of AIH. In other words, HLA-DR3, which is the first disease-susceptibility gene for AIH discovered in UK and the USA, is extremely rare in Asia including Japan. Moreover, HLA-DR4, which is more frequent than HLA-DR3 in Asia, is associated with a favorable response to treatment and improved prognosis. This also explains why diagnosis and treatment of AIH have not drawn as much attention as viral hepatitis. However, as a survey conducted in Japan shows, the number of patients diagnosed with AIH is increasing. However, the number of elderly patients positive for HLA-DR4 is also increasing in UK and the USA.

CONCLUSION

In the era of genome-wide association studies, further progress of studies on AIH, a typical disease model for immunological liver cell damage, is expected.

Advances in the diagnosis, pathogenesis, and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is characterized by chronic inflammation of the liver, interface hepatitis (based on histologic examination), hypergammaglobulinemia, and production of autoantibodies. Many clinical and basic science studies have provided important insights into the pathogenesis and treatment of AIH. Transgenic mice that express human antigens and develop autoantibodies, liver-infiltrating CD4(+) T cells, liver inflammation, and fibrosis have been developed as models of AIH. AIH has been associated with autoantibodies against members of the cytochrome P450 superfamily of enzymes, transfer RNA selenocysteine synthase, formiminotransferase cyclodeaminase, and the uridine diphosphate glucuronosyltransferases, whereas alleles such as DRB1*0301 and DRB1*0401 are genetic risk factors in white North American and northern European populations. Deficiencies in the number and function of CD4(+)CD25(+) (regulatory) T cells disrupt immune homeostasis and might be corrected as a therapeutic strategy. Treatment can be improved by continuing corticosteroid therapy until normal liver test results and normal liver tissue are within normal limits, instituting ancillary therapies to prevent drug-related side effects, identifying problematic patients early, and providing long-term maintenance therapy after patients experience a first relapse. Calcineurin inhibitors and mycophenolate mofetil are potential salvage therapies, and reagents such as recombinant interleukin-10, abatacept, and CD3-specific antibodies are feasible as therapeutics. Liver transplantation is an effective salvage therapy, even in the elderly, and AIH must be considered in all patients with graft dysfunction after liver transplantation. Identification of the key defects in immune homeostasis and antigen targets will direct new therapies.

Difficult treatment decisions in autoimmune hepatitis

Treatment decisions in autoimmune hepatitis are complicated by the diversity of its clinical presentations, uncertainties about its natural history, evolving opinions regarding treatment end points, varied nature of refractory disease, and plethora of alternative immunosuppressive agents. The goals of this article are to review the difficult treatment decisions and to provide the bases for making sound therapeutic judgments. The English literature on the treatment problems in autoimmune hepatitis were identified by Medline search up to October 2009 and 32 years of personal experience. Autoimmune hepatitis may have an acute severe presentation, mild inflammatory activity, lack autoantibodies, exhibit atypical histological changes (centrilobular zone 3 necrosis or bile duct injury), or have variant features reminiscent of another disease (overlap syndrome). Corticosteroid therapy must be instituted early, applied despite the absence of symptoms, or modified in an individualized fashion. Pursuit of normal liver tests and tissue is the ideal treatment end point, but this objective must be tempered against the risk of side effects. Relapse after treatment withdrawal requires long-term maintenance therapy, preferably with azathioprine. Treatment failure or an incomplete response warrants salvage therapy that can include conventional medications in modified dose or empirical therapies with calcineurin inhibitors or mycophenolate mofetil. Liver transplantation supersedes empirical drug therapy in decompensated patients. Elderly and pregnant patients warrant treatment modifications. Difficult treatment decisions in autoimmune hepatitis can be simplified by recognizing its diverse manifestations and individualizing treatment, pursuing realistic goals, applying appropriate salvage regimens, and identifying problematic patients early.

Overview: Liver disease and transplantation

Australia has had a proud and enviable record of seminal contributions to hepatology, with many contributors. Thus, any attempt to summarize these contributions ab initio in a brief review article is a significant challenge, primarily because it is so easy to overlook or underestimate particular aspects. In this article, I have confined my comments primarily to the areas where the contributions have had a significant global impact and have clearly been recognized internationally. This means that many worthwhile Australian additions will be omitted if there was less apparent international impact. The first significant interest in liver disease in Australia was from the Melbourne group at the Walter and Eliza Hall Institute (WEHI) and Royal Melbourne Hospital, leading to seminal contributions to the description, diagnosis, aetiopathogenesis and therapy of autoimmune hepatitis and primary biliary cirrhosis. Others from Royal Prince Alfred Hospital in Sydney contributed substantially to the effects of immunosuppression of autoimmune hepatitis and to early descriptions of primary sclerosing cholangitis. Other areas where Australians have contributed significantly include steatohepatitis, iron metabolism (and in particular hemochromatosis), viral hepatitis (both at the molecular and clinical level), portal hypertension, and transplant immunology. The remarkable contribution of Professor Dame Sheila Sherlock to Australian hepatology is also summarized.

Precise histological evaluation of liver biopsy specimen is indispensable for diagnosis and treatment of acute-onset autoimmune hepatitis

BACKGROUND

The diagnosis of acute-onset autoimmune hepatitis (AIH) has been difficult because patients do not always show clinicopathological features typical of AIH. We examined the important requirements for a definitive diagnosis of acute-onset AIH.

METHODS

Clinical, biochemical, and pathological features of 18 acute-onset AIH patients (16 women, 2 men; mean age, 54.3 +/- 12.3 years) with no history of liver disease and no signs of chronicity were examined.

RESULTS

Mean ALT was 679 +/- 431 IU/l, and mean T-Bil was 2.4 +/- 2.9 mg/dl. Mean IgG was 1801 +/- 446 mg/dl, with 7 patients (39%) showing normal levels. Antinuclear antibody was <or=1: 40 in 7 (39%). Liver histology showed severe activity in 17 (94%) of the patients and severe acute hepatitis in 7 (39%). Centrizonal necrosis and plasma cell accumulation were characteristic for acute-onset AIH. AIH score ranged from 7 to 18 (13.2 +/- 3.8) before treatment. All patients were diagnosed and treated early and responded completely to therapy.

CONCLUSIONS

Histological examination of the liver is necessary for early diagnosis of acute-onset AIH. Moreover, we should evaluate liver biopsy specimens precisely and should be ready for a timely initiation of corticosteroid therapy to improve the prognosis.

Autoimmune hepatitis: CT and MR imaging features with histopathological correlation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of budesonide in the treatment of autoimmune hepatitis in Canada

BACKGROUND

Autoimmune hepatitis (AIH) is a chronic inflammatory disease that is successfully treated with prednisone and/or azathioprine immunosuppressive therapy in 70% to 80% of patients. The remaining patients are intolerant or refractory to these standard medications. Budesonide, a synthetic glucocorticoid, undergoes a high degree of first-pass metabolism, reducing its systemic bioavailability, and has a 15-fold greater affinity for the glucocorticoid receptor than prednisolone. Budesonide may be a potentially useful systemic steroid-sparing immunosuppressive agent in the treatment of AIH.

OBJECTIVE

To review the Canadian experience using budesonide to treat AIH.

METHODS

Patients with AIH currently or previously treated with budesonide were identified through the Canadian Association for the Study of the Liver membership. Data were collected regarding their clinical and treatment history.

RESULTS

A total of nine patients were identified. All patients were female, with an average age of 39 years (range 12 to 66 years). The indications for budesonide were adverse side effects of prednisone in two patients, noncompliance with prednisone and azathioprine in one patient and intolerance to azathioprine resulting in prednisone dependence in the remaining six patients. Patients were treated in doses ranging from 9 mg daily to 3 mg every other day for 24 weeks to eight years. Seven of nine patients had a complete response, defined as sustained normalization of the aminotransferase levels. The remaining two patients were classified as nonresponders (less than a 50% reduction in pretreatment aminotransferase levels).

CONCLUSIONS

In Canada, budesonide has been successfully used in seven of nine patients with autoimmune hepatitis who were either intolerant to prednisone and azathioprine or prednisone-dependent. No adverse effects were reported with budesonide. Budesonide is potentially a valuable treatment option for AIH patients refractory or intolerant to standard therapy, and is deserving of further study.

Autoimmune hepatitis. Part B: diagnosis

Diagnostic criteria have been codified by the International Autoimmune Hepatitis Group, and a scoring system can quantify the strength of the diagnosis and over-ride the impact of absent or inconsistent features. The absence of a definable etiologic agent and precise diagnostic test, implies that the diagnosis may be missed or misapplied. Centrilobular (zone 3) necrosis may be an early form of autoimmune hepatitis and this pattern can transform to the classical pattern of interface hepatitis. An acute severe or fulminant presentation is possible, and different ethnic groups may have different manifestations and outcomes. Asymptomatic patients at presentation commonly become symptomatic, and treatment decisions must be based on objective features of disease severity and not the presence or absence of symptoms. Concurrent autoimmune diseases are frequent, and they may constitute an autoimmune polyglandular syndrome associated with a single gene mutation. Emerging autoantibodies of possible prognostic value are antibodies to soluble liver antigen/liver pancreas, asialoglycoprotein receptor, actin, and liver cytosol type 1. HLA DRB1*03, *04, *03-*04, *07, *13 and DQB1*02 are associated with the occurrence, clinical phenotype and outcome of autoimmune hepatitis. Variant syndromes should be suspected if cholestatic features are prominent and conventional treatment is ineffective.

Sustained remission after corticosteroid therapy for type 1 autoimmune hepatitis: a retrospective analysis

Autoimmune hepatitis commonly relapses after corticosteroid therapy, and long-term management strategies have been proposed based on the premise that repeated relapses after drug withdrawal are inevitable. Our goal was to determine the frequency that remission can be sustained after its induction and termination of therapy. A total of 107 patients who had entered remission on conventional regimens were assessed for sustained remission after initial treatment and after relapse and re-treatment. Re-treatment strategies included conventional regimens and long-term maintenance schedules. Twenty-two patients (21%) achieved a sustained remission after initial treatment, and 24 of 85 patients who relapsed and were re-treated (28%) had a similar outcome. The probability of a sustained remission was 47% after 10 years of follow-up. Patients who sustained remission after initial therapy were distinguished only by a lower serum gamma-globulin level at entry. Conventional re-treatment schedules after relapse were able to induce a sustained remission more commonly then long-term maintenance schedules (59% vs. 12%, P =.00002). In conclusion, patients who respond to initial corticosteroid therapy can achieve a sustained remission after treatment withdrawal or after relapse and re-treatment. All patients are candidates for this outcome, and withdrawal of medication, even during maintenance schedules, is necessary to assess its likelihood.

Alcohol consumption and the risk of developing liver cirrhosis: implications for future research

Studies of the association of alcohol consumption and liver cirrhosis were reviewed, focusing on possible biases of study design. Daily alcohol consumption (as opposed to intermittent binge drinking), amount of alcohol consumed, longer duration of alcohol abuse, and being female were associated with the increased risk of cirrhosis. Follow-up studies reviewed failed to take full advantage of the study design and added little information to existing literature. Retrospective studies were relatively free of bias and are valuable tools in estimating the risk of cirrhosis. Future research needs to take the following variables into consideration: better ascertainment of alcohol consumption, consumption patterns, changes in alcohol consumption, gender, and body weight.

Liver abnormalities in patients with lichen planus. A retrospective case-control study

A retrospective case-control study of 136 patients with lichen planus and 272 paired controls demonstrated a significantly higher occurrence of liver abnormalities in this dermatosis. There is currently no good explanation for the high occurrence rate of such abnormalities in lichen planus. Factors that alter epidermal cell antigenicity may induce reactions that can damage keratinocytes as well as hepatocytes.

Hepatocellular carcinoma in HBsAg-negative chronic active hepatitis

The occurrence of hepatocellular carcinoma in HBsAg-negative chronic active hepatitis is described in two patients. signs of the tumour appeared 18 years and nine years after the first clinical signs of chronic active hepatitis, although in one patients analysis of stored sera showed the serum alpha-fetoprotein levels had been rising over the previous 33 months. Female preponderance in HBsAg-negative chronic active hepatitis may partly account for the rarity of this complication, and the occurrence of hepatocellular carcinoma may also be a reflection of the better survival now being obtained in HBsAg-negative chronic hepatitis.

Deleterious effect of prednisolone in HBsAg-positive chronic active hepatitis

To study the efficacy of corticosteroids in chronic active hepatitis (CAH) positive for hepatitis B surface antigen (HBsAg), we pair-randomized 51 patients to receive either 15 to 20 mg of prednisolone per day or a placebo. After initial remission, the maintenance dosage of prednisolone was 10 mg per day, and the patients were prospectively followed for up to 3 1/2 years. Prednisolone decreased serum bilirubin (P < 0.05) and globulin (P < 0.01) at three months; it delayed other biochemical remission occurring after the second month of medication (P < 0.001); it hastened biochemical relapse (P < 0.0001); and it increased the frequency of complications (P < 0.0001) and the death rate (P < 0.01). We conclude that prednisolone has an overall harmful effect in patients with HBsAg-positive CAH.

Interpretation of laboratory tests of thyroid function in chronic active hepatitis

Because the incidence of thyroid disorder is much greater than expected in chronic active hepatitis we have evaluated routine in vivo and in vitro tests of thyroid function in forty one clinically euthryoid patients with chronic active hepatitis and in five patients with chronic active hepatitis and concomitant or previous clinical thyroid disease. Serum thyroxine, thyroid hormone binding, triiodothyronine, thyrotrophin releasing hormone tests and thyroidal uptake of radio-iodine all gave misleading information in some clinically euthyroid patients with chronic active hepatitis. However, the free thyroxine index calculated from the serum thyroxine and thyroid hormone binding level gave results that accorded with the clinical impression in all but two of the euthyroid patients whose results were borderline and subsequently normal and in all but one of those with past or current thyroid disorder. This suggests that anomalies of protein binding accounted for abnormal results in thyroxine and thyroid hormone binding levels.

Chronic liver disease: differences in autoimmune serological reactions between Australians and Asians

A total of 164 patients from Australia, Ceylon, India, Singapore, and Thailand were studied for the prevalence of autoantibodies associated with "idiopathic" chronic liver disease-namely, antinuclear antibody, smooth muscle antibody, and mitochondrial antibody. The prevalence of these autoantibodies was high among patients from Australia (55%), but was low among patients from Ceylon (14%), India (11%), Singapore (0%), and Thailand (8%). There are variations in types of hepatitis and cirrhosis between races, and this applies particularly to the type associated with autoimmune markers. This may be related to genetic differences that have evolved between peoples of European and Asian descent.