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Fujiwara K, Fukuda Y, Sanada M, Koizumi S, Seza K, Saito M, Yokosuka O, Kato N. Analysis of autoimmune hepatitis with acute presentation in the early stage of illness. J Gastroenterol Hepatol 2024. [PMID: 38860418 DOI: 10.1111/jgh.16657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/08/2024] [Accepted: 05/29/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND AND AIM There is no gold standard for making the diagnosis of autoimmune hepatitis (AIH), and the diagnosis of acute onset AIH (A-AIH) is most challenging. A-AIH sometimes develops into acute liver failure with poor prognosis if the diagnosis is delayed. Therefore, it is most important for the better prognosis to diagnose non-severe A-AIH early and treat appropriately. However, features in the early stage of A-AIH are unclear. We examined initial characteristics of non-severe A-AIH in detail and tried to find novel clinical features for the early diagnosis. METHODS Clinical, biochemical, immunological, radiological, and histological features of 71 patients (54 women, mean age 57.9 ± 14.3 years) with non-severe A-AIH admitted to community hospitals between 2001 and 2022 were analyzed retrospectively. RESULT Forty-six had no symptom on onset and liver injuries were discovered by regular medical checkups. The mean duration from onset to consultation was 25.0 ± 29.3 days. Liver histology showed acute hepatitis in 59% and chronic hepatitis in 41%. Patients with symptoms revealed more male sex (P = 0.039), higher alanine aminotransferase (P < 0.001), higher total bilirubin (P < 0.001), and higher rate of histological acute hepatitis (P = 0.0013) than those without symptoms significantly. Male sex, presence of symptoms on onset, occurrence of jaundice in the course, and histological acute hepatitis were correlated. CONCLUSIONS Sixty-five percent of non-severe A-AIH patients were asymptomatic on onset, suggesting that A-AIH would develop insidiously and present a longer clinical course than that reported. Male patients more often revealed true acute hepatitis clinically, biochemically, and histologically than female ones.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshihiro Fukuda
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Masahiko Sanada
- Department of Gastroenterology, Yusokai Saisei Hospital, Chiba, Japan
| | - Shuko Koizumi
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Katsushi Seza
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Masaya Saito
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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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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3
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Gomes NBN, Torres US, Silva GSE, Mamone POS, Ferraz MLCG, D’ippolito G. Magnetic resonance imaging findings in autoimmune hepatitis: how frequent and reproducible are they? Radiol Bras 2023; 56:308-316. [PMID: 38504809 PMCID: PMC10948163 DOI: 10.1590/0100-3984.2023.0044] [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: 05/06/2023] [Revised: 06/19/2023] [Accepted: 09/11/2023] [Indexed: 03/21/2024] Open
Abstract
Objective To determine the frequency and interobserver reproducibility of the magnetic resonance imaging (MRI) features considered diagnostic for autoimmune hepatitis. Materials and Methods Two abdominal radiologists, blinded to pathology data, reviewed the MRI examinations of 20 patients with autoimmune hepatitis, looking for liver enhancement, lymphadenopathy, portal hypertension, and chronic liver disease. The pattern of liver fibrosis was categorized as reticular, confluent, or mixed. Interobserver agreement was assessed by calculating intraclass correlation coefficients and kappa statistics. Results The most common abnormal finding on MRI was surface nodularity (in 85%), followed by liver fibrosis with a reticular pattern (in 80%)-categorized as mild (in 25.0%), moderate (in 43.8%), or severe (in 31.2%)-; heterogeneous liver enhancement (in 65%); splenomegaly (in 60%); caudate lobe enlargement (in 50%); and lymphadenopathy (in 40%). The interobserver agreement was almost perfect for surface nodularity (0.83), ascites (0.89), and liver volume (0.95), whereas it was just slight and fair for the degree of fibrosis and for heterogeneous liver enhancement (0.12 and 0.25, respectively). It was also slight and fair for expanded gallbladder fossa and enlarged preportal space (0.14 and 0.36, respectively), both of which are indicative of chronic liver disease. Conclusion The interobserver agreement was satisfactory for surface nodularity (the most prevalent abnormal MRI finding), ascites, liver volume, and splenomegaly. Conversely, it was only slight or fair for common but less objective criteria.
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Affiliation(s)
- Natália Borges Nunes Gomes
- Escola Paulista de Medicina da Universidade Federal de São
Paulo (EPM-Unifesp), São Paulo, SP, Brazil
- Grupo Fleury, São Paulo, SP, Brazil
| | - Ulysses S. Torres
- Escola Paulista de Medicina da Universidade Federal de São
Paulo (EPM-Unifesp), São Paulo, SP, Brazil
- Grupo Fleury, São Paulo, SP, Brazil
| | - Gabriella Souza e Silva
- Escola Paulista de Medicina da Universidade Federal de São
Paulo (EPM-Unifesp), São Paulo, SP, Brazil
- Grupo Fleury, São Paulo, SP, Brazil
| | | | | | - Giuseppe D’ippolito
- Escola Paulista de Medicina da Universidade Federal de São
Paulo (EPM-Unifesp), São Paulo, SP, Brazil
- Grupo Fleury, São Paulo, SP, Brazil
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4
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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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5
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Shokri Varniab Z, Pourabhari Langroudi A, Amouei M, Pak N, Khosravi B, Radmard AR. Abdominal Imaging Findings in Patients with COVID-19 Part 2: Solid Organs. Middle East J Dig Dis 2022; 14:373-381. [PMID: 37547497 PMCID: PMC10404099 DOI: 10.34172/mejdd.2022.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/10/2022] [Indexed: 08/08/2023] Open
Abstract
Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in China in December 2019, the globe has been dealing with an ever-increasing incidence of coronavirus disease 2019 (COVID-19). In addition to respiratory disorders, 40% of patients present with gastrointestinal (GI) involvement. Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography. After GI tract involvement, solid visceral organ infarction is the most prevalent abdominal abnormality in COVID-19. This review aims to gather the available data in the literature about imaging features of solid abdominal organs in patients with COVID-19. Gallbladder wall thickening and distension, cholelithiasis, hyperdense biliary sludge, acalculous cholecystitis, periportal edema, heterogeneous liver enhancement, and liver hypodensity and infarction are among hepatobiliary imaging findings in CT, particularly in patients admitted to ICU. Pancreatic involvement can develop as a result of direct SARS-CoV2 invasion with signs of acute pancreatitis in abdominal CT, such as edema and inflammation of the pancreas. Infarction was the most prevalent renal and splenic involvement in patients with COVID-19 who underwent abdominal CT presenting with areas of parenchymal hypodensity. In conclusion, although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome.
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Affiliation(s)
- Zahra Shokri Varniab
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mehrnam Amouei
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Pak
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bardia Khosravi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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6
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Fujiwara K, Yokosuka O, Kato N. Histological re-evaluation of autoimmune hepatitis with acute presentation. Liver Int 2022; 42:1916-1917. [PMID: 35596928 DOI: 10.1111/liv.15317] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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7
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Zeng W, Wu L, Ishigaki Y, Harimoto T, Hu Y, Sun Y, Wang Y, Suzuki T, Chen H, Ye D. An Activatable Afterglow/MRI Bimodal Nanoprobe with Fast Response to H
2
S for In Vivo Imaging of Acute Hepatitis. Angew Chem Int Ed Engl 2022. [DOI: 10.1002/ange.202111759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Wenhui Zeng
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Luyan Wu
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Yusuke Ishigaki
- Department of Chemistry Faculty of Science Hokkaido University N10 W8, North-ward Sapporo 060–0810 Japan
| | - Takashi Harimoto
- Department of Chemistry Faculty of Science Hokkaido University N10 W8, North-ward Sapporo 060–0810 Japan
| | - Yuxuan Hu
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Yidan Sun
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Yuqi Wang
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Takanori Suzuki
- Department of Chemistry Faculty of Science Hokkaido University N10 W8, North-ward Sapporo 060–0810 Japan
| | - Hong‐Yuan Chen
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
| | - Deju Ye
- State Key Laboratory of Analytical Chemistry for Life Science Chemistry and Biomedicine Innovation Center (ChemBIC) School of Chemistry and Chemical Engineering Nanjing University Nanjing 210023 China
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8
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Zeng W, Wu L, Ishigaki Y, Harimoto T, Hu Y, Sun Y, Wang Y, Suzuki T, Chen HY, Ye D. An Activatable Afterglow/MRI Bimodal Nanoprobe with Fast Response to H 2 S for In Vivo Imaging of Acute Hepatitis. Angew Chem Int Ed Engl 2021; 61:e202111759. [PMID: 34791772 DOI: 10.1002/anie.202111759] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/20/2021] [Indexed: 11/12/2022]
Abstract
Accurate detection of hepatic hydrogen sulfide (H2 S) to monitor H2 S-related enzymes' activity is critical for acute hepatitis diagnosis, but remains a challenge due to the dynamic and transient nature of H2 S. Here, we report a H2 S-activatable near-infrared afterglow/MRI bimodal probe F1-GdNP, which shows an "always-on" MRI signal and "off-on" afterglow signal toward H2 S. F1-GdNP shows fast response, high sensitivity and specificity toward H2 S, permitting afterglow imaging of H2 S and evaluation of cystathionine γ-lyase (CSE)'s activity in living mice. We further employ the high spatial-resolution MRI signal of F1-GdNP to track its delivery and accumulation in liver. Importantly, F1-GdNP offers a high signal-to-background ratio (SBR=86.2±12.0) to sensitively report on the increased hepatic H2 S level in the acute hepatitis mice via afterglow imaging, which correlated well with the upregulated CSE activity in the liver, showcasing the good potential of F1-GdNP for monitoring of acute hepatitis process in vivo.
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Affiliation(s)
- Wenhui Zeng
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Luyan Wu
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Yusuke Ishigaki
- Department of Chemistry, Faculty of Science, Hokkaido University, N10 W8, North-ward, Sapporo, 060-0810, Japan
| | - Takashi Harimoto
- Department of Chemistry, Faculty of Science, Hokkaido University, N10 W8, North-ward, Sapporo, 060-0810, Japan
| | - Yuxuan Hu
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Yidan Sun
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Yuqi Wang
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Takanori Suzuki
- Department of Chemistry, Faculty of Science, Hokkaido University, N10 W8, North-ward, Sapporo, 060-0810, Japan
| | - Hong-Yuan Chen
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
| | - Deju Ye
- State Key Laboratory of Analytical Chemistry for Life Science, Chemistry and Biomedicine Innovation Center (ChemBIC), School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, China
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9
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Guler E, Unal NG, Cinkooglu A, Savas R, Kose T, Pullukcu H, Harman M, Elmas NZ, Ramaiya NH, Ozutemiz AO. Correlation of liver-to-spleen ratio, lung CT scores, clinical, and laboratory findings of COVID-19 patients with two consecutive CT scans. Abdom Radiol (NY) 2021; 46:1543-1551. [PMID: 33051758 PMCID: PMC7553377 DOI: 10.1007/s00261-020-02805-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/19/2020] [Accepted: 09/30/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Given the lack of information about abdominal imaging findings and correlation with clinical features of COVID-19, we aimed to evaluate the changes in hepatic attenuation during the course of disease. Our aim was to correlate the liver-to-spleen ratio (L/S), clinical, laboratory findings, and lung CT scores of patients with COVID-19 who had two consecutive chest CTs. METHODS A retrospective search was performed between March 1, 2020 and April 26, 2020 to identify patients who had positive RT-PCR tests and two unenhanced chest CTs. Scans that were obtained at hospital admission and follow-up were reviewed to assess L/S and lung CT scores. Patients were divided into two groups based on lung CT scores (non-progressive vs progressive). Patient demographics, laboratory findings, length of hospital stay, and survival were noted from electronic medical records. RESULTS Twenty patients in the progressive group and 7 patients in the non-progressive group were identified. The mean L/S of the progressive group (1.13 ± 0.3) was lower than that of the non-progressive group (1.21 ± 0.29) at hospital admission but there was no significant difference between the two groups (p = 0.547). L/S at follow-up was significantly different between the groups as the mean L/S values of the progressive and non-progressive groups were 1.02 ± 0.23 and 1.25 ± 0.29, respectively (p = 0.009). L/S was negatively correlated with AST and ALT (r = - 0.46, p = 0.016 and r = - 0.534, p = 0.004, respectively). There were significant differences between the two groups in terms of WBC, neutrophil, lymphocyte, monocyte, and platelet counts that were obtained at hospital admission. Length of hospital stay was significantly longer in patients in the progressive group (p = 0.035). CONCLUSIONS Decrease in L/S may be observed in patients with elevated lung CT scores at follow-up. WBC, neutrophil, lymphocyte, monocyte, and platelet counts at hospital admission may predict the progression of COVID-19.
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Affiliation(s)
- Ezgi Guler
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, 35100, Turkey.
| | - Nalan Gulsen Unal
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Akin Cinkooglu
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, 35100, Turkey
| | - Recep Savas
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, 35100, Turkey
| | - Timur Kose
- Department of Biostatistics, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Husnu Pullukcu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Mustafa Harman
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, 35100, Turkey
| | - Nevra Z Elmas
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, 35100, Turkey
| | - Nikhil H Ramaiya
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Ahmet Omer Ozutemiz
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
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10
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Komori A. Recent updates on the management of autoimmune hepatitis. Clin Mol Hepatol 2021; 27:58-69. [PMID: 33291862 PMCID: PMC7820207 DOI: 10.3350/cmh.2020.0189] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
Autoimmune hepatitis (AIH) is an immunoinflammatory chronic liver disease with dynamic and rather heterogeneous disease manifestations. A trend of increasing prevalence of AIH has been observed worldwide, along with a relative increase in the percentage of male patients. AIH is characterized and diagnosed based on serum biochemistry and liver histology: elevated aminotransferases and serum immunoglobulin G (IgG), the presence of serum anti-nuclear antibody or anti-smooth muscle antibody, and interface lympho-plasmacytic hepatitis. Clinical manifestations differ among disease subtypes with distinct time-frames, i.e., AIH with a chronic insidious onset, and acute-onset AIH (the diagnosis of which is often challenging due to the lack of typical serum findings). The absence of disease-specific biomarkers or histological findings may expand the disease phenotype into drug-induced AIH-like liver injury. Corticosteroids and azathioprine are recommended first-line treatments for AIH. The complete normalization of aminotransferases and serum IgG is an essential treatment response to ensure long-term overall survival. An incomplete response or intolerance to these drugs is considered an indication for second-line treatment, especially with mycophenolate mofetil. Life-long maintenance treatment is required for the majority of patients, but the few who achieve prolonged and stringent biochemical remission with lower alanine aminotransferase and IgG within the normal range may be able to discontinue the medications. In the future, the quality of life of AIH patients should be managed by personalized medicine, including the appropriate selection and dosing of first-line therapy and perhaps alternating with potential therapeutics, and the prediction of the success of treatment withdrawal.
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Affiliation(s)
- Atsumasa Komori
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Omura, Japan
- Department of Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Omura, Japan
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11
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Rahim MN, Miquel R, Heneghan MA. Approach to the patient with acute severe autoimmune hepatitis. JHEP Rep 2020; 2:100149. [PMID: 32995712 PMCID: PMC7509236 DOI: 10.1016/j.jhepr.2020.100149] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Autoimmune hepatitis is associated with varied clinical presentations and natural history, as well as somewhat unpredictable treatment responses. Understanding how to stratify patients who require further escalation of therapy will help clinicians manage these patients. The presentation of acute severe autoimmune hepatitis (AS-AIH) is relatively uncommon, although its prevalence is potentially greater than currently perceived. Previous studies consist of small retrospective single-centre series and are not directly comparable due to the diversity of presentations, disease definitions and non-standardised treatment regimens. We define AS-AIH as those who present acutely with AIH and are icteric with an international normalised ratio ≥1.5 and no evidence of hepatic encephalopathy. Those with hepatic encephalopathy should be defined as having AS-AIH with acute liver failure. In this review, we provide a structured practical approach for diagnosing and managing this unique group of patients.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALF, acute liver failure
- ALI, acute liver injury
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- AS-AIH, acute severe autoimmune hepatitis
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- AUROC, analysis of area under the receiver operator characteristic curve
- Acute liver failure
- Acute severe presentation
- Autoimmune hepatitis
- CT, computed tomography
- Corticosteroids
- DILI, drug-induced liver injury
- EBV, Epstein-Barr virus
- HE, hepatic encephalopathy
- HLA, human leukocyte antigen
- IAIHG, International Autoimmune Hepatitis Group
- INR, international normalised ratio
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- MELD-Na, model for end-stage liver disease-sodium
- MHN, massive hepatic necrosis
- NAC, N-acetylcysteine
- PT, prothrombin time
- UKELD, United Kingdom end-stage liver disease
- USALF, United States Acute Liver Failure
- anti-LC-1, anti-liver cytosol-1
- anti-LKM, anti-liver kidney microsomal
- anti-SLA/LP, anti-soluble liver antigen/liver pancreas
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Affiliation(s)
- Mussarat N. Rahim
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK
| | - Rosa Miquel
- Liver Histopathology Laboratory, King's College Hospital, London, SE5 9RS, UK
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12
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Fujiwara K, Nakayama N, Kato N, Yokosuka O, Tsubouchi H, Takikawa H, Mochida S. Infectious complications and timing for liver transplantation in autoimmune acute liver failure in Japan: a subanalysis based on nationwide surveys between 2010 and 2015. J Gastroenterol 2020; 55:888-898. [PMID: 32556645 DOI: 10.1007/s00535-020-01699-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognosis of autoimmune acute liver failure (ALF) without liver transplantation (LT) is poor worldwide. We subanalyzed infectious complications of autoimmune ALF using data of nationwide surveys between 2010 and 2015 retrospectively and tried to determine when to evaluate the efficacy of corticosteroid (CS) treatment or abandon it for LT based on objective data. METHODS One hundred and forty-four patients with autoimmune ALF, comprising 79 ALF with coma ≤ I, 52 ALF with coma ≥ II and 13 late onset hepatic failure (LOHF), were analyzed. RESULTS CS was administered to 140 (97%) patients. Thirty-seven (26%) patients had infectious complications. Patients with infection revealed more advanced disease type (p < 0.001) and poorer spontaneous survival (p < 0.001) than those without infection. Median (interquartile range) duration between diagnosis of ALF and onset of infection was 18.5 (11-36) days, and that between introduction of CS and onset of infection was 17 (10.5-36) days. Seventy-nine (55%) recovered without LT, 14 (10%) received LT and 51 (35%) died without LT. Dead or transplanted patients were older (p = 0.0057), and revealed more advanced liver failure (p < 0.001) and more occurrence of infection (p < 0.001). CONCLUSIONS A critical point for evaluating the efficacy of CS treatment and switching to LT is at most 2-week after diagnosis of ALF and introduction of CS. More important, we should accelerate the point and prepare for LT in cases of ALF with coma ≥ II and LOHF, and we should have performed LT by then at the latest in case of failure to improve.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan.
- Faculty of Healthcare Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan.
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | | | - Hajime Takikawa
- Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
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Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72:671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] [Citation(s) in RCA: 429] [Impact Index Per Article: 107.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Cara L Mack
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David Adams
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David N Assis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nanda Kerkar
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, NY
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mohammad H Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
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Ozaki K, Kozaka K, Kosaka Y, Kimura H, Gabata T. Morphometric changes and imaging findings of diffuse liver disease in relation to intrahepatic hemodynamics. Jpn J Radiol 2020; 38:833-852. [PMID: 32347423 DOI: 10.1007/s11604-020-00978-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/13/2020] [Indexed: 01/20/2023]
Abstract
Diffuse hepatic diseases have a variety of etiologies, with each showing characteristic morphometric changes. These changes are closely related to micro- and macro-level intrahepatic hemodynamics, in addition to the specific underlying pathophysiology. Short-term disorders in intrahepatic hemodynamics caused by each pathophysiological condition are compensated for by the balance of blood perfusion systems using potential trans-sinusoidal, transversal, and transplexal routes of communication (micro-hemodynamics), while long-term alterations to the intrahepatic hemodynamics result in an increase in total hepatic vascular resistance. Blood flow disorders induced by this increased vascular resistance elicit hepatic cellular necrosis and fibrosis. These changes should be uniformly widespread throughout the whole liver. However, morphometric changes do not occur uniformly, with shrinkage or enlargement not occurring homogeneously. Against this background, several macro-intrahepatic hemodynamic effects arise, such as asymmetrical and complicating morphometric structures of the liver, intricate anatomy of portal venous flow and hepatic venous drainage, and zonal differentiation between central and peripheral zones. These hemodynamic factors and pathophysiological changes are related to characteristic morphometric changes in a complicated manner, based on the combination of selective atrophy and compensatory hypertrophy (atrophy-hypertrophy complex). These changes can be clearly depicted on CT and MR imaging.
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Affiliation(s)
- Kumi Ozaki
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan.
| | - Kazuto Kozaka
- Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yasuo Kosaka
- Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Hirohiko Kimura
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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Uchida Y, Uemura H, Yamaba S, Hamada D, Tarumoto N, Maesaki S, Mochida S. Significance of liver dysfunction associated with decreased hepatic CT attenuation values in Japanese patients with severe COVID-19. J Gastroenterol 2020; 55:1098-1106. [PMID: 32776161 PMCID: PMC7415328 DOI: 10.1007/s00535-020-01717-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 has emerged as a threat to human health. Liver dysfunction has been reported to occur frequently in patients with COVID-19, although its significance has not yet been elucidated. METHODS The subjects were 35 patients with COVID-19, and clinical characteristics were retrospectively analyzed. COVID-19 patients requiring ventilator were classified as having severe COVID-19. RESULTS All 35 patients were diagnosed as having mild-to-moderate COVID-19 at admission, but the severity aggravated to severe in 8 patients (22.9%) in hospital. Hepatocellular-type liver injury, defined as elevation of the serum AST and/or ALT levels to ≥ 3 times the ULN, was seen in 2 patients (5.7%), and cholestasis-type liver injury, defined as elevation of the serum ALP, γ-GTP and/or total bilirubin levels to ≥ twice the ULN, was seen in 4 patients (11.4%). A total of 9 patients (25.7%) fulfilled the criteria for liver injury. The percentage of patients with liver injury was higher in patients with severe COVID-19 than in the remaining patients (P = 0.001). Both the hepatic CT attenuation values and the liver-to-spleen attenuation (L/S) ratios at admission were lower in the former patients than in the latter patients (P < 0.001). ROC curve revealed the optimal cut-off value of the L/S ratio of 1.03 for discriminating between patients with severe and non-severe diseases. The hepatic CT attenuation values increased at the remission phase of the disease as compared to the values at admission (P = 0.012). CONCLUSION Liver dysfunction associated with reduced hepatic CT attenuation values correlated with the disease severity in patients with COVID-19.
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Affiliation(s)
- Yoshihito Uchida
- grid.410802.f0000 0001 2216 2631Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-Gun, Saitama, 350-0495 Japan
| | - Hayato Uemura
- grid.410802.f0000 0001 2216 2631Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-Gun, Saitama, 350-0495 Japan
| | - Shinpei Yamaba
- grid.410802.f0000 0001 2216 2631Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-Gun, Saitama, 350-0495 Japan
| | - Daisuke Hamada
- grid.410802.f0000 0001 2216 2631Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-Gun, Saitama, 350-0495 Japan
| | - Norihito Tarumoto
- grid.410802.f0000 0001 2216 2631Department of Infectious Disease and Infection Control, Saitama Medical University, Saitama, Japan
| | - Shigefumi Maesaki
- grid.410802.f0000 0001 2216 2631Department of Infectious Disease and Infection Control, Saitama Medical University, Saitama, Japan
| | - Satoshi Mochida
- grid.410802.f0000 0001 2216 2631Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-Gun, Saitama, 350-0495 Japan
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Rahim MN, Liberal R, Miquel R, Heaton ND, Heneghan MA. Acute Severe Autoimmune Hepatitis: Corticosteroids or Liver Transplantation? Liver Transpl 2019; 25:946-959. [PMID: 30900368 DOI: 10.1002/lt.25451] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
Abstract
Acute severe presentations of autoimmune hepatitis (AIH) represent a challenge for the transplant community. As a disease, it is poorly characterized, and there is a weak evidence base to guide diagnosis and treatment. Early identification of acute severe AIH is key because it determines the initiation of corticosteroids, which can be lifesaving. However, their use in this setting remains controversial. The Model for End-Stage Liver Disease score, severity of coagulopathy, and grade of encephalopathy may be predictors of outcome with corticosteroid therapy. The optimal timing of liver transplantation (LT) can be difficult to determine and, as such, the decision to proceed to transplantation should not be delayed by protracted courses of corticosteroids. The aim of this review is to better characterize this subset of patients; to differentiate them clinically, serologically, and histologically from chronic AIH and other causes of acute liver failure; and to present the role, predictors, and optimal timings of corticosteroid therapy and LT. Although this review is specific to adults, many principles hold true for the pediatric population.
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Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Rodrigo Liberal
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Rosa Miquel
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Nigel D Heaton
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
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Kotani K, Kawabe J, Higashiyama S, Yoshida A, Kawamura E, Tamori A, Shiomi S, Kawada N. Heterogeneous liver uptake of Tc-99m-GSA as quantified through SPECT/CT helps to evaluate the degree of liver fibrosis: A retrospective observational study. Medicine (Baltimore) 2018; 97:e11765. [PMID: 30075603 PMCID: PMC6081161 DOI: 10.1097/md.0000000000011765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Tc-99m-galactosyl human serum albumin (GSA) scintigraphy is used to assess the hepatic functional reserve, and allows for visual assessment of the residual hepatocyte distribution on single-photon emission computed tomography/computed tomography (SPECT/CT) images. The association between heterogeneous liver uptake of Tc-99m-GSA and liver fibrosis remains to be studied in detail. We analyzed this association.Fifty-one patients with chronic hepatobiliary disease undergoing a Tc-99m-GSA scintigraphy were included in this study. The receptor (LHL15) and blood clearance (HH15) indexes (the uptake ratios of the liver and heart) were obtained from dynamic planar images. The liver uptake count maximum-to-mean ratio (LUC Max/Mean) was calculated from single-photon emission computed tomography/computed tomography (SPECT/CT) images as an indicator of the Tc-99m-GSA liver uptake heterogeneity. We assessed the relationship between these quantified values and liver fibrosis.There were 30 Child-Pugh classification grade A patients, 16 grade B patients, and 5 grade C patients. Among the 30 patients whose liver histopathology was evaluable, those with advanced liver fibrosis (F2-4) had a lower LHL15 than those with mild liver fibrosis (F0-1) (median, 0.90 vs. 0.92, P = .04), and a higher LUC Max/Mean (median, 1.80 vs. 1.70, P = .02). The multivariate analysis identified platelets (P = .04) and the LUC Max/Mean (P = .04) as contributing factors of advanced liver fibrosis.These findings suggest that Tc-99m-GSA SPECT/CT can be used not only to assess the hepatic functional reserve, but also to evaluate a degree of liver fibrosis.
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Affiliation(s)
- Kohei Kotani
- Department of Hepatology, Graduate School of Medicine
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University
| | - Joji Kawabe
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University
| | - Shigeaki Higashiyama
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University
| | - Atsushi Yoshida
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University
| | - Etsushi Kawamura
- Department of Gastroenterology and Hepatology, Osaka City Juso Hospital
| | | | - Susumu Shiomi
- Department of Gastroenterology and Hepatology, Izumiotsu Municipal Hospital, Osaka, Japan
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18
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Liu Z, Li Y, Li W, Xiao C, Liu D, Dong C, Zhang M, Mäkilä E, Kemell M, Salonen J, Hirvonen JT, Zhang H, Zhou D, Deng X, Santos HA. Multifunctional Nanohybrid Based on Porous Silicon Nanoparticles, Gold Nanoparticles, and Acetalated Dextran for Liver Regeneration and Acute Liver Failure Theranostics. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:e1703393. [PMID: 29024054 DOI: 10.1002/adma.201703393] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/24/2017] [Indexed: 05/17/2023]
Abstract
Herein, a novel nanohybrid based on porous silicon, gold nanoparticles (Au NPs), and acetalated dextran (DPSi/DAu@AcDEX) is reported to encapsulate and deliver one drug and increase the computer tomography (CT) signal for acute-liver-failure (ALF) theranostics. A microfluidic-assisted method is used to co-encapsulate different NPs in a single step. By alternating the surface properties of different NPs and by modulating the composition of the organic phase, both PSi and Au NPs are effectively encapsulated into the polymer matrix simultaneously, thus further achieving a multifunctional application. This system can be used to identify pathologically changes in the tissues and selectively deliver drugs to these sites. The loading of a therapeutic compound (XMU-MP-1) improves the drug solubility, precise, in situ drug delivery, and the drug-functioning time. In vivo results confirm a superior treatment effect and better compliance of this newly developed nanoformulation than free compound. This nanosystem plays a crucial role in targeting the lesion area, thus increasing the local drug concentration important for ALF reverse-effect. Moreover, the residence of Au NPs within the matrix further endows our system for CT-imaging. Altogether, these results support that this nanohybrid is a potential theranostic platform for ALF.
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Affiliation(s)
- Zehua Liu
- Division of Pharmaceutical Chemistry and Technology, Drug Research Program, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
| | - Yunzhan Li
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Wei Li
- Division of Pharmaceutical Chemistry and Technology, Drug Research Program, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
| | - Chen Xiao
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Dongfei Liu
- Division of Pharmaceutical Chemistry and Technology, Drug Research Program, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science (HiLIFE), University of Helsinki, FI-00014, Helsinki, Finland
| | - Chao Dong
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Ming Zhang
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Ermei Mäkilä
- Laboratory of Industrial Physics, Department of Physics, University of Turku, FI-20014, Turku, Finland
| | - Marianna Kemell
- Department of Chemistry, University of Helsinki, FI-00014, Helsinki, Finland
| | - Jarno Salonen
- Laboratory of Industrial Physics, Department of Physics, University of Turku, FI-20014, Turku, Finland
| | - Jouni T Hirvonen
- Division of Pharmaceutical Chemistry and Technology, Drug Research Program, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
| | - Hongbo Zhang
- Department of Pharmaceutical Science, Åbo Akademi University, FI-20520, Turku, Finland
- Turku Center of Biotechnology, Åbo Akademi University, FI-20520, Turku, Finland
| | - Dawang Zhou
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Xianming Deng
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling, Network, School of Life Sciences, Xiamen University, 361101, Fujian, China
- State-Province Joint Engineering Laboratory of Targeted Drugs from Natural Products, School of Life Sciences, Xiamen University, 361101, Fujian, China
| | - Hélder A Santos
- Division of Pharmaceutical Chemistry and Technology, Drug Research Program, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science (HiLIFE), University of Helsinki, FI-00014, Helsinki, Finland
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Fujiwara K, Fukuda Y, Seza K, Saito M, Yasui S, Nakano M, Yokosuka O, Kato N. Long-term observation of acute-onset autoimmune hepatitis presenting clinically and radiologically as acute hepatitis. Hepatol Int 2018; 12:191-199. [DOI: 10.1007/s12072-018-9848-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/29/2018] [Indexed: 01/15/2023]
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Autoimmune acute liver failure and seronegative autoimmune liver disease in children: Are they different from classical disease? Eur J Gastroenterol Hepatol 2017; 29:1408-1415. [PMID: 28914695 DOI: 10.1097/meg.0000000000000975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Presentation as autoimmune acute liver failure (AI-ALF) and seronegative autoimmune liver disease (SN-AILD) represents two uncommon variants of AILD. We compared the clinical profile and outcome of AI-ALF with autoimmune-non-acute liver failure (AI-non-ALF) and also SN-AILD with seropositive autoimmune liver disease (SP-AILD). MATERIALS AND METHODS Children managed as AI-ALF and AI-non-ALF including SN-AILD and SP-AILD were enrolled and compared. AI-non-ALF was diagnosed by simplified diagnostic criteria and AI-ALF by Pediatric Acute Liver Failure Study Group criteria with positive autoantibody, exclusion of other etiologies, elevated immunoglobulin G and histology when available. RESULTS Seventy children [AI-ALF=15 and AI-non-ALF=55 (SN-AILD=11, SP-AILD=44)] were evaluated. Age at presentation [7 (1.2-16) vs. 9 (2-17) years] percentage of female patients (67 vs. 62%), and AILD type (type II, 53 vs. 31%) were similar in AI-ALF and AI-non-ALF patients], respectively. 8/15 AI-ALF cases were treated with steroids (improved-4, liver transplant-1, and death-3) and 7/15 died before initiation of therapy. Hepatic encephalopathy (100 vs. 16.3%; P<0.001), massive hepatic necrosis (60 vs. 0%; P<0.001), and higher pediatric end-stage liver disease [n=53, 29.9 (13.1-56.9) vs. 9.8 (-10-28.7) P<0.001], model for end-stage liver disease [n=17, 38.5 (24-46) vs. 18 (6-24); P=0.005], and Child-Turcotte-Pugh [n=70, 13 (8-13) vs. 9 (5-13); P<0.001] scores were features of AI-ALF. Poorer response to immunosuppression (4/8 vs. 48/55; P=0.02) and higher mortality (11/15 vs. 4/55; P=0.0001) were seen in AI-ALF than in AI-non-ALF patients. Clinicolaboratory profile, therapeutic response, and outcome were similar in SN-AILD and SP-AILD. CONCLUSION AI-ALF is characterized by poorer liver function, lower response to immunosuppression, and higher mortality compared with SP or SN AI-non-ALF, which are similar.
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Fujiwara K, Yasui S, Yokosuka O, Oda S, Kato N. Diagnostic utility of radiological heterogeneity in acute severe (fulminant) autoimmune hepatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:485-491. [PMID: 28660716 DOI: 10.1002/jhbp.487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Histological examination is useful for the diagnosis of acute severe (fulminant) autoimmune hepatitis (AIH), but it is sometimes difficult to perform liver biopsy due to the complicated coagulopathy and ascites. We have shown that heterogeneous hypoattenuation on unenhanced computed tomography (CT) is a characteristic imaging feature of acute severe (fulminant) AIH. In the present study, we examined the utility of the imaging feature by applying the score to diagnose acute severe (fulminant) AIH. METHODS Twenty-three patients with acute severe (fulminant) AIH were analyzed retrospectively. Modified AIH score was created by adding three points to AIH score with/without histological points in case of the presence of heterogeneous hypoattenuation on unenhanced CT. RESULTS Areas of hypoattenuation were present in 15 (65%) patients, all of which were heterogeneous pattern. Five (22%) patients were diagnosed as "definite" AIH, 16 (69%) as "probable" and two (9%) as "non-diagnosis" by the revised original score without histological score. By adding three points, two of "non-diagnosis" changed to "probable" AIH, and all patients were diagnosed as AIH. CONCLUSIONS Modified AIH score using heterogeneous CT image finding would be beneficial especially for patients in whom histological examinations cannot be performed because of complications.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Shin Yasui
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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Moini M, Pahlevan-Sabagh MR, Dehghani SM. Acute Liver Failure, Etiology, and Outcome: An Experience in a Referral Liver Transplant Center. HEPATITIS MONTHLY 2017; 17. [DOI: 10.5812/hepatmon.14086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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23
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Yasui S, Fujiwara K, Haga Y, Nakamura M, Mikata R, Arai M, Kanda T, Oda S, Yokosuka O. Infectious complications, steroid use and timing for emergency liver transplantation in acute liver failure: analysis in a Japanese center. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:756-762. [PMID: 27629813 DOI: 10.1002/jhbp.399] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/12/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Corticosteroid (CS) has been introduced in most acute liver failure (ALF) patients for the purpose of suppressing pro-inflammatory cytokines in Japan where a shortage of donor livers exists, whereas CS use is evaluated to be no benefit in Western countries. In the present study, we aimed to clarify the association between infectious complications and CS use in ALF, and determine when to evaluate treatment response and consider the timing for switching to liver transplantation (LT). METHODS Corticosteroid was administered to patients in the early stage prospectively. Clinical and biochemical features of 110 adult patients were analyzed. RESULTS Corticosteroids were administered to 78 (71%) patients. The duration between start of CS and onset of infection was 17 ± 10 days. Multivariate analysis revealed that infection was associated with age >50 years (P = 0.034) and T-BIL >15 mg/dl (P < 0.001), and not with CS use (P = 0.10). Accumulative incidence of infection was not different between patients with and without CS (P = 0.18). CONCLUSIONS Corticosteroid use did not significantly increase the incidence of infection. Two weeks after introduction of CS is a critical point for evaluating treatment response, avoiding infectious complications and switching to LT.
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Affiliation(s)
- Shin Yasui
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Keiichi Fujiwara
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yuuki Haga
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masato Nakamura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Rintaro Mikata
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tatsuo Kanda
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Morii K, Nagano Y, Yamamoto T, Nakamura S, Okushin H. Increasing incidence of elderly-onset autoimmune hepatitis. Geriatr Gerontol Int 2016; 17:1722-1728. [PMID: 27531184 DOI: 10.1111/ggi.12874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/16/2016] [Accepted: 06/23/2016] [Indexed: 12/24/2022]
Abstract
AIM Autoimmune hepatitis (AIH) commonly shows bimodal distribution of onset age: at young adulthood and at 50-60 years-of-age. However, in recent times, the incidence of elderly-onset AIH seems to be increasing. This study aimed to investigate whether the incidence of elderly-onset AIH is increasing, and whether these patients show any clinical features different from those observed in younger patients. METHODS Data about patients with newly diagnosed AIH visiting the Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan, were retrospectively collected for the period ranging from January 2010 to May 2016. A total of 71 patients (56 women and 15 men, age 18-88 years) were included in this study. Patients were divided into two cohorts: elderly (≥70 years; n = 28) and adult cohort (15-69 years; n = 43). Demographic and clinical characteristics, biochemical and serological markers, radiological and histological findings, and therapeutic courses were evaluated. RESULTS The median age of the patients was 65 years, the most frequent range being the 70s (37%), followed by the 60s (25%). The elderly cohort had significantly higher levels of serum immunoglobulin G and antinuclear antibody, lesser hepatitis activity scores, and lesser chance of developing other autoimmune diseases. They tended to have higher C-reactive protein levels and lower serum alanine aminotransferase levels. All patients achieved clinical remission after treatment. CONCLUSIONS This study clearly showed an increase in the incidence of elderly-onset AIH. These patients had some unique characteristics, showing that the development of elderly-onset AIH is influenced by age-associated immune dysfunction called immunosenescence. Geriatr Gerontol Int 2017; 17: 1722-1728.
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Affiliation(s)
- Kazuhiko Morii
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Yuh Nagano
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Takeharu Yamamoto
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Shinichiro Nakamura
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Hiroaki Okushin
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
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Ozaslan E, Efe C. Further considerations in autoimmune hepatitis. J Hepatol 2016; 64:1457-8. [PMID: 26916527 DOI: 10.1016/j.jhep.2015.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/14/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Ersan Ozaslan
- Associate Professor of Gastroenterology, Numune Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey.
| | - Cumali Efe
- Associate Professor of Gastroenterology, Batman State Hospital, Department of Gastroenterology, Batman, Turkey
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Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis: Current Status and Future Directions. Gut Liver 2016; 10:177-203. [PMID: 26934884 PMCID: PMC4780448 DOI: 10.5009/gnl15352] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Autoimmune hepatitis is characterized by autoantibodies, hypergammaglobulinemia, and interface hepatitis on histological examination. The features lack diagnostic specificity, and other diseases that may resemble autoimmune hepatitis must be excluded. The clinical presentation may be acute, acute severe (fulminant), or asymptomatic; conventional autoantibodies may be absent; centrilobular necrosis and bile duct changes may be present; and the disease may occur after liver transplantation or with features that suggest overlapping disorders. The diagnostic criteria have been codified, and diagnostic scoring systems can support clinical judgment. Nonstandard autoantibodies, including antibodies to actin, α-actinin, soluble liver antigen, perinuclear antineutrophil antigen, asialoglycoprotein receptor, and liver cytosol type 1, are tools that can support the diagnosis, especially in patients with atypical features. Prednisone or prednisolone in combination with azathioprine is the preferred treatment, and strategies using these medications in various doses can ameliorate treatment failure, incomplete response, drug intolerance, and relapse after drug withdrawal. Budesonide, mycophenolate mofetil, and calcineurin inhibitors can be considered in selected patients as frontline or salvage therapies. Molecular (recombinant proteins and monoclonal antibodies), cellular (adoptive transfer and antigenic manipulation), and pharmacological (antioxidants, antifibrotics, and antiapoptotic agents) interventions constitute future directions in management. The evolving knowledge of the pathogenic pathways and the advances in technology promise new management algorithms.
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Affiliation(s)
- Albert J. Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN,
USA
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Fujiwara K, Yasui S, Yonemitsu Y, Arai M, Kanda T, Fukuda Y, Nakano M, Oda S, Yokosuka O. Analysis of infectious complications and timing for emergency liver transplantation in autoimmune acute liver failure. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:212-9. [PMID: 26808231 DOI: 10.1002/jhbp.326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 01/20/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is one of major etiologies of acute liver failure (ALF), and the survival rate without liver transplantation (LT) of patients with fulminant AIH is especially poor worldwide. We investigated the clinicopathological features of infectious complications in autoimmune ALF retrospectively and tried to determine when to continue corticosteroid (CS) treatment or abandon it for LT. METHODS Twenty patients with autoimmune ALF, comprising five severe hepatitis, 13 fulminant hepatitis and two late onset hepatic failure, were analyzed. RESULTS Corticosteroids were administered to 19 patients. Seventeen infectious complications were observed in 12 patients. The median (range) duration between the introduction of CS and onset of infection was 15 (10–41) days. There were no significant differences in clinicobiochemical features between patients with and without infection. Of 20 patients, eight (40%) recovered without LT, four (20%) received LT and eight (40%) died without LT. Dead or transplanted patients had more advanced liver failure on admission than recovered ones (P < 0.01). CONCLUSIONS Two-week after the introduction of CS is a critical point for avoiding infectious complications. Therefore, we should have evaluated efficacy of CS and performed LT by then at the latest in case of failure to improve.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Shin Yasui
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yutaka Yonemitsu
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tatsuo Kanda
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yoshihiro Fukuda
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Masayuki Nakano
- Division of Pathology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Fujiwara K, Fukuda Y, Seza K, Saito M, Yasui S, Nakano M, Yokosuka O. High level of persistent liver injury is one of clinical characteristics in treatment-naïve acute onset autoimmune hepatitis: experience in a community hospital. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:174-80. [DOI: 10.1002/jhbp.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/08/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology and Nephrology, Graduate School of Medicine; Chiba University; 1-8-1 Inohana Chuo-ku, Chiba 260-8670 Japan
| | - Yoshihiro Fukuda
- Department of Gastroenterology; Seikeikai Chiba Medical Center; Chiba Japan
| | - Katsushi Seza
- Department of Gastroenterology; Seikeikai Chiba Medical Center; Chiba Japan
| | - Masaya Saito
- Department of Gastroenterology; Seikeikai Chiba Medical Center; Chiba Japan
| | - Shin Yasui
- Department of Gastroenterology and Nephrology, Graduate School of Medicine; Chiba University; 1-8-1 Inohana Chuo-ku, Chiba 260-8670 Japan
| | - Masayuki Nakano
- Division of Pathology; Shonan Fujisawa Tokushukai Hospital; Fujisawa Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine; Chiba University; 1-8-1 Inohana Chuo-ku, Chiba 260-8670 Japan
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Fujiwara K, Yasui S, Nakano M, Yonemitsu Y, Arai M, Kanda T, Fukuda Y, Oda S, Yokosuka O. Severe and fulminant hepatitis of indeterminate etiology in a Japanese center. Hepatol Res 2015; 45:E141-9. [PMID: 25582192 DOI: 10.1111/hepr.12483] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/22/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
AIM The outcome of acute liver failure (ALF) is influenced by its etiology, making etiological consideration of ALF important. However, specific etiology could not be identified in 30-40% of adult patients in a Japanese nationwide survey. We examined our patients with severe (SH) and fulminant hepatitis (FH) of indeterminate etiology for the better understanding of ALF. METHODS We investigated 106 adult patients with SH or FH including 24 of indeterminate etiology between 2000 and 2013, retrospectively. RESULTS Of 24 patients, 12 were men. Seventeen were SH and seven FH (three FH acute type and four FH subacute type). Eighty-three percent of patients were positive for antinuclear antibody. Seventeen recovered without liver transplantation (LT), two received LT and five died without LT. Histology of 15 patients showed a pattern of acute hepatitis (massive necrosis in four, submassive necrosis in one, severe acute hepatitis in two and acute hepatitis in eight). The involvement of immune-mediated liver injury was histologically suggested in some patients. CONCLUSION There was no large cluster of etiology in our patients with indeterminate cause. The causes of ALF of indeterminate etiology were the mixture of various minor or rare ones, if precise diagnosis of acute AIH was done. Outcome of our patients with indeterminate cause was not poor if they were treated as early as possible after the diagnosis of severe disease. Careful examination of unknown viral infection, drugs, toxins, undefined metabolic disorders and histology may help detect some of these etiologies.
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Affiliation(s)
| | - Shin Yasui
- Departments of Gastroenterology and Nephrology
| | - Masayuki Nakano
- Division of Pathology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Japan
| | | | - Makoto Arai
- Departments of Gastroenterology and Nephrology
| | | | - Yoshihiro Fukuda
- Department of Gastroenterology, Seikeikai Chiba Medical Center, Chiba
| | - Shigeto Oda
- Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University
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Ozaslan E, Efe C, Ozaslan NG. Are There Any Etiology-Based Specific Findings of Imaging Appearance in Acute Liver Failure? Dig Dis Sci 2015. [PMID: 26204977 DOI: 10.1007/s10620-015-3816-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Ersan Ozaslan
- Department of Gastroenterology, Numune Education and Research Hospital, Cukurambar Mah. 1429. Cad. 24/2, Cankaya, Ankara, Turkey,
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Weingarten MA, Sande AA. Acute liver failure in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2015; 25:455-73. [PMID: 25882813 DOI: 10.1111/vec.12304] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/26/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To define acute liver failure (ALF), review the human and veterinary literature, and discuss the etiologies and current concepts in diagnostic and treatment options for ALF in veterinary and human medicine. ETIOLOGY In veterinary medicine ALF is most commonly caused by hepatotoxin exposure, infectious agents, inflammatory diseases, trauma, and hypoxic injury. DIAGNOSIS A patient may be deemed to be in ALF when there is a progression of acute liver injury with no known previous hepatic disease, the development of hepatic encephalopathy of any grade that occurs within 8 weeks after the onset of hyperbilirubinemia (defined as plasma bilirubin >50 μM/L [>2.9 mg/dL]), and the presence of a coagulopathy. Diagnostic testing to more specifically characterize liver dysfunction or pathology is usually required. THERAPY Supportive care to aid the failing liver and compensate for the lost functions of the liver remains the cornerstone of care of patients with ALF. Advanced therapeutic options such as extracorporeal liver assist devices and transplantation are currently available in human medicine. PROGNOSIS The prognosis for ALF depends upon the etiology, the degree of liver damage, and the response to therapy. In veterinary medicine, the prognosis is generally poor.
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Sato H, Tomita K, Yasue C, Umeda R, Ebinuma H, Ogata S, Du W, Soga S, Maruta K, Yasutake Y, Narimatsu K, Usui S, Watanabe C, Komoto S, Teratani T, Suzuki T, Yokoyama H, Saito H, Nagao S, Hibi T, Miura S, Kanai T, Hokari R. Pregnant woman with non-comatose autoimmune acute liver failure in the second trimester rescued using medical therapy: A case report. Hepatol Res 2015; 45:349-55. [PMID: 24739014 DOI: 10.1111/hepr.12344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 04/09/2014] [Accepted: 04/14/2014] [Indexed: 12/12/2022]
Abstract
We present the case of a 25-year-old woman at 16 weeks of gestation who presented with non-comatose autoimmune acute liver failure and was at high risk of developing fulminant hepatitis. Predictive formulas indicated a high probability of developing fulminant hepatitis. Unenhanced computed tomography showed marked hepatic atrophy and broadly heterogeneous hypoattenuating areas. The course of her illness was subacute, and the etiology of liver injury was unclear. Considering all of the above, we predicted a poor prognosis. Plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy were initiated just after admission. A few days after admission, a high titer (×80) of antinuclear antibody was noted. Because autoimmune hepatitis (AIH) was considered a cause of liver failure, treatment with moderate prednisolone (30 mg/day) doses was administrated, with careful consideration of her pregnancy. Thereafter, her laboratory findings and clinical course gradually improved without the need for liver transplantation. A liver biopsy at 18 days after admission indicated a diagnosis of AIH. She continued the pregnancy and delivered a healthy baby without any complications. Eventually, prednisolone doses were decreased to 10 mg, after which her liver function worsened. The second liver biopsy also indicated a diagnosis of AIH. Accordingly, low-dose prednisolone and azathioprine doses (50 mg/day) were administrated to recover her liver function, after which her liver function regained normalcy. This case illustrates that a pregnant woman with non-comatose autoimmune acute liver failure in the first or second trimester of pregnancy and her fetus can be rescued by PE/CHDF therapy and safe moderate doses of prednisolone.
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Affiliation(s)
- Hirokazu Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Defense Medical College, Saitama, Japan
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34
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Fujiwara K, Ohtsuka M, Yokosuka O. Radiologic and histologic heterogeneity in a case of autoimmune acute liver failure. Clin Gastroenterol Hepatol 2014; 12:e19-20. [PMID: 23962551 DOI: 10.1016/j.cgh.2013.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/31/2013] [Accepted: 08/10/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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A case of primary biliary cirrhosis and autoimmune hepatitis overlap showing acute presentation and transient seropositivity for immunoglobulin G and anti-nuclear antibody. Clin J Gastroenterol 2013; 6:465-9. [PMID: 26182138 DOI: 10.1007/s12328-013-0423-9] [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: 07/15/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Abstract
Autoimmune hepatitis (AIH) is generally regarded as a clinically and histologically "chronic" hepatitis. It often shows acute presentation like acute hepatitis without typical clinicopathological features of AIH, especially in a case of overlap with primary biliary cirrhosis (PBC). A 52-year-old man showed mild liver dysfunction for the first time at an annual medical check. Two months later, he showed jaundice, and laboratory tests revealed elevation of liver enzymes, hyperbilirubinemia and prolonged prothrombin time activity like acute liver failure. Anti-mitochondrial antibody was positive and other viral and autoimmune markers were negative. His liver function tests improved upon treatment with ursodeoxycholic acid and maximum intravenous glycyrrhizin (IVGL), but liver dysfunction was again exacerbated after the gradual reduction of IVGL. He showed transient elevation of immunoglobulin G (IgG) and anti-nuclear antibody (ANA) at only one point, and liver histology was compatible with PBC and AIH overlap syndrome. Corticosteroid was administered and his liver function tests returned to normal. It is important for the diagnosis of acute onset AIH to monitor IgG level and ANA titer, especially in patients without IgG and ANA elevations at first appearance.
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Czaja AJ. Letter: treatment of autoimmune acute liver failure--beyond consensus guidelines; author's reply. Aliment Pharmacol Ther 2013; 38:1144. [PMID: 24099481 DOI: 10.1111/apt.12498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 08/30/2013] [Indexed: 12/08/2022]
Affiliation(s)
- A J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Czaja AJ. Review article: the management of autoimmune hepatitis beyond consensus guidelines. Aliment Pharmacol Ther 2013; 38:343-64. [PMID: 23808490 DOI: 10.1111/apt.12381] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 05/30/2013] [Accepted: 06/03/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Consensus guidelines aid in the diagnosis and management of autoimmune hepatitis, but they are frequently based on low-quality clinical evidence, conflicting experiences and divergent opinions. Recommendations may be weak, discrepant or non-existent at critical decision points. AIMS To identify the decision points where guidelines are weak or non-existent and review the evidence essential in the decision process. METHODS Full-text articles published in English using the keyword 'autoimmune hepatitis' were identified by PubMed from 1972 to 2013. Personal experience and investigations in autoimmune hepatitis also identified important contributions. RESULTS Seventy per cent of the guidelines developed by the American Association for the Study of Liver Diseases and 48% of those proposed by the British Society of Gastroenterology are based on low-quality evidence, conflicting experiences or divergent opinions. The key uncertainties in diagnosis relate to the timing of liver biopsy, recognising acute severe (fulminant) disease, interpreting coincidental nonclassical histological changes, accommodating atypical or deficient features in non-White patients, differentiating drug-induced from classical disease and identifying overlap syndromes. The key uncertainties in management relate to pre-treatment testing for thiopurine methyltransferase activity, treating asymptomatic mild disease, determining treatment end points, managing suboptimal responses, incorporating nonstandard medications as front-line and salvage agents, using azathioprine in pregnancy and instituting surveillance for hepatocellular carcinoma. CONCLUSIONS Consensus guidelines are fraught with uncertainties in the diagnosis and management of autoimmune hepatitis. Each decision point must counterbalance the current available evidence and tailor the application of this evidence to the individual patient.
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Affiliation(s)
- A J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Tanaka A. Acute presentation of autoimmune hepatitis: How to find and manage still remains unsolved. Hepatol Res 2013; 43:577-9. [PMID: 23730706 DOI: 10.1111/hepr.12031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Itabashi, Japan
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Abstract
Autoimmune hepatitis frequently has an abrupt onset of symptoms, and it can present with acute liver failure. The abrupt presentation can indicate spontaneous exacerbation of a pre-existent chronic disease, newly created disease, a superimposed infectious or toxic injury, or new disease after viral infection, drug therapy, or liver transplantation. Deficiencies in the classical phenotype may include a low serum immunoglobulin G level and low or absent titers of the conventional autoantibodies. The original revised diagnostic scoring system of the International Autoimmune Hepatitis Group can guide the diagnostic evaluation, but low scores do not preclude the diagnosis. Liver tissue examination is valuable to exclude viral-related or drug-induced liver injury and support the diagnosis by demonstrating centrilobular necrosis (usually with interface hepatitis), lymphoplasmacytic infiltration, hepatocyte rosettes, and fibrosis. Conventional therapy with prednisone and azathioprine induces clinical and laboratory improvement in 68-75 % of patients with acute presentations, and high dose prednisone or prednisolone (preferred drug) is effective in 20-100 % of patients with acute severe (fulminant) presentations. Failure to improve or worsening of any clinical or laboratory feature within 2 weeks of treatment or worsening of a mathematical model of end-stage liver disease within 7 days justifies liver transplantation in acute liver failure. Liver transplantation for acute severe (fulminant) autoimmune hepatitis is as successful as liver transplantation for autoimmune hepatitis with a chronic presentation and other types of acute liver failure (patient survival >1 year, 80-94 %). Liver transplantation should not be delayed or superseded by protracted corticosteroid therapy or the empiric institution of nonstandard medications.
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Fujiwara K, Yasui S, Yokosuka O. Autoimmune acute liver failure: an emerging etiology for intractable acute liver failure. Hepatol Int 2012. [PMID: 26201768 DOI: 10.1007/s12072-012-9402-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Keiichi Fujiwara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Shin Yasui
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Osamu Yokosuka
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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