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Kowdley KV, Bowlus CL, Levy C, Akarca US, Alvares-da-Silva MR, Andreone P, Arrese M, Corpechot C, Francque SM, Heneghan MA, Invernizzi P, Jones D, Kruger FC, Lawitz E, Mayo MJ, Shiffman ML, Swain MG, Valera JM, Vargas V, Vierling JM, Villamil A, Addy C, Dietrich J, Germain JM, Mazain S, Rafailovic D, Taddé B, Miller B, Shu J, Zein CO, Schattenberg JM. Efficacy and Safety of Elafibranor in Primary Biliary Cholangitis. N Engl J Med 2024; 390:795-805. [PMID: 37962077 DOI: 10.1056/nejmoa2306185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Primary biliary cholangitis is a rare, chronic cholestatic liver disease characterized by the destruction of interlobular bile ducts, leading to cholestasis and liver fibrosis. Whether elafibranor, an oral, dual peroxisome proliferator-activated receptor (PPAR) α and δ agonist, may have benefit as a treatment for primary biliary cholangitis is unknown. METHODS In this multinational, phase 3, double-blind, placebo-controlled trial, we randomly assigned (in a 2:1 ratio) patients with primary biliary cholangitis who had had an inadequate response to or unacceptable side effects with ursodeoxycholic acid to receive once-daily elafibranor, at a dose of 80 mg, or placebo. The primary end point was a biochemical response (defined as an alkaline phosphatase level of <1.67 times the upper limit of the normal range, with a reduction of ≥15% from baseline, and normal total bilirubin levels) at week 52. Key secondary end points were normalization of the alkaline phosphatase level at week 52 and a change in pruritus intensity from baseline through week 52 and through week 24, as measured on the Worst Itch Numeric Rating Scale (WI-NRS; scores range from 0 [no itch] to 10 [worst itch imaginable]). RESULTS A total of 161 patients underwent randomization. A biochemical response (the primary end point) was observed in 51% of the patients (55 of 108) who received elafibranor and in 4% (2 of 53) who received placebo, for a difference of 47 percentage points (95% confidence interval [CI], 32 to 57; P<0.001). The alkaline phosphatase level normalized in 15% of the patients in the elafibranor group and in none of the patients in the placebo group at week 52 (difference, 15 percentage points; 95% CI, 6 to 23; P = 0.002). Among patients who had moderate-to-severe pruritus (44 patients in the elafibranor group and 22 in the placebo group), the least-squares mean change from baseline through week 52 on the WI-NRS did not differ significantly between the groups (-1.93 vs. -1.15; difference, -0.78; 95% CI, -1.99 to 0.42; P = 0.20). Adverse events that occurred more frequently with elafibranor than with placebo included abdominal pain, diarrhea, nausea, and vomiting. CONCLUSIONS Treatment with elafibranor resulted in significantly greater improvements in relevant biochemical indicators of cholestasis than placebo. (Funded by GENFIT and Ipsen; ELATIVE ClinicalTrials.gov number, NCT04526665.).
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Affiliation(s)
- Kris V Kowdley
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Christopher L Bowlus
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Cynthia Levy
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Ulus S Akarca
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Mario Reis Alvares-da-Silva
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Pietro Andreone
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Marco Arrese
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Christophe Corpechot
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Sven M Francque
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Michael A Heneghan
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Pietro Invernizzi
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - David Jones
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Frederik C Kruger
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Eric Lawitz
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Marlyn J Mayo
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Mitchell L Shiffman
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Mark G Swain
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - José Miguel Valera
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Victor Vargas
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - John M Vierling
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Alejandra Villamil
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Carol Addy
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Julie Dietrich
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Jean-Michel Germain
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Sarah Mazain
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Dragutin Rafailovic
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Bachirou Taddé
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Benjamin Miller
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Jianfen Shu
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Claudia O Zein
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
| | - Jörn M Schattenberg
- From Liver Institute Northwest, Seattle (K.V.K.); the Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento (C.L.B.); Schiff Center for Liver Diseases, University of Miami, Miami (C.L.); the Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey (U.S.A.); Gastroenterology and Hepatology Division, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (M.R.A.-S.); Medicina Interna Metabolica, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena and Università di Modena e Reggio Emilia, Modena (P.A.), and the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza (P.I.) - all in Italy; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago (M.A.), and Sección de Gastroenterología, Hospital San Juan de la Serena, Coquimbo (J.M. Valera) - both in Chile; the Reference Center for Inflammatory Biliary Disease and Autoimmune Hepatitis, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, AP-HP, Sorbonne University, Paris (C.C.), GENFIT, Loos (J.-M.G., D.R., B.T.), and Ipsen, Boulogne-Billancourt (S.M.) - all in France; the Department of Gastroenterology and Hepatology, Antwerp University Hospital, and InflaMed Center of Excellence, Laboratory of Experimental Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Antwerp University - both in Antwerp, Belgium (S.M.F.); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London (M.A.H.), the Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Center, Newcastle University, Newcastle Upon Tyne (D.J.) - all in the United Kingdom; the Department of Gastroenterology and Hepatology, Mediclinic Durbanville, and Tiervlei Trial Centre - both in Cape Town, South Africa (F.C.K.); the Texas Liver Institute, University of Texas Health, San Antonio (E.L.), the Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M. Vierling) - all in Texas; the Liver Institute of Virginia, Bon Secours Mercy Health, Richmond (M.L.S.); the Liver Unit, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (M.G.S.); Liver Unit, European Reference Network RARE-LIVER, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CiberEhd, Barcelona (V.V.); Hepatic Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); GENFIT (C.A., J.D.) and Ipsen (B.M., J.S., C.O.Z.) - both in Cambridge, MA; and the Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, and the Department of Medicine II, Saarland University and Saarland University Medical Center, Homburg - both in Germany (J.M.S.)
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Hirschfield GM, Bowlus CL, Mayo MJ, Kremer AE, Vierling JM, Kowdley KV, Levy C, Villamil A, Ladrón de Guevara Cetina AL, Janczewska E, Zigmond E, Jeong SH, Yilmaz Y, Kallis Y, Corpechot C, Buggisch P, Invernizzi P, Londoño Hurtado MC, Bergheanu S, Yang K, Choi YJ, Crittenden DB, McWherter CA. A Phase 3 Trial of Seladelpar in Primary Biliary Cholangitis. N Engl J Med 2024; 390:783-794. [PMID: 38381664 DOI: 10.1056/nejmoa2312100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Effective treatments for patients with primary biliary cholangitis are limited. Seladelpar, a peroxisome proliferator-activated receptor delta agonist, has potential benefits. METHODS In this phase 3, 12-month, double-blind, placebo-controlled trial, we randomly assigned (in a 2:1 ratio) patients who had had an inadequate response to or who had a history of unacceptable side effects with ursodeoxycholic acid to receive oral seladelpar at a dose of 10 mg daily or placebo. The primary end point was a biochemical response, which was defined as an alkaline phosphatase level less than 1.67 times the upper limit of the normal range, with a decrease of 15% or more from baseline, and a normal total bilirubin level at month 12. Key secondary end points were normalization of the alkaline phosphatase level at month 12 and a change in the score on the pruritus numerical rating scale (range, 0 [no itch] to 10 [worst itch imaginable]) from baseline to month 6 among patients with a baseline score of at least 4 (indicating moderate-to-severe pruritus). RESULTS Of the 193 patients who underwent randomization and treatment, 93.8% received ursodeoxycholic acid as standard-of-care background therapy. A greater percentage of the patients in the seladelpar group than in the placebo group had a biochemical response (61.7% vs. 20.0%; difference, 41.7 percentage points; 95% confidence interval [CI], 27.7 to 53.4, P<0.001). Normalization of the alkaline phosphatase level also occurred in a greater percentage of patients who received seladelpar than of those who received placebo (25.0% vs. 0%; difference, 25.0 percentage points; 95% CI, 18.3 to 33.2, P<0.001). Seladelpar resulted in a greater reduction in the score on the pruritus numerical rating scale than placebo (least-squares mean change from baseline, -3.2 vs. -1.7; least-squares mean difference, -1.5; 95% CI, -2.5 to -0.5, P = 0.005). Adverse events were reported in 86.7% of the patients in the seladelpar group and in 84.6% in the placebo group, and serious adverse events in 7.0% and 6.2%, respectively. CONCLUSIONS In this trial involving patients with primary biliary cholangitis, the percentage of patients who had a biochemical response and alkaline phosphatase normalization was significantly greater with seladelpar than with placebo. Seladelpar also significantly reduced pruritus among patients who had moderate-to-severe pruritus at baseline. The incidence and severity of adverse events were similar in the two groups. (Funded by CymaBay Therapeutics; RESPONSE ClinicalTrials.gov number, NCT04620733; EudraCT number, 2020-004348-27.).
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Affiliation(s)
- Gideon M Hirschfield
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Christopher L Bowlus
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Marlyn J Mayo
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Andreas E Kremer
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - John M Vierling
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Kris V Kowdley
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Cynthia Levy
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Alejandra Villamil
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Alma L Ladrón de Guevara Cetina
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Ewa Janczewska
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Ehud Zigmond
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Sook-Hyang Jeong
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Yusuf Yilmaz
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Yiannis Kallis
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Christophe Corpechot
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Peter Buggisch
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Pietro Invernizzi
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Maria Carlota Londoño Hurtado
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Sandrin Bergheanu
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Ke Yang
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Yun-Jung Choi
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Daria B Crittenden
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
| | - Charles A McWherter
- From the Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University Health Network, Toronto General Hospital, Toronto (G.M.H.); the Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento (C.L.B.), and CymaBay Therapeutics, Newark (K.Y., Y.-J.C., D.B.C., C.A.M.) - both in California; the University of Texas Southwestern Medical School, Dallas (M.J.M.), and the Departments of Medicine and Surgery, Baylor College of Medicine, Houston (J.M.V.) - both in Texas; the Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (A.E.K.); Liver Institute Northwest, Seattle (K.V.K.); the Division of Digestive Health and Liver Diseases, University of Miami, Miami (C.L.); the Liver Autoimmunity Unit, Hospital Italiano de Buenos Aires, Buenos Aires (A.V.); Centro de Investigación y Gastroenterología, Mexico City (A.L.L.G.C.); the Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland (E.J.); the Gastroenterology Institute, Tel Aviv Sourasky Medical Center, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.Z.); the Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, South Korea (S.-H.J.); the Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey (Y.Y.); Barts Liver Centre, Blizard Institute, Queen Mary University of London, London (Y.K.); the Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, French Network for Rare Liver Disease in Children and Adults FILFOIE, European Reference Network RARE-LIVER, Saint-Antoine Hospital and Research Center, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris (C.C.); Liver Centre Hamburg at Ifi-Institute, Hamburg, Germany (P.B.); the Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, and the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori - both in Monza, Italy (P.I.); the Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBEREHD, European Reference Network on Hepatological Diseases (ERN-LIVER), University of Barcelona, Barcelona (M.C.L.H.); and Saberg Clinical Research, the Hague, the Netherlands (S.B.). Dr. Hirschfield is the Lily and Terry Horner Chair in Autoimmune Liver Disease Research at Toronto General Hospital
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3
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Zheng L, Tian S, Yang C, Li B, Jia G, Liu Y, Sun R, Wang X, Deng J, Zhang M, Cui L, Guo C, Zhou X, Leung PSC, Bowlus CL, Gershwin ME, Shang Y, Han Y. Hypercholesterolemia Is Associated With Dysregulation of Lipid Metabolism and Poor Prognosis in Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00167-8. [PMID: 38354969 DOI: 10.1016/j.cgh.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND & AIMS Hypercholesterolemia is frequently diagnosed in patients with primary biliary cholangitis (PBC). However, its association with the prognosis and lipid metabolism is unknown. In this study, we aimed to investigate the prognostic value of baseline total cholesterol (TC) levels in PBC and characterized the associated lipid metabolism. METHODS Five hundred and thirty-one patients with PBC without prior cirrhosis-related complications were randomly divided into the derivation and validation cohorts at a ratio of 7:3. Complete clinical data were obtained and analyzed. The endpoints were defined as liver-related death, liver transplantation, and cirrhosis-related complications. Lipidomics was performed in 89 patients and 28 healthy controls. RESULTS Baseline TC was independently associated with poor liver-related outcomes, and adjusted C-statistics were 0.80 (95% confidence interval [CI]: 0.74-0.85) and 0.88 (95% CI: 0.78-0.91) in the derivation and validation cohorts, respectively. The predictive ability of TC for disease outcomes was stable over time and comparable with the Globe score. The 200 mg/dL cut-off optimally divided patients into low- and high-TC groups. A combination of TC and Globe score provided a more accurate stratification of patients into risk subgroups. Lipidomics indicated an up-regulation of lipid families in high-TC patients. Pathway analysis of 66 up-regulated lipids revealed the dysregulation of glycerophospholipid and sphingolipid metabolism in high-TC patients, which were associated with poor liver-related outcomes. CONCLUSIONS Our results indicate that patients with PBC having baseline TC levels above 200 mg/dL have unique lipidome characteristics and are at a higher risk of poor liver-related outcomes.
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Affiliation(s)
- Linhua Zheng
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Siyuan Tian
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Chunmei Yang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Bo Li
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Gui Jia
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Yansheng Liu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Ruiqing Sun
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Xiufang Wang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Juan Deng
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Miao Zhang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Lina Cui
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Changcun Guo
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Xinmin Zhou
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China
| | - Patrick S C Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, California
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Davis, California
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, California.
| | - Yulong Shang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China.
| | - Ying Han
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, China.
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4
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Mohamed R, Tejaswi S, Aabakken L, Ponsioen CY, Bowlus CL, Adler DG, Forbes N, Paulsen V, Voermans RP, Urayama S, Peetermans J, Rousseau MJ, Eksteen B. Per-oral cholangioscopy in patients with primary sclerosing cholangitis: a 12-month follow-up study. Endosc Int Open 2024; 12:E237-E244. [PMID: 38362361 PMCID: PMC10869209 DOI: 10.1055/a-2236-7557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/22/2023] [Indexed: 02/17/2024] Open
Abstract
Background and study aims Patients with primary sclerosing cholangitis (PSC) have a 9% to 20% lifetime incidence of cholangiocarcinoma (CCA). Per-oral cholangioscopy (POCS) added to endoscopic retrograde cholangiography (ERC) could potentially improve detection of CCA occurrence. We prospectively assessed POCS identification of 12-month CCA incidence in PSC patients undergoing ERC. Patients and methods Consecutive patients with PSC, an indication for ERC, and no prior liver transplantation were enrolled. During the index procedure, POCS preceded planned therapeutic maneuvers. The primary endpoint was ability for POCS visualization with POCS-guided biopsy to identify CCA during 12-month follow-up. Secondary endpoints included ability of ERC/cytology to identify CCA, repeat ERC, liver transplantation, and serious adverse events (SAEs). Results Of 42 patients enrolled, 36 with successful cholangioscope advancement were analyzed. Patients had a mean age 43.5±15.6 years and 61% were male. Three patients diagnosed with CCA had POCS visualization impressions of benign/suspicious/suspicious, and respective POCS-guided biopsy findings of suspicious/positive/suspicious for malignancy at the index procedure. The three CCA cases had ERC visualization impressions of benign/benign/suspicious, and respective cytology findings of atypical/atypical/suspicious for malignancy. No additional patients were diagnosed with CCA during median 11.5-month follow-up. Twenty-three repeat ERCs (5 including POCS) were performed in 14 patients. Five patients had liver transplantation, one after CCA diagnosis and four after benign cytology at the index procedure. Three patients (7.1%) had post-ERC pancreatitis. No SAEs were POCS-related. Conclusions In PSC patients, POCS visualization/biopsy and ERC/cytology each identified three cases of CCA. Some patients had a repeat procedure and none experienced POCS-related SAEs.
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Affiliation(s)
- Rachid Mohamed
- Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Sooraj Tejaswi
- Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento, United States
| | - Lars Aabakken
- Dept of Transplantation Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Cyriel Y Ponsioen
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Christopher L Bowlus
- Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento, United States
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Adventist Porter Hospital, Denver,
| | - Nauzer Forbes
- Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Vemund Paulsen
- Dept of Transplantation Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Rogier P. Voermans
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Shiro Urayama
- Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento, United States
| | - Joyce Peetermans
- Clinical Endoscopy, Boston Scientific Corporation, Marlborough, United States
| | - Matthew J Rousseau
- Clinical Endoscopy, Boston Scientific Corporation, Marlborough, United States
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5
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Shah SK, Bowlus CL. Autoimmune Markers in Primary Biliary Cholangitis. Clin Liver Dis 2024; 28:93-101. [PMID: 37945165 DOI: 10.1016/j.cld.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease. The most common antibody associated with PBC is the anti-mitochondrial antibody (AMA), present in 90% to 95% of patients. For patients who are AMA-negative, novel biomarkers, such as antinuclear antibody-specific antibodies Sp100 and gp210 and anti-kelch-like-12 and anti-hexokinase-1 antibodies, may further aid in the diagnosis of PBC. Several laboratory methods, including immunofluorescence, enzyme-linked immunosorbent assay, immunoblotting, and bead-based assays, exist to evaluate for the presence of antibodies. This article describes various methods used to evaluate antibodies as well as describe the antibodies present in PBC.
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Affiliation(s)
- Shivani K Shah
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA 95817, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA 95817, USA.
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6
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Yazdanfar M, Zepeda J, Dean R, Wu J, Levy C, Goldberg D, Lammert C, Prenner S, Reddy KR, Pratt D, Forman L, Assis DN, Lytvyak E, Montano-Loza AJ, Gordon SC, Carey EJ, Ahn J, Schlansky B, Korzenik J, Karagozian R, Hameed B, Chandna S, Yu L, Bowlus CL. African American race does not confer an increased risk of clinical events in patients with primary sclerosing cholangitis. Hepatol Commun 2024; 8:e0366. [PMID: 38285883 PMCID: PMC10830082 DOI: 10.1097/hc9.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/01/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The natural history of primary sclerosing cholangitis (PSC) among African Americans (AA) is not well understood. METHODS Transplant-free survival and hepatic decompensation-free survival were assessed using a retrospective research registry from 16 centers throughout North America. Patients with PSC alive without liver transplantation after 2008 were included. Diagnostic delay was defined from the first abnormal liver test to the first abnormal cholangiogram/liver biopsy. Socioeconomic status was imputed by the Zip code. RESULTS Among 850 patients, 661 (77.8%) were non-Hispanic Whites (NHWs), and 85 (10.0%) were AA. There were no significant differences by race in age at diagnosis, sex, or PSC type. Inflammatory bowel disease was more common in NHWs (75.8% vs. 51.8% p=0.0001). The baseline (median, IQR) Amsterdam-Oxford Model score was lower in NHWs (14.3, 13.4-15.2 vs. 15.1, 14.1-15.7, p=0.002), but Mayo risk score (0.03, -0.8 to 1.1 vs. 0.02, -0.7 to 1.0, p=0.83), Model for End-stage Liver Disease (5.9, 2.8-10.7 vs. 6.4, 2.6-10.4, p=0.95), and cirrhosis (27.4% vs. 27.1%, p=0.95) did not differ. Race was not associated with hepatic decompensation, and after adjusting for clinical variables, neither race nor socioeconomic status was associated with transplant-free survival. Variables independently associated with death/liver transplant (HR, 95% CI) included age at diagnosis (1.04, 1.02-1.06, p<0.0001), total bilirubin (1.06, 1.04-1.08, p<0.0001), and albumin (0.44, 0.33-0.61, p<0.0001). AA race did not affect the performance of prognostic models. CONCLUSIONS AA patients with PSC have a lower rate of inflammatory bowel disease but similar progression to hepatic decompensation and liver transplant/death compared to NHWs.
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Affiliation(s)
- Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Richard Dean
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Jialin Wu
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - Cynthia Levy
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - David Goldberg
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | | | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Lisa Forman
- University of Colorado, Denver, Colorado, USA
| | | | - Ellina Lytvyak
- Division of Preventive Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart C. Gordon
- Henry Ford Health and Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Joseph Ahn
- Oregon Health Sciences University, Portland, Oregon, USA
| | | | | | | | - Bilal Hameed
- UC San Francisco, San Francisco, California, USA
| | | | - Lei Yu
- University of Washington, Seattle, Washington, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
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7
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Mayo MJ, Vierling JM, Bowlus CL, Levy C, Hirschfield GM, Neff GW, Galambos MR, Gordon SC, Borg BB, Harrison SA, Thuluvath PJ, Goel A, Shiffman ML, Swain MG, Jones DEJ, Trivedi P, Kremer AE, Aspinall RJ, Sheridan DA, Dörffel Y, Yang K, Choi YJ, McWherter CA. Open-label, clinical trial extension: Two-year safety and efficacy results of seladelpar in patients with primary biliary cholangitis. Aliment Pharmacol Ther 2024; 59:186-200. [PMID: 37904314 DOI: 10.1111/apt.17755] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/02/2023] [Accepted: 09/26/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Seladelpar is a potent and selective peroxisome proliferator-activated receptor-δ agonist that targets multiple cell types involved in primary biliary cholangitis (PBC), leading to anti-cholestatic, anti-inflammatory and anti-pruritic effects. AIMS To evaluate the long-term safety and efficacy of seladelpar in patients with PBC. METHODS In an open-label, international, long-term extension study, patients with PBC completing seladelpar lead-in studies continued treatment. Seladelpar was taken orally once daily at doses of 5 or 10 mg with dose adjustment permitted for safety or tolerability. The primary analysis was for safety and the secondary efficacy analysis examined biochemical markers of cholestasis and liver injury. The study was terminated early due to the unexpected histological findings in a concurrent study for non-alcoholic steatohepatitis, which were subsequently found to predate treatment. Safety and efficacy data were analysed through 2 years. RESULTS There were no serious treatment-related adverse events observed among 106 patients treated with seladelpar for up to 2 years. There were four discontinuations for safety, one possibly related to seladelpar. Among 53 patients who completed 2 years of seladelpar, response rates increased from years 1 to 2 for the composite endpoint (alkaline phosphatase [ALP] <1.67 × ULN, ≥15% decrease in ALP, and total bilirubin ≤ULN) and ALP normalisation from 66% to 79% and from 26% to 42%, respectively. In those with elevated bilirubin at baseline, 43% achieved normalisation at year 2. CONCLUSIONS Seladelpar was safe, and markedly improved biochemical markers of cholestasis and liver injury in patients with PBC. These effects were maintained or improved throughout the second year. CLINICALTRIALS gov: NCT03301506; Clinicaltrialsregister.eu: 2017-003910-16.
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Affiliation(s)
- Marlyn J Mayo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - John M Vierling
- Department of Medicine, Section of Gastroenterology and Hepatology, Department of Surgery, Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
- Schiff Center for Liver Diseases, University of Miami, Miami, Florida, USA
| | | | - Guy W Neff
- Covenant Metabolic Specialists LLC, Sarasota and Fort Myers, Florida, USA
| | | | - Stuart C Gordon
- Division of Hepatology, Henry Ford Health, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Brian B Borg
- Southern Therapy and Advanced Research LLC, Jackson, Mississippi, USA
| | | | - Paul J Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aparna Goel
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Mitchell L Shiffman
- Liver Institute of Virginia, Bon Secours Mercy Health, Richmond and Newport News, Virginia, USA
| | - Mark G Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David E J Jones
- Institute of Cellular Medicine and National Institute for Health Research (NIHR), Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Palak Trivedi
- National Institute for Health Research Birmingham (NIHR) Biomedical Research Centre (BRC), Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Andreas E Kremer
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Richard J Aspinall
- Department of Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - David A Sheridan
- Faculty of Health, University of Plymouth and South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Yvonne Dörffel
- Medical Outpatient Department, Charité Universitätsmedizin, Berlin, Germany
| | - Ke Yang
- Biometrics, CymaBay Therapeutics, Inc, Newark, California, USA
| | - Yun-Jung Choi
- Research and Development, CymaBay Therapeutics, Inc, Newark, California, USA
| | - Charles A McWherter
- Research and Development, CymaBay Therapeutics, Inc, Newark, California, USA
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8
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Grave EC, Loehfelm T, Corwin MT, Zepeda J, Bath HK, Dhaliwal S, Yazdanfar M, Bowlus CL. Interobserver agreement and prognostic value of image-based scoring systems in patients with primary sclerosing cholangitis. Abdom Radiol (NY) 2024; 49:60-68. [PMID: 37831167 DOI: 10.1007/s00261-023-04051-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a cholestatic liver disease that progresses to cirrhosis and liver failure. The Anali and Amsterdam scores are based upon imaging features on MRI and ERCP, respectively. AIMS We aimed to compare the interobserver variability and performances of these scores. METHODS Patients with PSC with at least 1 MRCP were included. Images were independently scored by 2 experts. Agreement and prognostic performance with a primary end point of hepatic decompensation was assessed. RESULTS Fifty-nine patients were included (67.8% male, 86.4% IBD). Interobserver agreement for the Anali and Amsterdam scores were moderate (k = 0.49; 95% CI 0.35-0.64 and k = 0.43; 95% CI 0.30-0.56, respectively). Among the Anali components, dysmorphy (caudate/right lobe ratio > 0.9) had fair agreement (k = 0.37; 95% CI 0.14-0.60) and portal hypertension (k = 0.64, 95% CI 0.32-0.89) and intrahepatic dilation (k = 0.70; 95% CI 0.53-0.87) had substantial agreement. The Amsterdam extrahepatic and intrahepatic scores had fair agreement (k = 0.38; 95% CI 0.23-0.52) and moderate agreement (k = 0.50; 95% CI 0.34-0.67), respectively. Anali score (HR 5.90, 95% CI 1.64-21.21), total bilirubin (HR = 3.23; 95% Cl 1.06-9.91), and age (HR = 1.05; 95% CI 1.00-1.11) were independent predictors of hepatic decompensation. Mayo risk score and Anali score had good discriminative ability with c-statistics of 0.78 (CI 0.59-0.96) and 0.76 (CI 0.56-0.91). Anali score remained an independent predictor after adjusting for Mayo risk score. CONCLUSION Anali score adds additional predictive value for hepatic decompensation in patients with PSC.
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Affiliation(s)
- Erick Cruz Grave
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Thomas Loehfelm
- Department of Radiology, University of California Davis School of Medicine, Sacramento, USA
| | - Michael T Corwin
- Department of Radiology, University of California Davis School of Medicine, Sacramento, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Harjot K Bath
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Sandeep Dhaliwal
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, USA.
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, Suite 3500, Sacramento, CA, 95817, USA.
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Mayo MJ, Vierling JM, Bowlus CL. Editorial: The evolving paradigms and treatments for primary biliary cholangitis-Authors' reply. Aliment Pharmacol Ther 2024; 59:282. [PMID: 38153281 DOI: 10.1111/apt.17798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
LINKED CONTENTThis article is linked to Mayo et al papers. To view these articles, visithttps://doi.org/10.1111/apt.17755andhttps://doi.org/10.1111/apt.17779
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Affiliation(s)
- Marlyn J Mayo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - John M Vierling
- Department of Medicine, Section of Gastroenterology and Hepatology, Department of Surgery, Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
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10
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Bowlus CL, Levy C. Optimizing treatment of primary biliary cholangitis: Is good, good enough? Hepatology 2024; 79:3-5. [PMID: 37526603 DOI: 10.1097/hep.0000000000000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Affiliation(s)
| | - Cynthia Levy
- Schiff Center for Liver Disease and Division of Gastroenterology and Hepatology, University of Miami, Miami, Florida, USA
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Kremer AE, Mayo MJ, Hirschfield GM, Levy C, Bowlus CL, Jones DE, Johnson JD, McWherter CA, Choi YJ. Seladelpar treatment reduces IL-31 and pruritus in patients with primary biliary cholangitis. Hepatology 2023:01515467-990000000-00693. [PMID: 38117036 DOI: 10.1097/hep.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND AIMS Pruritus is a debilitating symptom for many people living with primary biliary cholangitis (PBC). In studies with seladelpar, a selective peroxisome proliferator-activated receptor-delta agonist, patients with PBC experienced significant improvement in pruritus and reduction of serum bile acids. Interleukin-31 (IL-31) is a cytokine known to mediate pruritus, and blocking IL-31 signaling provides relief in pruritic skin diseases. This study examined the connection between seladelpar's antipruritic effects and IL-31 and bile acid levels in patients with PBC. APPROACH AND RESULTS IL-31 levels were quantified in serum samples from the ENHANCE study of patients with PBC receiving daily oral doses of placebo (n = 55), seladelpar 5 mg (n = 53) or 10 mg (n = 53) for 3 months, and for healthy volunteers (n = 55). IL-31 levels were compared with pruritus using a numerical rating scale (NRS, 0-10) and with bile acid levels. Baseline IL-31 levels closely correlated with pruritus NRS ( r = 0.54, p < 0.0001), and total ( r = 0.54, p < 0.0001) and conjugated bile acids (up to 0.64, p < 0.0001). Decreases in IL-31 were observed with seladelpar 5 mg (-30%, p = 0.0003) and 10 mg (-52%, p < 0.0001) versus placebo (+31%). Patients with clinically meaningful improvement in pruritus (NRS ≥ 2 decrease) demonstrated greater dose-dependent reductions in IL-31 compared to those without pruritus improvement (NRS < 2 decrease). Strong correlations were observed for the changes between levels of IL-31 and total bile acids ( r = 0.63, p < 0.0001) in the seladelpar 10 mg group. CONCLUSIONS Seladelpar decreased serum IL-31 and bile acids in patients with PBC. The reductions of IL-31 and bile acids correlated closely with each other and pruritus improvement, suggesting a mechanism to explain seladelpar's antipruritic effects.
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Affiliation(s)
- Andreas E Kremer
- Department of Gastroenterology and Hepatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, Texas, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
- Schiff Center for Liver Diseases, University of Miami, Miami, Florida, USA
| | - Christopher L Bowlus
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - David E Jones
- Clinical and Translation Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Yun-Jung Choi
- CymaBay Therapeutics, Inc., Fremont, California, USA
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12
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Shao T, Hsu R, Rafizadeh DL, Wang L, Bowlus CL, Kumar N, Mishra J, Timilsina S, Ridgway WM, Gershwin ME, Ansari AA, Shuai Z, Leung PSC. The gut ecosystem and immune tolerance. J Autoimmun 2023; 141:103114. [PMID: 37748979 DOI: 10.1016/j.jaut.2023.103114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
The gastrointestinal tract is home to the largest microbial population in the human body. The gut microbiota plays significant roles in the development of the gut immune system and has a substantial impact on the maintenance of immune tolerance beginning in early life. These microbes interact with the immune system in a dynamic and interdependent manner. They generate immune signals by presenting a vast repertoire of antigenic determinants and microbial metabolites that influence the development, maturation and maintenance of immunological function and homeostasis. At the same time, both the innate and adaptive immune systems are involved in modulating a stable microbial ecosystem between the commensal and pathogenic microorganisms. Hence, the gut microbial population and the host immune system work together to maintain immune homeostasis synergistically. In susceptible hosts, disruption of such a harmonious state can greatly affect human health and lead to various auto-inflammatory and autoimmune disorders. In this review, we discuss our current understanding of the interactions between the gut microbiota and immunity with an emphasis on: a) important players of gut innate and adaptive immunity; b) the contribution of gut microbial metabolites; and c) the effect of disruption of innate and adaptive immunity as well as alteration of gut microbiome on the molecular mechanisms driving autoimmunity in various autoimmune diseases.
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Affiliation(s)
- Tihong Shao
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China; Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Ronald Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Desiree L Rafizadeh
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, China
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Narendra Kumar
- Department of Pharmaceutical Science, ILR-College of Pharmacy, Texas A&M University, 1010 W. Ave B. MSC 131, Kingsville, TX, 78363, USA
| | - Jayshree Mishra
- Department of Pharmaceutical Science, ILR-College of Pharmacy, Texas A&M University, 1010 W. Ave B. MSC 131, Kingsville, TX, 78363, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - William M Ridgway
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Aftab A Ansari
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
| | - Patrick S C Leung
- Division of Rheumatology/Allergy and Clinical Immunology, Department of Internal Medicine, University of California, Davis, CA, 95616, USA.
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13
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Hirschfield GM, Shiffman ML, Gulamhusein A, Kowdley KV, Vierling JM, Levy C, Kremer AE, Zigmond E, Andreone P, Gordon SC, Bowlus CL, Lawitz EJ, Aspinall RJ, Pratt DS, Raikhelson K, Gonzalez-Huezo MS, Heneghan MA, Jeong SH, Ladrón de Guevara AL, Mayo MJ, Dalekos GN, Drenth JP, Janczewska E, Leggett BA, Nevens F, Vargas V, Zuckerman E, Corpechot C, Fassio E, Hinrichsen H, Invernizzi P, Trivedi PJ, Forman L, Jones DE, Ryder SD, Swain MG, Steinberg A, Boudes PF, Choi YJ, McWherter CA. Seladelpar efficacy and safety at 3 months in patients with primary biliary cholangitis: ENHANCE, a phase 3, randomized, placebo-controlled study. Hepatology 2023; 78:397-415. [PMID: 37386786 PMCID: PMC10344437 DOI: 10.1097/hep.0000000000000395] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS ENHANCE was a phase 3 study that evaluated efficacy and safety of seladelpar, a selective peroxisome proliferator-activated receptor-δ (PPAR) agonist, versus placebo in patients with primary biliary cholangitis with inadequate response or intolerance to ursodeoxycholic acid (UDCA). APPROACH AND RESULTS Patients were randomized 1:1:1 to oral seladelpar 5 mg (n=89), 10 mg (n=89), placebo (n=87) daily (with UDCA, as appropriate). Primary end point was a composite biochemical response [alkaline phosphatase (ALP) < 1.67×upper limit of normal (ULN), ≥15% ALP decrease from baseline, and total bilirubin ≤ ULN] at month 12. Key secondary end points were ALP normalization at month 12 and change in pruritus numerical rating scale (NRS) at month 6 in patients with baseline score ≥4. Aminotransferases were assessed. ENHANCE was terminated early following an erroneous safety signal in a concurrent, NASH trial. While blinded, primary and secondary efficacy end points were amended to month 3. Significantly more patients receiving seladelpar met the primary end point (seladelpar 5 mg: 57.1%, 10 mg: 78.2%) versus placebo (12.5%) ( p < 0.0001). ALP normalization occurred in 5.4% ( p =0.08) and 27.3% ( p < 0.0001) of patients receiving 5 and 10 mg seladelpar, respectively, versus 0% receiving placebo. Seladelpar 10 mg significantly reduced mean pruritus NRS versus placebo [10 mg: -3.14 ( p =0.02); placebo: -1.55]. Alanine aminotransferase decreased significantly with seladelpar versus placebo [5 mg: 23.4% ( p =0.0008); 10 mg: 16.7% ( p =0.03); placebo: 4%]. There were no serious treatment-related adverse events. CONCLUSIONS Patients with primary biliary cholangitis (PBC) with inadequate response or intolerance to UDCA who were treated with seladelpar 10 mg had significant improvements in liver biochemistry and pruritus. Seladelpar appeared safe and well tolerated.
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Affiliation(s)
- Gideon M. Hirschfield
- University Health Network and Division of Gastroenterology and Hepatology, Toronto Centre for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell L. Shiffman
- Liver Institute of Virginia, Bon Secours Mercy Health, Bon Secours Liver Institute of Richmond, Richmond, Virginia, USA
- Bon Secours Liver Institute of Hampton Roads, Newport News, Virginia, USA
| | - Aliya Gulamhusein
- University Health Network and Department of Medicine, Toronto Centre for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | | | - John M. Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Andreas E. Kremer
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Ehud Zigmond
- Center for Autoimmune Liver Diseases, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Maternal-Infantile and Adult, University of Modena and Reggio Emilia, Modena, Italy
- Postgraduate School of Allergy and Clinical Immunology, University of Modena and Reggio Emilia, Italy
| | - Stuart C. Gordon
- Division of Hepatology, Henry Ford Hospital, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Eric J. Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Richard J. Aspinall
- Department of Hepatology, Portsmouth Liver Centre, Portsmouth Hospitals National Health Service Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Daniel S. Pratt
- Autoimmune and Cholestatic Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karina Raikhelson
- Saint Petersburg State University, St. Petersburg, Russia
- City Hospital 31, St. Petersburg, Russia
| | | | - Michael A. Heneghan
- King’s College Hospital National Health Service Foundation Trust, London, UK
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | - Marlyn J. Mayo
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, USA
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Joost P.H. Drenth
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Ewa Janczewska
- Department of Basic Medical Sciences, Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice, Poland
- ID Clinic, Myslowice, Poland
| | - Barbara A. Leggett
- School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Frederik Nevens
- University Hospitals KU Leuven, Belgium
- Center of European Reference Network (ERN) RARE-LIVER, Leuven, Belgium
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Eli Zuckerman
- Liver Unit, Carmel Medical Center, Technion, Faculty of Medicine, Israeli Association for the Study of the Liver, Haifa, Israel
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology and Gastroenterology Department (MIVB-H), Filière Maladies Rares: Maladies Rares du Foie de l’Adulte et de l’Enfant (FILFOIE), European Reference Network (ERN) RARE-LIVER, Inserm, Centre de Recherche Saint-Antoine (CRSA), Assistance Publique-Hopitaux of Paris (AP-HP), Saint-Antoine Hospital, Sorbonne Universités, Paris, France
| | - Eduardo Fassio
- DIM Clínica Privada, Ramos Mejía, Buenos Aires province, Argentina
| | | | - Pietro Invernizzi
- Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milano-Bicocca, Monza, Italy
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori & European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Monza, Italy
| | - Palak J. Trivedi
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, UK
| | - Lisa Forman
- University of Colorado, Aurora, Colorado, USA
| | - David E.J. Jones
- Institute of Cellular Medicine and National Institute for Health Research (NIHR) Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen D. Ryder
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre at Nottingham University Hospitals National Health Service (NHS) Trust and the University of Nottingham, Queens Medical Centre, Nottingham, UK
| | - Mark G. Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Assis DN, Bowlus CL. Recent Advances in the Management of Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2023; 21:2065-2075. [PMID: 37084929 DOI: 10.1016/j.cgh.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by fibroinflammatory damage to the biliary tree, typically in the setting of inflammatory bowel disease, with an increased risk of liver failure and cholangiocarcinoma. A complex pathophysiology, heterogeneity in clinical features, and the rare nature of the disease have contributed to the lack of effective therapy to date. However, recent innovations in the characterization and prognostication of patients with PSC, in addition to new tools for medical management and emerging pharmacologic agents, give rise to the potential for meaningful progress in the next several years. This review summarizes current concepts in PSC and highlights particular areas in need of further study.
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Bowlus CL, Arrivé L, Bergquist A, Deneau M, Forman L, Ilyas SI, Lunsford KE, Martinez M, Sapisochin G, Shroff R, Tabibian JH, Assis DN. Reply: Insurance should cover vancomycin for primary sclerosing cholangitis. Hepatology 2023; 77:E176-E177. [PMID: 36695291 DOI: 10.1097/hep.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis Health, Sacramento, California, USA
| | | | - Annika Bergquist
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Mark Deneau
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lisa Forman
- Division of Gastroenterology, University of Colorado, Aurora, Colorado, USA
| | - Sumera I Ilyas
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Keri E Lunsford
- New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Mercedes Martinez
- Vagelos College of Physician and Surgeons, Columbia University, New York, New York, USA
| | | | - Rachna Shroff
- Division of Hematology and Oncology Tucson, University of Arizona, Arizona, USA
| | - James H Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David N Assis
- Yale School of Medicine, New Haven, Connecticut, USA
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Bowlus CL, Eksteen B, Cheung AC, Thorburn D, Moylan CA, Pockros PJ, Forman LM, Dorenbaum A, Hirschfield GM, Kennedy C, Jaecklin T, McKibben A, Chien E, Baek M, Vig P, Levy C. Safety, tolerability, and efficacy of maralixibat in adults with primary sclerosing cholangitis: Open-label pilot study. Hepatol Commun 2023; 7:02009842-202306010-00003. [PMID: 37184523 DOI: 10.1097/hc9.0000000000000153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/16/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is frequently associated with pruritus, which significantly impairs quality of life. Maralixibat is a selective ileal bile acid transporter (IBAT) inhibitor that lowers circulating bile acid (BA) levels and reduces pruritus in cholestatic liver diseases. This is the first proof-of-concept study of IBAT inhibition in PSC. METHODS This open-label study evaluated the safety and tolerability of maralixibat ≤10 mg/d for 14 weeks in adults with PSC. Measures of pruritus, biomarkers of BA synthesis, cholestasis, and liver function were also assessed. RESULTS Of 27 enrolled participants, 85.2% completed treatment. Gastrointestinal treatment-emergent adverse events (TEAEs) occurred in 81.5%, with diarrhea in 51.9%. TEAEs were mostly mild or moderate (63.0%); 1 serious TEAE (cholangitis) was considered treatment related. Mean serum BA (sBA) levels decreased by 16.7% (-14.84 µmol/L; 95% CI, -27.25 to -2.43; p = 0.0043) by week 14/early termination (ET). In participants with baseline sBA levels above normal (n = 18), mean sBA decreased by 40.0% (-22.3 µmol/L, 95% CI, -40.38 to -4.3; p = 0.004) by week 14/ET. Liver enzyme elevations were not significant; however, increases of unknown clinical significance in conjugated bilirubin levels were observed. ItchRO weekly sum scores decreased from baseline to week 14/ET by 8.4% (p = 0.0495), by 12.6% (p = 0.0275) in 18 participants with pruritus at baseline, and by 70% (p = 0.0078) in 8 participants with ItchRO daily average score ≥3 at baseline. CONCLUSIONS Maralixibat was associated with reduced sBA levels in adults with PSC. In participants with more severe baseline pruritus, pruritus improved significantly from baseline. TEAEs were mostly gastrointestinal related. These results support further investigation of IBAT inhibitors for adults with PSC-associated pruritus. ClinicalTrials.gov: NCT02061540.
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Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | | | - Angela C Cheung
- Division of Gastroenterology, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital and Institute of Liver and Digestive Health, University College London, Royal Free Campus, Hampstead, London, UK
| | - Cynthia A Moylan
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Paul J Pockros
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California, USA
| | - Lisa M Forman
- Division of Gastroenterology-Hepatology, University of Colorado, Aurora, Colorado, USA
| | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Elaine Chien
- Mirum Pharmaceuticals, Foster City, California, USA
| | | | - Pamela Vig
- Mirum Pharmaceuticals, Foster City, California, USA
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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Trauner M, Chung C, Sterling K, Liu X, Lu X, Xu J, Tempany-Afdhal C, Goodman ZD, Färkkilä M, Tanaka A, Trivedi P, Kowdley KV, Bowlus CL, Levy C, Myers RP. PRIMIS: design of a pivotal, randomized, phase 3 study evaluating the safety and efficacy of the nonsteroidal farnesoid X receptor agonist cilofexor in noncirrhotic patients with primary sclerosing cholangitis. BMC Gastroenterol 2023; 23:75. [PMID: 36922785 PMCID: PMC10015541 DOI: 10.1186/s12876-023-02653-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/13/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic progressive liver disease leading to biliary fibrosis and cirrhosis. Cilofexor is a nonsteroidal farnesoid X receptor agonist that demonstrated significant improvements in liver biochemistry and markers of cholestasis in patients with PSC in a phase 2 study. We describe here the rationale, design, and implementation of the phase 3 PRIMIS trial, the largest placebo-controlled trial in PSC. METHODS Adults with large-duct PSC without cirrhosis are randomized 2:1 to receive oral cilofexor 100 mg once daily or placebo for up to 96 weeks during the blinded phase. Patients completing the blinded phase are eligible to receive open-label cilofexor 100 mg daily for up to 96 weeks. The primary objective is to evaluate whether cilofexor reduces the risk of fibrosis progression compared with placebo. Liver biopsy is performed at screening and Week 96 of the blinded phase for histologic assessment of fibrosis. The primary endpoint-chosen in conjunction with guidance from the U.S. Food and Drug Administration-is the proportion of patients with ≥ 1-stage increase in fibrosis according to Ludwig histologic classification at week 96. Secondary objectives include evaluation of changes in liver biochemistry, serum bile acids, liver fibrosis assessed by noninvasive methods, health-related quality of life, and safety of cilofexor. CONCLUSION The phase 3 PRIMIS study is the largest randomized, double-blind, placebo-controlled trial in PSC to date and will allow for robust evaluation of the efficacy and safety of cilofexor in noncirrhotic patients with large-duct PSC. TRIAL REGISTRATION ClinicalTrials.gov NCT03890120; registered 26/03/2019.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | | | - Kate Sterling
- Gilead Sciences, Inc., 333 Lakeside Dr, Foster City, CA, 94404, USA
| | - Xiangyu Liu
- Gilead Sciences, Inc., 333 Lakeside Dr, Foster City, CA, 94404, USA
| | - Xiaomin Lu
- Gilead Sciences, Inc., 333 Lakeside Dr, Foster City, CA, 94404, USA.
| | - Jun Xu
- Gilead Sciences, Inc., 333 Lakeside Dr, Foster City, CA, 94404, USA
| | - Clare Tempany-Afdhal
- Department of Radiology, Ferenc Jolesz National Center for Image Guided Therapy, Brigham and Women's Hospital, 75 Francis St, L1 Rm 050, Boston, MA, 02115, USA
| | - Zachary D Goodman
- Hepatic Pathology Consultation and Research, Inova Fairfax Hospital, 8110 Gatehouse Rd, Falls Church, VA, 22042, USA
| | - Martti Färkkilä
- Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-Ku, Tokyo, 173-8605, Japan
| | - Palak Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, ITM Building, Mindelsohn Way, Edgbaston, Birmingham, B15 2TT, UK
| | - Kris V Kowdley
- Liver Institute Northwest, 3216 NE 45 Pl #212, Seattle, WA, 98105, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, 4150 V Street, Sacramento, CA, 95817, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami, Jackson Medical Towers, 1500 NW 12 Ave, Suite 1101 ET, Miami, FL, 33136, USA
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Bowlus CL, Arrivé L, Bergquist A, Deneau M, Forman L, Ilyas SI, Lunsford KE, Martinez M, Sapisochin G, Shroff R, Tabibian JH, Assis DN. AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma. Hepatology 2023; 77:659-702. [PMID: 36083140 DOI: 10.1002/hep.32771] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology , University of California Davis Health , Sacramento , California , USA
| | | | - Annika Bergquist
- Karolinska Institutet , Karolinska University Hospital , Stockholm , Sweden
| | - Mark Deneau
- University of Utah , Salt Lake City , Utah , USA
| | - Lisa Forman
- University of Colorado , Aurora , Colorado , USA
| | - Sumera I Ilyas
- Mayo Clinic College of Medicine and Science , Rochester , Minnesota , USA
| | - Keri E Lunsford
- Rutgers University-New Jersey Medical School , Newark , New Jersey , USA
| | - Mercedes Martinez
- Vagelos College of Physicians and Surgeons , Columbia University , New York , New York , USA
| | | | | | - James H Tabibian
- David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | - David N Assis
- Yale School of Medicine , New Haven , Connecticut , USA
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19
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Xu J, Wang Y, Khoshdeli M, Peach M, Chuang J, Lin J, Tsai W, Mahadevan S, Minto W, Diehl L, Gupta R, Trauner M, Patel K, Noureddin M, Kowdley KV, Gulamhusein A, Bowlus CL, Huss RS, Myers RP, Chung C, Billin AN. IL-31 levels correlate with pruritus in patients with cholestatic and metabolic liver diseases and is farnesoid X receptor responsive in NASH. Hepatology 2023; 77:20-32. [PMID: 35686937 PMCID: PMC9970017 DOI: 10.1002/hep.32599] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/03/2022] [Accepted: 05/12/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Pruritus is associated with multiple liver diseases, particularly those with cholestasis, but the mechanism remains incompletely understood. Our aim was to evaluate serum IL-31 as a putative biomarker of pruritus in clinical trials of an farnesoid X receptor (FXR) agonist, cilofexor, in patients with NASH, primary sclerosing cholangitis (PSC), and primary biliary cholangitis (PBC). APPROACH AND RESULTS Serum IL-31 was measured in clinical studies of cilofexor in NASH, PSC, and PBC. In patients with PSC or PBC, baseline IL-31 was elevated compared to patients with NASH and healthy volunteers (HVs). IL-31 correlated with serum bile acids among patients with NASH, PBC, and PSC. Baseline IL-31 levels in PSC and PBC were positively correlated with Visual Analog Scale for pruritus and 5-D itch scores. In patients with NASH, cilofexor dose-dependently increased IL-31 from Week (W)1 to W24. In patients with NASH receiving cilofexor 100 mg, IL-31 was higher in those with Grade 2-3 pruritus adverse events (AEs) than those with Grade 0-1 pruritus AEs. IL-31 weakly correlated with C4 at baseline in patients with NASH, and among those receiving cilofexor 100 mg, changes in IL-31 and C4 from baseline to W24 were negatively correlated. IL-31 messenger RNA (mRNA) was elevated in hepatocytes from patients with PSC and NASH compared to HVs. In a humanized liver murine model, obeticholic acid increased IL-31 mRNA expression in human hepatocytes and serum levels of human IL-31. CONCLUSIONS IL-31 levels correlate with pruritus in patients with cholestatic disease and NASH, with FXR agonist therapy resulting in higher serum levels in the latter group. IL-31 appears to derive in part from increased hepatocyte expression. These findings have therapeutic implications for patients with liver disease and pruritus.
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Affiliation(s)
- Jun Xu
- Gilead Sciences, Inc., Foster City, California, USA
| | - Ya Wang
- Gilead Sciences, Inc., Foster City, California, USA
| | | | - Matt Peach
- Gilead Sciences, Inc., Foster City, California, USA
| | | | - Julie Lin
- Gilead Sciences, Inc., Foster City, California, USA
| | - Wen‐Wei Tsai
- Gilead Sciences, Inc., Foster City, California, USA
| | | | - Wesley Minto
- Gilead Sciences, Inc., Foster City, California, USA
| | - Lauri Diehl
- Gilead Sciences, Inc., Foster City, California, USA
| | - Ruchi Gupta
- Gilead Sciences, Inc., Foster City, California, USA
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Keyur Patel
- University of Toronto, Toronto, Ontario, Canada
| | - Mazen Noureddin
- Fatty Liver Program, Cedars‐Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | - Ryan S. Huss
- Gilead Sciences, Inc., Foster City, California, USA
| | | | - Chuhan Chung
- Gilead Sciences, Inc., Foster City, California, USA
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20
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Murillo Perez CF, Fisher H, Hiu S, Kareithi D, Adekunle F, Mayne T, Malecha E, Ness E, van der Meer AJ, Lammers WJ, Trivedi PJ, Battezzati PM, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Parés A, Londoño MC, Invernizzi P, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Gulamhusein A, Janssen HLA, Smith R, Flack S, Mulcahy V, Trauner M, Bowlus CL, Lindor KD, Corpechot C, Jones D, Mells G, Hirschfield GM, Wason J, Hansen BE. Greater Transplant-Free Survival in Patients Receiving Obeticholic Acid for Primary Biliary Cholangitis in a Clinical Trial Setting Compared to Real-World External Controls. Gastroenterology 2022; 163:1630-1642.e3. [PMID: 36150526 DOI: 10.1053/j.gastro.2022.08.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/19/2022] [Accepted: 08/30/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The Primary Biliary Cholangitis (PBC) Obeticholic Acid (OCA) International Study of Efficacy (POISE) randomized, double-blind, placebo-controlled trial demonstrated that OCA reduced biomarkers associated with adverse clinical outcomes (ie, alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase) in patients with PBC. The objective of this study was to evaluate time to first occurrence of liver transplantation or death in patients with OCA in the POISE trial and open-label extension vs comparable non-OCA-treated external controls. METHODS Propensity scores were generated for external control patients meeting POISE eligibility criteria from 2 registry studies (Global PBC and UK-PBC) using an index date selected randomly between the first and last date (inclusive) on which eligibility criteria were met. Cox proportional hazards models weighted by inverse probability of treatment assessed time to death or liver transplantation. Additional analyses (Global PBC only) added hepatic decompensation to the composite end point and assessed efficacy in patients with or without cirrhosis. RESULTS During the 6-year follow-up, there were 5 deaths or liver transplantations in 209 subjects in the POISE cohort (2.4%), 135 of 1381 patients in the Global PBC control (10.0%), and 281 of 2135 patients in the UK-PBC control (13.2%). The hazard ratios (HRs) for the primary outcome were 0.29 (95% CI, 0.10-0.83) for POISE vs Global PBC and 0.30 (95% CI, 0.12-0.75) for POISE vs UK-PBC. In the Global PBC study, HR was 0.20 (95% CI, 0.03-1.22) for patients with cirrhosis and 0.31 (95% CI, 0.09-1.04) for those without cirrhosis; HR was 0.42 (95% CI, 0.21-0.85) including hepatic decompensation. CONCLUSIONS Patients treated with OCA in a trial setting had significantly greater transplant-free survival than comparable external control patients.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Holly Fisher
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Tracy Mayne
- Intercept Pharmaceuticals, Morristown, New Jersey
| | | | - Erik Ness
- Intercept Pharmaceuticals, Morristown, New Jersey
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Frederik Nevens
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | | | | | - Andrew L Mason
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Albert Parés
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Maria-Carlota Londoño
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Pietro Invernizzi
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; San Gerardo Hospital, Monza, Italy
| | | | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marlyn J Mayo
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - George N Dalekos
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Xavier Verhelst
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rachel Smith
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Steve Flack
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Victoria Mulcahy
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | - David Jones
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - George Mells
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James Wason
- Department of Biostatistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands, Toronto, Ontario, Canada; IHPME, University of Toronto, Toronto, Ontario, Canada.
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21
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Levy C, Kendrick S, Bowlus CL, Tanaka A, Jones D, Kremer AE, Mayo MJ, Haque N, von Maltzahn R, Allinder M, Swift B, McLaughlin MM, Hirschfield GM. GLIMMER: A Randomized Phase 2b Dose-Ranging Trial of Linerixibat in Primary Biliary Cholangitis Patients With Pruritus. Clin Gastroenterol Hepatol 2022:S1542-3565(22)01021-7. [PMID: 36343847 DOI: 10.1016/j.cgh.2022.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS GLIMMER assessed dose-response, efficacy, and safety of linerixibat, an ileal bile acid transporter inhibitor in development for cholestatic pruritus associated with primary biliary cholangitis (PBC). METHODS GLIMMER was a Phase 2b, multicenter, randomized, parallel-group study in adults with PBC and moderate-to-severe pruritus (≥4 on 0-10 numerical rating scale [NRS]). After 4 weeks of single-blind placebo, patients with NRS ≥3 were randomized (3:1) to double-blind linerixibat/placebo for 12 weeks (to week 16), followed by single-blind placebo (to week 20). The primary objective was to investigate dose-related changes in mean worst daily itch (MWDI) score. RESULTS One hundred forty-seven patients received placebo (n = 36) or linerixibat (once daily: 20 mg, n = 16; 90 mg, n = 23; 180 mg, n = 27; twice daily: 40 mg, n = 23; 90 mg, n = 22). Linerixibat groups exhibited ≥2-point mean reductions in MWDI from baseline at week 16; however, differences from placebo were not significant. Post hoc analysis of change from baseline in monthly itch score over the treatment period (Phase 3 endpoint) showed significant differences between placebo and linerixibat 180 mg once daily (P = .0424), 40 mg twice daily (P = .0105), and 90 mg twice daily (P = .0370). A significant relationship between total daily dose and response was observed post hoc in the per protocol population (P = .0542). Consistent with mechanism of action, diarrhea was the most frequent adverse event, and incidence increased with dose. CONCLUSIONS Linerixibat effect on itch was not significantly different versus placebo in the primary intent-to-treat analysis but was associated with a significant dose-dependent reduction in itch in the per protocol population. A well-tolerated dose was identified for Phase 3 investigation for cholestatic pruritus in PBC. CLINICALTRIALS gov ID: NCT02966834.
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Affiliation(s)
- Cynthia Levy
- Digestive Health and Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, and Schiff Center for Liver Diseases, University of Miami, Miami, Florida
| | | | | | | | - David Jones
- Newcastle University, Newcastle, United Kingdom
| | - Andreas E Kremer
- Department of Gastroenterology and Hepatology, University of Zürich, Zürich, Switzerland; Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nürnberg, Germany
| | | | | | | | | | | | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada.
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22
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Bowlus CL, Levy C, Hirschfield GM. Reply to: "Seladelpar in patients with primary biliary cholangitis: Need for a closer look!". J Hepatol 2022; 77:1452-1453. [PMID: 35977610 DOI: 10.1016/j.jhep.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Christopher L Bowlus
- Department of Internal Medicine, University of California, Davis, Davis, California, United States.
| | - Cynthia Levy
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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23
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Liu CH, Bowlus CL. Treatment of Primary Biliary Cholangitis: First-Line and Second-Line Therapies. Clin Liver Dis 2022; 26:705-726. [PMID: 36270725 DOI: 10.1016/j.cld.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune disease of the interlobular bile ducts leading to secondary damage of hepatocytes and may progress to cirrhosis and liver failure. The first-line treatment is ursodeoxycholic acid; up to 40% of patients do not have an adequate response and remain at risk of disease progression. Obeticholic acid has been conditionally approved for the treatment of PBC as add-on therapy and bezafibrate has shown similar efficacy in this group of patients. Several new therapies are in development and may further add to the treatment options available to patients with PBC.
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Affiliation(s)
- Chung-Heng Liu
- Drexel University College of Medicine, 2900 W Queen Ln, Philadelphia, PA 19129 USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA 95817, USA.
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24
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Liu B, Yang GX, Sun Y, Tomiyama T, Zhang W, Leung PSC, He XS, Dhaliwal S, Invernizzi P, Gershwin ME, Bowlus CL. Decreased CD57 expression of natural killer cells enhanced cytotoxicity in patients with primary sclerosing cholangitis. Front Immunol 2022; 13:912961. [PMID: 36059513 PMCID: PMC9434697 DOI: 10.3389/fimmu.2022.912961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background/aims Primary sclerosing cholangitis (PSC) is a chronic inflammatory biliary disease for which the immunopathological basis remains an enigma. Natural killer (NK) cells are key components of innate immunity and seemingly play diversified roles in different autoimmune disorders (AIDs). The aim of this study was to determine the role of NK cells in the pathogenesis of PSC. Methods The frequency and phenotype of circulating NK cells in a large cohort of patients with PSC and healthy controls (HCs) were systematically examined. In addition, the functional capacity of NK cells including cytotoxicity and cytokine production was studied. Results The frequency of CD3−CD56dimCD16+ (defined as CD56dim) NK cells in PSC patients was significantly lower in comparison to HCs. CD56dim NK cells from PSC displayed a more immature phenotype including high expression of the natural killing receptor NKp46 and downregulation of the highly differentiated NK cell marker CD57. Interestingly, the reduction of CD57 expression of NK cells was associated with the disease severity of PSC. In addition, PSC CD56dim NK cells exhibited increased CD107a degranulation and cytolytic activity toward target cells compared with HCs. Further analysis demonstrated that CD57−CD56dim NK cells from PSC had elevated expression of NKp46, NKp30, IL-2 receptor, and KLRG1 and higher cytotoxic capacity as compared to CD57+CD56dim NK cells. Conclusions Our data demonstrate that the differentiation of PSC NK cells is dysregulated with enhanced cytotoxic activity. This change is likely to be functionally involved in pathogenesis and disease progression, deducing the potential of NK-directed immunotherapy for PSC.
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Affiliation(s)
- Bin Liu
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Department of Rheumatology and Immunology, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guo-Xiang Yang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- *Correspondence: Guo-Xiang Yang, ; Christopher L. Bowlus,
| | - Ying Sun
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Department of Liver Disease, Senior Department of Hepatology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Takashi Tomiyama
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Weici Zhang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Patrick S. C. Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Xiao-Song He
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Sandeep Dhaliwal
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, CA, United States
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, CA, United States
- *Correspondence: Guo-Xiang Yang, ; Christopher L. Bowlus,
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25
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Trauner M, Bowlus CL, Gulamhusein A, Hameed B, Caldwell SH, Shiffman ML, Landis C, Muir AJ, Billin A, Xu J, Liu X, Lu X, Chung C, Myers RP, Kowdley KV. Safety and sustained efficacy of the farnesoid X receptor (FXR) agonist cilofexor over a 96-week open-label extension in patients with PSC. Clin Gastroenterol Hepatol 2022; 21:1552-1560.e2. [PMID: 35934287 DOI: 10.1016/j.cgh.2022.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 06/09/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a major unmet medical need in clinical hepatology. Cilofexor is a nonsteroidal farnesoid X receptor agonist being evaluated for the treatment of PSC. Here, we describe the safety and preliminary efficacy of cilofexor in a 96-week, open-label extension (OLE) of a phase II trial. METHODS Noncirrhotic subjects with large-duct PSC who completed the 12-week, blinded phase of a phase II study (NCT02943460) were eligible, after a 4-week washout period, for a 96-week OLE with cilofexor 100 mg daily. Safety, liver biochemistry, and serum markers of fibrosis, cellular injury, and pharmacodynamic effects of cilofexor (fibroblast growth factor 19, C4, and bile acids [BAs]) were evaluated. RESULTS Among 52 subjects enrolled in the phase II study, 47 (90%) continued in the OLE phase (median age, 44 years; 60% male patients, 60% with inflammatory bowel disease, and 45% on ursodeoxycholic acid [UDCA]). At OLE baseline (BL), the median serum alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were 368 U/L (interquartile range [IQR], 277-468 U/L) and 417 U/L (IQR, 196-801 U/L), respectively. Of the 47 subjects enrolled, 15 (32%) discontinued treatment prematurely (pruritus [n = 5], other adverse events [n = 5], subject decision/investigator discretion [n = 5]). At week 96, reductions in liver biochemistry parameters occurred, including serum ALP (median, -8.3% [IQR, -25.9% to 11.0%]; P = .066), GGT (-29.8% [IQR, -42.3% to -13.9%]; P < .001), alanine aminotransaminase (ALT) (-29.8% [IQR, -43.7% to -6.6%]; P = .002), and aspartate aminotransaminase (AST) (-16.7% [IQR, -35.3% to 1.0%]; P = .010), and rebounded after 4 weeks of untreated follow-up. ALP response (≥20% reduction from BL to week 96) was similar in the presence or absence of UDCA therapy (29% vs 39%; P = .71). At week 96, cilofexor treatment was associated with a significant reduction in serum 7α-hydroxy-4-cholesten-3-one (C4) (-29.8% [IQR, -64.3% to -8.5%]; P = .001). In subjects with detectable serum BAs at BL (n = 40), BAs decreased -23.9% (IQR, -44.4% to -0.6%; P = .006) at week 48 (n = 28) and -25.7% (IQR, -35.9% to 53.7%; P = .91) at week 96 (n = 26). Serum cytokeratin 18 (CK18) M30 and M65 were reduced throughout the OLE; significant reductions were observed at week 72 (CK18 M30, -17.3% [IQR, -39.3% to 8.8%]; P = .018; CK18 M65, -43.5% [IQR, -54.9% to 15.3%]; P = .096). At week 96, a small, but statistically significant absolute increase of 0.15 units in Enhanced Liver Fibrosis score was observed compared with BL (median, 9.34 vs 9.53; P = .028). CONCLUSIONS In this 96-week OLE of a phase II study of PSC, cilofexor was safe and improved liver biochemistry and biomarkers of cholestasis and cellular injury. CLINICALTRIALS gov identifier: NCT02943460.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, California
| | | | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco School of Medicine, San Francisco, California
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia School of Medicine, Charlottesville, Virginia
| | | | - Charles Landis
- Division of Gastroenterology & Hepatology, University of Washington School of Medicine, Seattle, Washington
| | - Andrew J Muir
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | | | - Jun Xu
- Gilead Sciences, Inc, Foster City, California
| | - Xiangyu Liu
- Gilead Sciences, Inc, Foster City, California
| | - Xiaomin Lu
- Gilead Sciences, Inc, Foster City, California
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26
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Li J, Lu M, Zhou Y, Bowlus CL, Lindor K, Rodriguez-Watson C, Romanelli RJ, Haller IV, Anderson H, VanWormer JJ, Boscarino JA, Schmidt MA, Daida YG, Sahota A, Vincent J, Wu KHH, Trudeau S, Rupp LB, Melkonian C, Gordon SC. Dynamic Risk Prediction of Response to Ursodeoxycholic Acid Among Patients with Primary Biliary Cholangitis in the USA. Dig Dis Sci 2022; 67:4170-4180. [PMID: 34499271 DOI: 10.1007/s10620-021-07219-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) remains the first-line therapy for primary biliary cholangitis (PBC); however, inadequate treatment response (ITR) is common. The UK-PBC Consortium developed the modified UDCA Response Score (m-URS) to predict ITR (using alkaline phosphatase [ALP] > 1.67 times the upper limit of normal [*ULN]) at 12 months post-UDCA initiation). Using data from the US-based Fibrotic Liver Disease Consortium, we assessed the m-URS in our multi-racial cohort. We then used a dynamic modeling approach to improve prediction accuracy. METHODS Using data collected at the time of UDCA initiation, we assessed the m-URS using the original formula; then, by calibrating coefficients to our data, we also assessed whether it remained accurate when using Paris II criteria for ITR. Next, we developed and validated a dynamic risk prediction model that included post-UDCA initiation laboratory data. RESULTS Among 1578 patients (13% men; 8% African American, 9% Asian American/American Indian/Pacific Islander; 25% Hispanic), the rate of ITR was 27% using ALP > 1.67*ULN and 45% using Paris II criteria. M-URS accuracy was "very good" (AUROC = 0.87, sensitivity = 0.62, and specificity = 0.82) for ALP > 1.67*ULN and "moderate" (AUROC = 0.74, sensitivity = 0.57, and specificity = 0.70) for Paris II. Our dynamic model significantly improved accuracy for both definitions of ITR (ALP > 1.67*ULN: AUROC = 0.91; Paris II: AUROC = 0.81); specificity approached 100%. Roughly 9% of patients in our cohort were at the highest risk of ITR. CONCLUSIONS Early identification of patients who will not respond to UDCA treatment using a dynamic prediction model based on longitudinal, repeated risk factor measurements may facilitate earlier introduction of adjuvant treatment.
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Affiliation(s)
- Jia Li
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA.
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | | | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Carla Rodriguez-Watson
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Innovation in Medical Evidence Development and Surveillance, The Reagan-Udall Foundation for the FDA, Washington, DC, USA
| | | | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, MN, USA
| | - Heather Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, PA, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Amandeep Sahota
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | | | - Kuan-Han Hank Wu
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Christina Melkonian
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health System, and Wayne State University School of Medicine, Detroit, MI, USA
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27
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Trivedi PJ, Bowlus CL, Yimam KK, Razavi H, Estes C. Epidemiology, Natural History, and Outcomes of Primary Sclerosing Cholangitis: A Systematic Review of Population-based Studies. Clin Gastroenterol Hepatol 2022; 20:1687-1700.e4. [PMID: 34474162 DOI: 10.1016/j.cgh.2021.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to quantify the global epidemiology of primary sclerosing cholangitis (PSC), alongside the incidence of liver transplantation, cancer, and death, through robust systematic review of population-based data. METHODS We searched MEDLINE and EMBASE up to and including June 30, 2020 to identify population-based studies reporting the incidence and/or prevalence of PSC. Studies that did not report original data, or of exclusively pediatric-onset disease (diagnosis age <16 years) or exclusively PSC-associated with inflammatory bowel disease were excluded. RESULTS Of 4922 published studies, 17 fulfilled inclusion criteria; 16 documenting incidence and 14 prevalence. The highest reported incidence of PSC was reported in Northern Europe (Finland, 1.58 and Norway, 1.3 per-100,000 population, respectively) and North America (Minnesota, 1.47); with the lowest being observed across the Mediterranean Basin (Italy, 0.1). Prevalence ranged from 31.7 in Finland and 23.99 in Minnesota, to 1.33 in Singapore and 0.0 in Alaska. Of studies reporting temporal occurrence, an increase in disease incidence was observed across North America and Northern Europe (4 studies), alongside an increase in prevalence over time (4 studies). The incidence and risks for clinical outcomes were presented by 9 of the included studies. Median transplant-free survival ranged from 9.7 (United States) to 20.6 years (Netherlands), with standardized mortality ratios of 2.5 and 4.2 compared with the control population. The standardized incidence of cholangiocarcinoma ranged from 235 (Finland) to 398 (Netherlands). CONCLUSIONS Estimates of PSC incidence and prevalence vary, with most studies conducted in North America and Western Europe; the latter showing a steady increase in disease occurrence over time. Further research is needed to understand changes in disease epidemiology, including etiological drivers, the implications of rising case burden on health care policy, and better appreciation of PSC in the developing world.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom; Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, United Kingdom
| | | | - Kidist K Yimam
- Department of Hepatology and Liver Transplantation California Pacific Medical Center, San Francisco, California
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, Colorado
| | - Chris Estes
- Center for Disease Analysis Foundation, Lafayette, Colorado.
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28
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Bowlus CL, Galambos MR, Aspinall RJ, Hirschfield GM, Jones DEJ, Dörffel Y, Gordon SC, Harrison SA, Kremer AE, Mayo MJ, Thuluvath PJ, Levy C, Swain MG, Neff GW, Sheridan DA, Stanca CM, Berg CP, Goel A, Shiffman ML, Vierling JM, Boudes P, Steinberg A, Choi YJ, McWherter CA. A phase II, randomized, open-label, 52-week study of seladelpar in patients with primary biliary cholangitis. J Hepatol 2022; 77:353-364. [PMID: 35367282 DOI: 10.1016/j.jhep.2022.02.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS We examined the efficacy and safety of seladelpar, a selective peroxisome proliferator-activated receptor-delta agonist, in adults with primary biliary cholangitis (PBC) at risk of disease progression (alkaline phosphatase [ALP] ≥1.67xupper limit of normal [ULN]) who were receiving or intolerant to ursodeoxycholic acid. METHODS In this 52-week, phase II, dose-ranging, open-label study, patients were randomized (1:1) to seladelpar 5 mg/day (n = 53) or 10 mg/day (n = 55) or assigned to 2 mg/day (n = 11; United Kingdom sites after interim analysis) for 12 weeks. Doses could then be uptitrated to 10 mg/day. The primary efficacy endpoint was ALP change from baseline to Week 8. RESULTS Mean baseline ALP was 300, 345, and 295 U/L in the 2 mg, 5 mg, and 10 mg cohorts, respectively. Twenty-one percent of patients had cirrhosis, 71% had pruritus. At Week 8, mean ± standard error ALP reductions from baseline were 26 ± 2.8%, 33 ± 2.6%, and 41 ± 1.8% in the 2 mg (n = 11), 5 mg (n = 49), and 10 mg (n = 52) cohorts (all p ≤0.005), respectively. Responses were maintained or improved at Week 52, after dose escalation in 91% and 80% of the 2 mg and 5 mg cohorts, respectively. At Week 52, composite response (ALP <1.67xULN, ≥15% ALP decrease, and normal total bilirubin) rates were 64%, 53%, and 67%, and ALP normalization rates were 9%, 13%, and 33% in the 2 mg, 5 mg, and 10 mg cohorts, respectively. Pruritus visual analog scale score was decreased in the 5 mg and 10 mg cohorts. There were no treatment-related serious adverse events, and 4 patients discontinued due to adverse events. CONCLUSIONS Seladelpar demonstrated robust, dose-dependent, clinically significant, and durable improvements in biochemical markers of cholestasis and inflammation in patients with PBC at risk of disease progression. Seladelpar appeared safe and well tolerated and was not associated with any increase in pruritus. CLINICALTRIALS GOV NUMBER NCT02955602 CLINICALTRIALSREGISTER. EU NUMBER 2016-002996-91 LAY SUMMARY: Current treatment options for patients living with primary biliary cholangitis (PBC) are not optimal due to inadequate effectiveness or undesirable side effects. Patients with PBC who took seladelpar, a new treatment being developed for PBC, at increasing doses (2, 5, or 10 mg/day) for 1 year had clinically significant, dose-dependent improvements in key liver tests. Treatment appeared safe and was not associated with any worsening in patient self-reported itch scores.
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Affiliation(s)
- Christopher L Bowlus
- Department of Internal Medicine, University of California, Davis, Davis, California, United States.
| | - Michael R Galambos
- Digestive Healthcare of Georgia P.C., Piedmont Atlanta Hospital, Atlanta, Georgia, United States
| | - Richard J Aspinall
- Department of Hepatology, Portsmouth Liver Centre, Portsmouth Hospitals National Health Service Trust, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David E J Jones
- Institute of Cellular Medicine and NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Yvonne Dörffel
- Outpatient Clinic, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, United Kingdom; Pinnacle Clinical Research Center, San Antonio, Texas, United States
| | - Andreas E Kremer
- Department of Medicine 1, Gastroenterology, Hepatology, Pneumology and Endocrinology, Friedrich-Alexander-University of Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany; Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Paul J Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States; Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Cynthia Levy
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Mark G Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Guy W Neff
- Covenant Research, LLC, Sarasota, Florida, United States
| | - David A Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and University Hospitals Plymouth National Health Service Trust, Plymouth, United Kingdom
| | - Carmen M Stanca
- Transplant Hepatology, NYU Langone Health, New York, New York, United States
| | - Christoph P Berg
- Department of Internal Medicine I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, California, United States
| | - Mitchell L Shiffman
- Liver Institute of Virginia, Bon Secours Mercy Health, Richmond, Virginia, United States
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Pol Boudes
- CymaBay Therapeutics, Inc, Newark, California, United States
| | | | - Yun-Jung Choi
- CymaBay Therapeutics, Inc, Newark, California, United States
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29
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Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary biliary cholangitis: 2021 practice guidance update from the American Association for the Study of Liver Diseases. Hepatology 2022; 75:1012-1013. [PMID: 34431119 DOI: 10.1002/hep.32117] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 12/08/2022]
Affiliation(s)
| | | | - James Boyer
- Yale School of MedicineNew HavenConnecticutUSA
| | | | - Marlyn Mayo
- University of Texas Southwestern Medical CenterDallasTexasUSA
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30
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Kremer AE, Mayo MJ, Hirschfield G, Levy C, Bowlus CL, Jones DE, Steinberg A, McWherter CA, Choi YJ. Seladelpar improved measures of pruritus, sleep, and fatigue and decreased serum bile acids in patients with primary biliary cholangitis. Liver Int 2022; 42:112-123. [PMID: 34403559 DOI: 10.1111/liv.15039] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) can result in life-altering cholestatic pruritus and fatigue, but treatment options are limited. Seladelpar, a peroxisome proliferator-activated receptor-delta (PPARδ) agonist, has demonstrated potent anti-cholestatic effects in clinical studies. This open-label, uncontrolled phase 2 study in PBC patients evaluated the effects of 1-year of seladelpar treatment on measures of pruritus and quality of life. METHODS Self-reported experiences of 101 PBC patients were collected at baseline and after 1 year of seladelpar treatment using the pruritus visual analog scale (VAS), 5D-itch scale, and PBC-40 questionnaires along with bile acid profiles. RESULTS In patients with moderate-to-severe pruritus, substantial improvement in pruritus was seen in 58% and 93% of patients in 5/10 mg and 10 mg treatment groups, respectively. After 1 year, patients reporting improvement substantially outnumbered those who worsened in the total 5-D itch (including individual domains) and PBC-40 (itch and fatigue domains) questionnaires. Improvement in sleep disturbance at 1-year was reported in 81% (5/10 mg) and 78% (10 mg) of the patients with baseline itch-related sleep disturbance by 5-D itch score with similar results using the PBC-40 sleep questionnaire. Seladelpar-treated patients had significant reductions of 46% (5/10 mg) and 31% (10 mg) in the serum bile acid precursor C4 and reductions of up to 38% in serum bile acids. CONCLUSIONS Seladelpar treatment for 1 year led to consistent improvement in both symptom burden and biochemical response, suggesting its potential as a single agent to address two key unmet needs in PBC patients.
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Affiliation(s)
- Andreas E Kremer
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Department of Medicine 1, University Hospital Erlangen and Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX, USA
| | - Gideon Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine. Miami, Florida, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California Davis, Sacramento, CA, USA
| | - David E Jones
- Clinical and Translation Research Institute, Newcastle University, Newcastle upon Tyne, UK
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31
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Ponsioen CY, Assis DN, Boberg KM, Bowlus CL, Deneau M, Thorburn D, Aabakken L, Färkkilä M, Petersen B, Rupp C, Hübscher SG. Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process. Gastroenterology 2021; 161:1764-1775.e5. [PMID: 34384749 DOI: 10.1053/j.gastro.2021.07.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
| | - David N Assis
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Kirsten M Boberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine, and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway; ERN RARE Liver, Hamburg, Germany
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California
| | - Mark Deneau
- University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital and Institute for Liver and Digestive Health, University College London, London, United Kingdom; ERN RARE Liver, Hamburg, Germany
| | - Lars Aabakken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine, and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway; ERN RARE Liver, Hamburg, Germany
| | - Martti Färkkilä
- Abdominal Center, Helsinki University Hospital, Helsinki, Finland; ERN RARE Liver, Hamburg, Germany
| | - Bret Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Christian Rupp
- Department of Internal Medicine IV, Gastroenterology, and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan G Hübscher
- Institute of Immunology and Immunotherapy, University of Birmingham and, Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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32
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Mazi TA, Borkowski K, Newman JW, Fiehn O, Bowlus CL, Sarkar S, Matsukuma K, Ali MR, Kieffer DA, Wan YJY, Stanhope KL, Havel PJ, Medici V. Ethnicity-specific alterations of plasma and hepatic lipidomic profiles are related to high NAFLD rate and severity in Hispanic Americans, a pilot study. Free Radic Biol Med 2021; 172:490-502. [PMID: 34182070 PMCID: PMC8712226 DOI: 10.1016/j.freeradbiomed.2021.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/19/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a progressive condition that includes steatosis (NAFL) and nonalcoholic steatohepatitis (NASH). In the U.S., Hispanics (HIS) are afflicted with NAFLD at a higher rate and severity compared to other ethnicities. To date, the mechanisms underlying this disparity have not been elucidated. In this pilot study, we compared untargeted plasma metabolomic profiles for primary metabolism, complex lipids, choline and related compounds between a group of HIS (n = 7) and White Caucasian (CAU, n = 8) subjects with obesity and biopsy-characterized NAFL to ethnicity-matched lean healthy controls (n = 14 HIS and 8 CAU). We also compared liver and plasma metabolomic profiles in a group of HIS and CAU subjects with obesity and NASH of comparable NAFLD Activity Scores, to BMI-matched NASH-free subjects in both ethnicities. Results highlight signs of metabolic dysregulation observed in HIS, independent of obesity, including higher plasma triglycerides, acylcarnitines, and free fatty acids. With NASH progression, there were ethnicity-related differences in the hepatic profile, including higher free fatty acids and lysophospholipids seen in HIS, suggesting lipotoxicity is involved in the progression of NASH. We also observed greater hepatic triglyceride content, higher plasma triglyceride concentrations and lower hepatic phospholipids with signs of impaired hepatic mitochondrial β-oxidation. These findings provide preliminary evidence indicating ethnicity-related variations that could potentially modulate the risk for progression of NALD to NASH.
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Affiliation(s)
- Tagreed A Mazi
- Department of Nutrition, University of California Davis, 3135 Meyer Hall, One Shields Avenue, Davis, CA, 95616, USA; Department of Community Health Sciences-Clinical Nutrition, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh, 11433, Saudi Arabia.
| | - Kamil Borkowski
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, 95616, USA
| | - John W Newman
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, 95616, USA; United States Department of Agriculture-Agriculture Research Service-Western Human Nutrition Research Center, Davis, CA, 95616, USA; Department of Nutrition, University of California-Davis, Davis, CA, 95616, USA
| | - Oliver Fiehn
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, 95616, USA
| | - Christopher L Bowlus
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of California Davis, 4150 V Street, Suite 3500 Sacramento, CA, 95817, USA
| | - Souvik Sarkar
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of California Davis, 4150 V Street, Suite 3500 Sacramento, CA, 95817, USA
| | - Karen Matsukuma
- Department of Pathology and Laboratory Medicine, University of California-Davis, Sacramento, CA, 95817, USA
| | - Mohamed R Ali
- Department of Surgery, University of California, Davis, 2221 Stockton Boulevard, Cypress Building, Sacramento, CA, 95817, USA
| | - Dorothy A Kieffer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of California Davis, 4150 V Street, Suite 3500 Sacramento, CA, 95817, USA
| | - Yu-Jui Y Wan
- Department of Pathology and Laboratory Medicine, University of California-Davis, Sacramento, CA, 95817, USA
| | - Kimber L Stanhope
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA, 95616, USA
| | - Peter J Havel
- Department of Nutrition, University of California-Davis, Davis, CA, 95616, USA; Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA, 95616, USA
| | - Valentina Medici
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of California Davis, 4150 V Street, Suite 3500 Sacramento, CA, 95817, USA.
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Maverakis E, Merleev AA, Park D, Kailemia MJ, Xu G, Ruhaak LR, Kim K, Hong Q, Li Q, Leung P, Liakos W, Wan YJY, Bowlus CL, Marusina AI, Lal NN, Xie Y, Luxardi G, Lebrilla CB. Glycan biomarkers of autoimmunity and bile acid-associated alterations of the human glycome: Primary biliary cirrhosis and primary sclerosing cholangitis-specific glycans. Clin Immunol 2021; 230:108825. [PMID: 34403816 DOI: 10.1016/j.clim.2021.108825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/13/2022]
Abstract
We have recently introduced multiple reaction monitoring (MRM) mass spectrometry as a novel tool for glycan biomarker research and discovery. Herein, we employ this technique to characterize the site-specific glycan alterations associated with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). Glycopeptides associated with disease severity were also identified. Multinomial regression modelling was employed to construct and validate multi-analyte diagnostic models capable of accurately distinguishing PBC, PSC, and healthy controls from one another (AUC = 0.93 ± 0.03). Finally, to investigate how disease-relevant environmental factors can influence glycosylation, we characterized the ability of bile acids known to be differentially expressed in PBC to alter glycosylation. We hypothesize that this could be a mechanism by which altered self-antigens are generated and become targets for immune attack. This work demonstrates the utility of the MRM method to identify diagnostic site-specific glycan classifiers capable of distinguishing even related autoimmune diseases from one another.
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Affiliation(s)
- Emanual Maverakis
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA.
| | - Alexander A Merleev
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Dayoung Park
- Department of Chemistry, University of California Davis, Davis, CA, USA; Department of Surgery, Center for Drug Discovery and Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Wyss Institute of Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | | | - Gege Xu
- Department of Chemistry, University of California Davis, Davis, CA, USA
| | - L Renee Ruhaak
- Department of Chemistry, University of California Davis, Davis, CA, USA; Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, ZA, Leiden, the Netherlands
| | - Kyoungmi Kim
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - Qiuting Hong
- Department of Chemistry, University of California Davis, Davis, CA, USA
| | - Qiongyu Li
- Department of Chemistry, University of California Davis, Davis, CA, USA
| | - Patrick Leung
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis School of Medicine, Davis, CA, USA
| | - William Liakos
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Yu-Jui Yvonne Wan
- Department of Medical Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, CA, USA
| | - Alina I Marusina
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Nelvish N Lal
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Yixuan Xie
- Department of Chemistry, University of California Davis, Davis, CA, USA
| | - Guillaume Luxardi
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Carlito B Lebrilla
- Department of Chemistry, University of California Davis, Davis, CA, USA; Department of Biochemistry and Molecular Medicine, University of California Davis, Davis, CA, USA; Foods for Health Institute, University of California Davis, Davis, CA, USA
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Trivedi PJ, Muir AJ, Levy C, Bowlus CL, Manns MP, Lu X, Crans G, Chung C, Subramanian GM, Myers RP, Goodman Z, Chalasani N, Vierling JM, Guha IN, Hirschfield GM. Inter- and Intra-individual Variation, and Limited Prognostic Utility, of Serum Alkaline Phosphatase in a Trial of Patients With Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2021; 19:1248-1257. [PMID: 32707342 DOI: 10.1016/j.cgh.2020.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 06/05/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Serum alkaline phosphatase (ALP) and the enhanced liver fibrosis (ELF) score are used as endpoints in trials of patients with primary sclerosing cholangitis (PSC). We aimed to quantify inter- and intra-individual variation in levels of ALP and the ELF score over time, and evaluated their association with fibrosis progression. METHODS We analyzed data from 234 patients with large-duct PSC enrolled in a 2-year, phase 2b placebo-controlled trial of simtuzumab. Participants were assessed by laboratory tests every 4 weeks, and liver biopsies collected at time of screening, week 48, and week 96. RESULTS Serum levels of ALP and ELF scores did not differ significantly between simtuzumab and placebo groups, so the data were pooled. Median per-patient variations in ALP between clinic visits were approximately 12% over 12 weeks, 20% over 48 weeks, and 20% over 96 weeks. Reductions, unrelated to study intervention, of more than 40% in ALP were observed in 10.9% of patients with baseline activity greater than 2-fold the upper limit of normal (ULN) and 12.5% of patients with more than 3-fold the ULN at 1 year. At 2 years, reductions of more than 40% in ALP were observed in 15.8% of patients with baseline activity greater than 2-fold the ULN and 17.9% of patients with more than 3-fold the ULN. Among the 209 patients with Ishak fibrosis stage 0-4 at baseline, serum ALP activity did not associate with development of cirrhosis or with a 2-point increase in fibrosis stage at 2 years. In contrast, the median per-patient variation in ELF scores between clinic visits was approximately 3% over 12 weeks, 4% over 48 weeks, and 4% over 96 weeks. Elevated ELF scores at baseline and at weeks 12, 24 and 48, each associated with development of cirrhosis at 2 years (odds ratio >2.75; P < .01 for all timepoints). ELF scores at baseline and weeks 12, 24 and 48, also associated with a 2-point increase in fibrosis stage at 2 years (odds ratios all greater than 2; P < .01 for all timepoints). CONCLUSIONS In an analysis of data from patients with large-duct PSC enrolled in a prospective trial, we found large interindividual and intraindividual variations in serum ALP activity. Serum ALP activity did not associate with disease progression over a 2-year period. Variations in ELF score were smaller, and scores determined at multiple timepoints associated with fibrosis progression and development of cirrhosis.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, United Kingdom; University Hospitals Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
| | - Andrew J Muir
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Xiaomin Lu
- Gilead Sciences, Inc, Foster City, California
| | | | | | | | | | | | - Naga Chalasani
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Indra Neil Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, ON, Canada.
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Hirschfield G, Jones D, Carbone M, Bowlus CL, Nevens F, Kremer AE, Liberman A, MacConell L, Hansen BE. A43 LONG-TERM EFFICACY AND SAFETY OF OBETICHOCLIC ACID IN PRIMARY BILIARY CHOLANGITIS: RESPONDER ANALYSIS OF OVER 5 YEARS OF TREATMENT IN THE POISE TRIAL. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Obeticholic acid (OCA), a potent farnesoid X receptor agonist, is approved as second-line treatment for primary biliary cholangitis (PBC) in patients with an incomplete response or intolerance to ursodeoxycholic acid.
Aims
We evaluated the effect of OCA in PBC patients enrolled in the POISE trial, comparing those who did or did not achieve the POISE response criteria.
Methods
The phase 3, randomized, double-blind, 1-year POISE trial evaluated the efficacy and safety of OCA 5 and 10 mg vs placebo in patients with PBC; a 5-year open-label extension followed in which all patients received OCA. This analysis evaluated longer-term efficacy and safety in patients who achieved the POISE primary endpoint of alkaline phosphatase (ALP) <1.67 × upper limit of normal (ULN), total bilirubin <ULN, and ALP decrease >15% from baseline after 1 year of OCA and in patients who were incomplete responders.
Results
The analysis included 86 patients who achieved the POISE primary endpoint at year 1 of OCA treatment and 107 incomplete responders (mean baseline ALP, 268 vs 356 U/L, respectively; P<0.0001). Mean change from baseline in ALP at year 5 was –101 U/L for responders and –121 U/L for incomplete responders (P<0.0001; Figure). Median (Q1, Q3) baseline GLOBE 10-year risk of event scores were 16 (11, 23) for responders and 25 (15, 43) for incomplete responders. Change from baseline in median (Q1, Q3) GLOBE 10-year risk of event at year 1, which includes age and thus increases with time, was –2 (–4, 2) for responders and –2 (–6, 4) for incomplete responders; at year 5, these changes were 2 (–2, 7) and 4 (–4, 11), respectively. Median (Q1, Q3) baseline UK-PBC 10-year risk of event scores were 5 (3, 8) for responders and 8 (4, 16) for incomplete responders. Change from baseline in median (Q1, Q3) UK-PBC 10-year risk of event at year 1 was –1 (–3, 0.2) for responders and –1 (–3, 1) for incomplete responders; at year 5, these changes were –0.8 (–2, 0.2) and –0.05 (–2, 2), respectively. The most frequently reported AEs among responders and incomplete responders were pruritus (67%, 86%) and fatigue (35%, 31%).
Conclusions
OCA treatment improved key biochemical markers of PBC, regardless of achieving the POISE primary endpoint after 1 year of OCA treatment. Changes in biochemical parameters over time were often similar between groups.
Funding Agencies
Intercept Pharmaceuticals
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Affiliation(s)
| | - D Jones
- Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - M Carbone
- Universita degli Studi di Milano-Bicocca, Milano, Lombardia, Italy
| | - C L Bowlus
- University of California Davis School of Medicine, Sacramento, CA
| | - F Nevens
- University Hospitals KU, Leuven, Belgium
| | - A E Kremer
- Friedrich Alexander University of Erlangen–Nürnberg, Erlangen, Germany
| | - A Liberman
- Intercept Pharmaceuticals, San Diego, CA
| | | | - B E Hansen
- University of Toronto, Toronto, ON, Canada
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Eksteen B, Bowlus CL, Montano-Loza AJ, Lefebvre E, Fischer L, Vig P, Martins EB, Ahmad J, Yimam KK, Pockros PJ, Feld JJ, Minuk G, Levy C. Efficacy and Safety of Cenicriviroc in Patients With Primary Sclerosing Cholangitis: PERSEUS Study. Hepatol Commun 2021; 5:478-490. [PMID: 33681680 PMCID: PMC7917279 DOI: 10.1002/hep4.1619] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/10/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022] Open
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease with no approved treatments. C-C chemokine receptor types 2 and 5 (CCR2/CCR5) play an important role in inflammation and fibrosis and are potential therapeutic targets for PSC. We evaluated the efficacy and safety of cenicriviroc (CVC), a dual antagonist of CCR2 and CCR5, for the treatment of PSC. This was a single-arm, open-label, exploratory study of CVC in adults with a clinical diagnosis of PSC, serum alkaline phosphatase (ALP) ≥1.5 times the upper limit of normal (ULN), with or without inflammatory bowel disease, across eight sites in the United States and Canada. The primary endpoint was percent change in ALP over 24 weeks; key secondary efficacy endpoints were proportion of participants who achieved ALP normalization and overall response (decrease to <1.5 times the ULN or 50% decrease). Of the 24 participants, 20 completed the study. The mean age was 43 years, 50% were female, and the mean body mass index was 25 kg/m2. From a median ALP baseline of 369 U/L (range: 173, 1,377 U/L), a median absolute reduction of 49.5 U/L (range: -460, 416 U/L) was achieved at week 24, corresponding to a median reduction of 18.0% (range: -46%, 89%). No participant achieved ALP normalization or a 50% decrease; 2 participants (10%) achieved a reduction in ALP to < 1.5 times the ULN, and 4 had ≥25% increase. Twenty participants (83.3%) reported at least one adverse event; most were mild to moderate in severity. The most frequent events were rash, fatigue, and dizziness. Conclusion: After 24 weeks of CVC treatment, adults with PSC achieved a modest reduction (median 18%) in the surrogate endpoint of ALP. CVC was well tolerated, and no new safety signals were observed. ClinicalTrials.gov identifier: NCT02653625.
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Affiliation(s)
| | | | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonABCanada
| | | | | | | | | | - Jawad Ahmad
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Kidist K Yimam
- Department of Hepatology and Liver TransplantationCalifornia Pacific Medical CenterSan FranciscoCAUSA
| | - Paul J Pockros
- Scripps Clinic and Scripps Translational Science InstituteLa JollaCAUSA
| | - Jordan J Feld
- Toronto Center for Liver DiseaseToronto General HospitalUniversity of TorontoTorontoONCanada
| | - Gerald Minuk
- John Buhler Research CenterUniversity of ManitobaWinnipegMBCanada
| | - Cynthia Levy
- Schiff Center for Liver DiseasesUniversity of MiamiMiamiFLUSA
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Gindin Y, Chung C, Jiang Z, Zhou JZ, Xu J, Billin AN, Myers RP, Goodman Z, Landi A, Houghton M, Green RM, Levy C, Kowdley KV, Bowlus CL, Muir AJ, Trauner M. A Fibrosis-Independent Hepatic Transcriptomic Signature Identifies Drivers of Disease Progression in Primary Sclerosing Cholangitis. Hepatology 2021; 73:1105-1116. [PMID: 32745270 PMCID: PMC8048608 DOI: 10.1002/hep.31488] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Primary sclerosing cholangitis (PSC) is a heterogeneous cholangiopathy characterized by progressive biliary fibrosis. RNA sequencing of liver tissue from patients with PSC (n = 74) enrolled in a 96-week clinical trial was performed to identify associations between biological pathways that were independent of fibrosis and clinical events. APPROACH AND RESULTS The effect of fibrosis was subtracted from gene expression using a computational approach. The fibrosis-adjusted gene expression patterns were associated with time to first PSC-related clinical event (e.g., cholangitis, hepatic decompensation), and differential expression based on risk groups and Ingenuity Pathway Analysis were performed. Baseline demographic data were representative of PSC: median age 48 years, 71% male, 49% with inflammatory bowel disease, and 44% with bridging fibrosis or cirrhosis. The first principle component (PC1) of RNA-sequencing data accounted for 18% of variance and correlated with fibrosis stage (ρ = -0.80; P < 0.001). After removing the effect of fibrosis-related genes, the first principle component was not associated with fibrosis (ρ = -0.19; P = 0.11), and a semisupervised clustering approach identified two distinct patient clusters with differential risk of time to first PSC-related event (P < 0.0001). The two groups had similar fibrosis stage, hepatic collagen content, and α-smooth muscle actin expression by morphometry, Enhanced Liver Fibrosis score, and serum liver biochemistry, bile acids, and IL-8 (all P > 0.05). The top pathways identified by Ingenuity Pathway Analysis were eukaryotic translation inhibition factor 2 (eIF2) signaling and regulation of eIF4/p70S6K signaling. Genes involved in the unfolded protein response, activating transcription factor 6 (ATF6) and eIF2, were differentially expressed between the PSC clusters (down-regulated in the high-risk group by log-fold changes of -0.18 [P = 0.02] and -0.16 [P = 0.02], respectively). Clinical events were enriched in the high-risk versus low-risk group (38% [12/32] vs. 2.4% [1/42], P < 0.0001). CONCLUSIONS Removing the contribution of fibrosis-related pathways uncovered alterations in the unfolded protein response, which were associated with liver-related complications in PSC.
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Affiliation(s)
| | | | | | | | - Jun Xu
- Gilead Sciences, Inc.Foster CityCA
| | | | | | | | - Abdolamir Landi
- Department of Medical Microbiology and ImmunologyLi Ka Shing Institute of VirologyUniversity of AlbertaEdmontonABCanada
| | - Michael Houghton
- Department of Medical Microbiology and ImmunologyLi Ka Shing Institute of VirologyUniversity of AlbertaEdmontonABCanada
| | - Richard M Green
- Division of Gastroenterology and HepatologyDepartment of MedicineFeinberg School of Medicine atNorthwestern UniversityChicagoIL
| | | | | | - Christopher L Bowlus
- Division of Gastroenterology and HepatologyUniversity of California at DavisSacramentoCA
| | | | - Michael Trauner
- Division of Gastroenterology and HepatologyDepartment of Medicine IIIMedical University of ViennaViennaAustria
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Shah SK, Bowlus CL. Bugs in Bile: A Fly in the Ointment? Liver Transpl 2020; 26:1571-1572. [PMID: 33010103 DOI: 10.1002/lt.25908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Shivani K Shah
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA
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Lu M, Bowlus CL, Lindor K, Rodriguez-Watson CV, Romanelli RJ, Haller IV, Anderson H, VanWormer JJ, Boscarino JA, Schmidt MA, Daida YG, Sahota A, Vincent J, Li J, Trudeau S, Rupp LB, Gordon SC. Validity of an Automated Algorithm to Identify Cirrhosis Using Electronic Health Records in Patients with Primary Biliary Cholangitis. Clin Epidemiol 2020; 12:1261-1267. [PMID: 33204167 PMCID: PMC7666983 DOI: 10.2147/clep.s262558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Biopsy remains the gold standard for determining fibrosis stage in patients with primary biliary cholangitis (PBC), but it is unavailable for most patients. We used data from the 11 US health systems in the FibrOtic Liver Disease Consortium to explore a combination of biochemical markers and electronic health record (EHR)-based diagnosis/procedure codes (DPCs) to identify the presence of cirrhosis in PBC patients. Methods Histological fibrosis staging data were obtained from liver biopsies. Variables considered for the model included demographics (age, gender, race, ethnicity), total bilirubin, alkaline phosphatase, albumin, aspartate aminotransferase (AST) to platelet ratio index (APRI), Fibrosis 4 (FIB4) index, AST to alanine aminotransferase (ALT) ratio, and >100 DPCs associated with cirrhosis/decompensated cirrhosis, categorized into ten clusters. Using least absolute shrinkage and selection operator regression (LASSO), we derived and validated cutoffs for identifying cirrhosis. Results Among 4328 PBC patients, 1350 (32%) had biopsy data; 121 (9%) were staged F4 (cirrhosis). DPC clusters (including codes related to cirrhosis and hepatocellular carcinoma diagnoses/procedures), Hispanic ethnicity, ALP, AST/ALT ratio, and total bilirubin were retained in the final model (AUROC=0.86 and 0.83 on learning and testing data, respectively); this model with two cutoffs divided patients into three categories (no cirrhosis, indeterminate, and cirrhosis) with specificities of 81.8% (for no cirrhosis) and 80.3% (for cirrhosis). A model excluding DPCs retained ALP, AST/ALT ratio, total bilirubin, Hispanic ethnicity, and gender (AUROC=0.81 and 0.78 on learning and testing data, respectively). Conclusion An algorithm using laboratory results and DPCs can categorize a majority of PBC patients as cirrhotic or noncirrhotic with high accuracy (with a small remaining group of patients' cirrhosis status indeterminate). In the absence of biopsy data, this EHR-based model can be used to identify cirrhosis in cohorts of PBC patients for research and/or clinical follow-up.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | | | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Carla V Rodriguez-Watson
- Center for Health Research Kaiser Permanente Mid-Atlantic Research Institute, Rockville, MD; Reagan-Udall Foundation for the FDA, Washington, DC, USA
| | | | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, MN, USA
| | - Heather Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, PA, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawai'i, Honolulu, HI, USA
| | - Amandeep Sahota
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | | | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System; and Wayne State University School of Medicine, Detroit, MI, USA
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Song J, Li Y, Bowlus CL, Yang G, Leung PSC, Gershwin ME. Cholangiocarcinoma in Patients with Primary Sclerosing Cholangitis (PSC): a Comprehensive Review. Clin Rev Allergy Immunol 2020; 58:134-149. [PMID: 31463807 DOI: 10.1007/s12016-019-08764-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholangiocarcinoma (CCA) is the most common malignancy in patients with primary sclerosing cholangitis (PSC) and carries a high rate of mortality. Although the pathogenesis of CCA in PSC is largely unknown, inflammation-driven carcinogenesis concomitant with various genetic and epigenetic abnormalities are underlying factors. The majority of CCA cases develop from a dominant stricture (DS), which is defined as a stricture with a diameter < 1.5 mm in the common bile duct or < 1.0 mm in the hepatic duct. In PSC patients presenting with an abrupt aggravation of jaundice, pain, fatigue, pruritus, weight loss, or worsening liver biochemistries, CCA should be suspected and evaluated utilizing a variety of diagnostic modalities. However, early recognition of CCA in PSC remains a major challenge. Importantly, 30-50% of CCA in PSC patients are observed within the first year following the diagnosis of PSC followed by an annual incidence ranging from 0.5 to 1.5 per 100 persons, which is nearly 10 to 1000 times higher than that in the general population. Cumulative 5-year, 10-year, and lifetime incidences are 7%, 8-11%, and 9-20%, respectively. When PSC-associated CCA is diagnosed, most tumors are unresectable, and no effective medications are available. Given the poor therapeutic outcome, the surveillance and management of PSC patients who are at an increased risk of developing CCA are of importance. Such patients include older males with large-duct PSC and possibly concurrent ulcerative colitis. Thus, more attention should be paid to patients with these clinical features, in particular within the first year after PSC diagnosis. In contrast, CCA is less frequently observed in pediatric or female PSC patients or in those with small-duct PSC or concurrent Crohn's disease. Recently, new biomarkers such as antibodies to glycoprotein 2 have been found to be associated with an increased risk of developing CCA in PSC. Herein, we review the literature on the pathogenesis, incidence, clinical features, and risk factors, with a focus on various diagnostic modalities of PSC-associated CCA.
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Affiliation(s)
- Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang, 110004, Liaoning, People's Republic of China.,Division of Rheumatology, Allergy and Clinical Immunology, University of California, 451 Health Science Drive, Suite 6510, Davis, CA, 95616, USA
| | - Yang Li
- Department of Intensive Care Unit (ICU), Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang, Liaoning, 110004, People's Republic of China
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
| | - GuoXiang Yang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, 451 Health Science Drive, Suite 6510, Davis, CA, 95616, USA
| | - Patrick S C Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, 451 Health Science Drive, Suite 6510, Davis, CA, 95616, USA.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, 451 Health Science Drive, Suite 6510, Davis, CA, 95616, USA.
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Kowdley KV, Vuppalanchi R, Levy C, Floreani A, Andreone P, LaRusso NF, Shrestha R, Trotter J, Goldberg D, Rushbrook S, Hirschfield GM, Schiano T, jin Y, Pencek R, MacConell L, Shapiro D, Bowlus CL. A randomized, placebo-controlled, phase II study of obeticholic acid for primary sclerosing cholangitis. J Hepatol 2020; 73:94-101. [PMID: 32165251 PMCID: PMC8157171 DOI: 10.1016/j.jhep.2020.02.033] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 02/04/2020] [Accepted: 02/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a rare, cholestatic liver disease with no currently approved therapies. Obeticholic acid (OCA) is a potent farnesoid X receptor (FXR) agonist approved for the treatment of primary biliary cholangitis. We investigated the efficacy and safety of OCA in patients with PSC. METHODS AESOP was a phase II, randomized, double-blind, placebo-controlled, dose-finding study. Eligible patients were 18 to 75 years of age with a diagnosis of PSC and serum alkaline phosphatase (ALP) ≥2× the upper limit of normal (ULN) and total bilirubin <2.5× ULN. Patients were randomized 1:1:1 to receive placebo, OCA 1.5-3.0 mg, or OCA 5-10 mg once daily for a 24-week, double-blind phase followed by a 2-year, long-term safety extension (LTSE). Primary endpoints were change in ALP from baseline to week 24, and safety. RESULTS The intent-to-treat population comprised 76 patients randomized to placebo (n = 25), OCA 1.5-3.0 mg (n = 25), and OCA 5-10 mg (n = 26). At week 24, serum ALP was significantly reduced with OCA 5-10 mg vs. placebo (least-square [LS] mean difference = -83.4 [SE = 40.3] U/L; 95% CI -164.28 to -2.57; p = 0.043). Serum ALP was not significantly reduced with OCA 1.5-3.0 mg vs. placebo at week 24 (LS mean [SE] difference = -78.29 [41.81] U/L; 95% CI -162.08 to 5.50; p = 0.067). Total bilirubin remained comparable to baseline in all groups. The most common treatment-emergent adverse event was dose-related pruritus (placebo 46%; OCA 1.5-3.0 mg 60%; OCA 5-10 mg 67%). Reductions in ALP were maintained during the LTSE, and no new safety signals emerged. CONCLUSIONS Treatment with OCA 5-10 mg reduced serum ALP in patients with PSC. Mild to moderate dose-related pruritus was the most common adverse event. REGISTRATION ClinicalTrials.gov: NCT02177136; EudraCT: 2014-002205-38. LAY SUMMARY Primary sclerosing cholangitis (PSC) is a long-term disease that damages the bile ducts in the liver over time. In the AESOP clinical study in patients with PSC, obeticholic acid reduced serum alkaline phosphatase (a potential marker of disease severity) during an initial 24-week treatment period. The result was sustained during the 2-year, long-term extension of the study. The most common side effect of obeticholic acid in the study was itchy skin, which is consistent with earlier clinical studies.
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Affiliation(s)
- Kris V. Kowdley
- Liver Institute Northwest, Seattle, WA, USA,Corresponding author. Address: Liver Institute Northwest, 3216 NE 45th Place, Suite 212, Seattle, WA 98105, USA. Tel: 206-536-3030, fax: 206-524-0749. (K.V. Kowdley)
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cynthia Levy
- Division of Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Pietro Andreone
- SMECHIMAI Department, Università di Modena e Reggio-Emilia, Modena, Italy
| | - Nicholas F. LaRusso
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Roshan Shrestha
- Department of Transplantation, Piedmont Transplant Institute, Atlanta, GA, USA
| | - James Trotter
- Division of Transplant Hepatology, Baylor University, Dallas, TX, USA
| | - David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Simon Rushbrook
- Faculty of Medicine and Health Sciences, Norwich Medical School, Norwich, UK
| | | | - Thomas Schiano
- Recanati/Miller Transplantation Institute/Division of Liver Diseases, The Mount Sinai Medical Center, New York, NY, USA
| | - Yuying jin
- Intercept Pharmaceuticals, Inc., San Diego, CA, USA
| | | | | | | | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California, Davis, Sacramento, CA, USA
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Bowlus CL, Pockros PJ, Kremer AE, Parés A, Forman LM, Drenth JPH, Ryder SD, Terracciano L, Jin Y, Liberman A, Pencek R, Iloeje U, MacConell L, Bedossa P. Long-Term Obeticholic Acid Therapy Improves Histological Endpoints in Patients With Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2020; 18:1170-1178.e6. [PMID: 31606455 DOI: 10.1016/j.cgh.2019.09.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/06/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) is an autoimmune disease characterized by bile duct destruction that can progress to cirrhosis. A liver biopsy substudy was conducted in the PBC obeticholic acid (OCA) International Study of Efficacy (POISE) to determine the long-term effects of OCA on liver damage and fibrosis in patients with PBC. POISE is a phase 3, double-blind, placebo-controlled, randomized trial with a 5-year open-label extension that evaluated 5 to 10 mg OCA daily in patients who were intolerant or unresponsive to ursodeoxycholic acid. METHODS Liver biopsy specimens were collected from 17 patients at time of enrollment in the double-blind phase and after 3 years of OCA treatment. Histologic evaluations were performed by 2 pathologists in a blinded, randomized fashion to determine the effects of OCA on fibrosis and other histologic parameters. Collagen morphometry assessments were performed by automated second harmonic generation and 2-photon excitation microscopy to observe quantitative measures of fibrosis. RESULTS From the time of enrollment until 3 years of treatment, most patients had improvements or stabilization in fibrosis (71%), bile duct loss (76%), ductopenia (82%), ductular reaction (82%), interface hepatitis (100%), and lobular hepatitis (94%). Over the 3-year period, we found significant reductions in collagen area ratio (median, -2.1; first quartile, -4.6, third quartile, -0.3; P = .013), collagen fiber density (median, -0.8; first quartile, -2.5; third quartile, 0; P = .021), collagen reticulation index (median, -0.1; first quartile, -0.3; third quartile, 0; P = .008), and fibrosis composite score (median, -1.0; first quartile, -2.5; third quartile, -0.5; P = .002). CONCLUSIONS A subanalysis of data from the POISE study showed that long-term OCA treatment in patients with PBC is associated with improvements or stabilization of disease features, including ductular injury, fibrosis, and collagen morphometry features (ClinicalTrials.gov no: NCT01473524 and EudraCT no: 2011-004728-36).
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Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California.
| | - Paul J Pockros
- Division of Gastroenterology/Hepatology, Scripps Clinic and Scripps Translational Science Institute, San Diego, La Jolla, California
| | - Andreas E Kremer
- Department of Medicine I, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Albert Parés
- Hospital Clinic, University of Barcelona, Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain
| | - Lisa M Forman
- Division of Gastroenterology-Hepatology, University of Colorado, Aurora, Colorado
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephen D Ryder
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | | | - Yuying Jin
- Intercept Pharmaceuticals, San Diego, California
| | | | | | - Uche Iloeje
- Intercept Pharmaceuticals, San Diego, California
| | | | - Pierre Bedossa
- Department of Pathology, Physiology and Imaging, University Paris Diderot, Paris, France
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Louie JS, Grandhe S, Matsukuma K, Bowlus CL. Primary Biliary Cholangitis: A Brief Overview. Clin Liver Dis (Hoboken) 2020; 15:100-104. [PMID: 32257120 PMCID: PMC7128028 DOI: 10.1002/cld.867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/23/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-3-reading-louie a video presentation of this article.
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Affiliation(s)
- Justin S. Louie
- Division of Gastroenterology & Hepatology, UC Davis School of MedicineUniversity of California DavisSacramentoCA
| | - Sirisha Grandhe
- Division of Gastroenterology & Hepatology, UC Davis School of MedicineUniversity of California DavisSacramentoCA
| | - Karen Matsukuma
- Department of PathologyUniversity of California DavisSacramentoCA
| | - Christopher L. Bowlus
- Division of Gastroenterology & Hepatology, UC Davis School of MedicineUniversity of California DavisSacramentoCA
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Bowlus CL, Levy C. Editorial: biochemical responses do not tell the whole story in primary biliary cholangitis. Aliment Pharmacol Ther 2020; 51:177-178. [PMID: 31850576 DOI: 10.1111/apt.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Christopher L Bowlus
- Department of Gastroenterology, University of California - Davis, Sacramento, CA, USA
| | - Cynthia Levy
- Department of Medicine, University of Miami, Miami, FL, USA
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Lynch KD, Chapman RW, Keshav S, Montano-Loza AJ, Mason AL, Kremer AE, Vetter M, de Krijger M, Ponsioen CY, Trivedi P, Hirschfield G, Schramm C, Liu CH, Bowlus CL, Estes DJ, Pratt D, Hedin C, Bergquist A, de Vries AC, van der Woude CJ, Yu L, Assis DN, Boyer J, Ytting H, Hallibasic E, Trauner M, Marschall HU, Daretti LM, Marzioni M, Yimam KK, Perin N, Floreani A, Beretta-Piccoli BT, Rogers JK, Levy C. Effects of Vedolizumab in Patients With Primary Sclerosing Cholangitis and Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:179-187.e6. [PMID: 31100458 PMCID: PMC6941216 DOI: 10.1016/j.cgh.2019.05.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/05/2019] [Accepted: 05/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gut-homing lymphocytes that express the integrin α4β7 and CCR9 might contribute to development of primary sclerosing cholangitis (PSC). Vedolizumab, which blocks the integrin α4β7, is used to treat patients with inflammatory bowel diseases (IBD), but there are few data on its efficacy in patients with PSC. We investigated the effects of vedolizumab in a large international cohort of patients with PSC and IBD. METHODS We collected data from European and North American centers participating in the International PSC Study Group from patients with PSC and IBD who received at least 3 doses of vedolizumab (n = 102; median vedolizumab treatment duration, 412 days). Demographic and clinical data were collected from baseline and during the follow-up period (until liver transplantation, death, or 56 days after the final vedolizumab infusion). We analyzed overall changes in biochemical features of liver and proportions of patients with reductions in serum levels of alkaline phosphatase (ALP) of 20% or more, from baseline through last follow-up evaluation. Other endpoints included response of IBD to treatment (improved, unchanged, or worsened, judged by the treating clinician, as well as endoscopic score) and liver-related outcomes. RESULTS In the entire cohort, the median serum level of ALP increased from 1.54-fold the upper limit of normal at baseline to 1.64-fold the upper limit of normal at the last follow-up examination (P = .018); serum levels of transaminases and bilirubin also increased by a small amount between baseline and the last follow-up examination. Serum levels of ALP decreased by 20% or more in 21 patients (20.6%); only the presence of cirrhosis (odds ratio, 4.48; P = .019) was independently associated with this outcome. Of patients with available endoscopic data, 56.8% had a response of IBD to treatment. Liver-related events occurred in 21 patients (20.6%), including bacterial cholangitis, cirrhosis decompensation, or transplantation. CONCLUSIONS In an analysis of patients with PSC and IBD in an international study group, we found no evidence for a biochemical response to vedolizumab, although serum level of ALP decreased by 20% or more in a subset of patients. Vedolizumab appears to be well tolerated and the overall response of IBD was the same as expected for patients without PSC.
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Affiliation(s)
- Kate D Lynch
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Roger W Chapman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Satish Keshav
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Andrew L Mason
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Andreas E Kremer
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Marcel Vetter
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Manon de Krijger
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands
| | - Palak Trivedi
- Centre for Liver and Gastroenterology Research, National Institute for Health Research, Birmingham Biomedical Research Centre, Birmingham, United Kingdom; University Hospitals Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Gideon Hirschfield
- Centre for Liver and Gastroenterology Research, National Institute for Health Research, Birmingham Biomedical Research Centre, Birmingham, United Kingdom; University Hospitals Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Toronto Centre for Liver Disease, University Health Network and University of Toronto, Toronto, Canada
| | - Christoph Schramm
- First Department of Medicine and Martin Zeitz Centre for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chung Heng Liu
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California
| | - Derek J Estes
- Division of Hepatology, University of Miami, Miami, Florida
| | - Daniel Pratt
- Autoimmune and Cholestatic Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Charlotte Hedin
- Patient Flow Gastrointestinal Diseases, Patient Area Gastroenterology, Dermatovenerology and Rheumatology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Annika Bergquist
- Centre for Digestive Diseases, Division of Hepatology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lei Yu
- Liver Care & Transplantation Services, University of Washington Medical Center, Seattle, Washington
| | - David N Assis
- Yale Autoimmune and Cholestatic Liver Disease Program, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - James Boyer
- Yale Autoimmune and Cholestatic Liver Disease Program, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Henriette Ytting
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Emina Hallibasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University if Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University if Vienna, Vienna, Austria
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Luigi M Daretti
- Clinic of Gastroenterology and Hepatology, Ospedali Riuniti University Hospital, Ancona, Italy
| | - Marco Marzioni
- Clinic of Gastroenterology and Hepatology, Ospedali Riuniti University Hospital, Ancona, Italy
| | - Kidist K Yimam
- Division of Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco, California
| | - Nicola Perin
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Jennifer K Rogers
- Department of Statistics, University of Oxford, Oxford, United Kingdom
| | - Cynthia Levy
- Division of Hepatology, University of Miami, Miami, Florida.
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Dubrovsky AMK, Bowlus CL. Statins, Fibrates, and Other Peroxisome Proliferator-Activated Receptor Agonists for the Treatment of Cholestatic Liver Diseases. Gastroenterol Hepatol (N Y) 2020; 16:31-38. [PMID: 33867886 PMCID: PMC8040906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are autoimmune cholestatic liver diseases that commonly result in the need for liver transplantation. The lack of an effective therapy for PSC remains a largely unmet need in hepatology, and although the majority of patients with PBC will have an adequate response to ursodeoxycholic acid and/or obeticholic acid, there is a need for treatment among patients who do not respond completely to these therapies. Investigations of statins, fibrates, and other peroxisome proliferator-activated receptor (PPAR) agonists suggest clinical benefit with some of these agents. Statins have recently been suggested to improve outcomes in patients with PSC but have not demonstrated benefit in patients with PBC, whereas fibrates and newer PPAR agonists appear to improve biochemical markers linked to better clinical outcomes in patients with PBC. Further research is needed to fully understand the clinical efficacy of these agents in the treatment of PBC and PSC.
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Affiliation(s)
- Alanna M K Dubrovsky
- Ms Dubrovsky is a medical student and Dr Bowlus is a professor and chief of the Division of Gastroenterology and Hepatology at the University of California Davis School of Medicine in Sacramento, California
| | - Christopher L Bowlus
- Ms Dubrovsky is a medical student and Dr Bowlus is a professor and chief of the Division of Gastroenterology and Hepatology at the University of California Davis School of Medicine in Sacramento, California
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Trauner M, Gindin Y, Jiang Z, Chung C, Subramanian GM, Myers RP, Gulamhusein A, Kowdley KV, Levy C, Goodman Z, Manns MP, Muir AJ, Bowlus CL. Methylation signatures in peripheral blood are associated with marked age acceleration and disease progression in patients with primary sclerosing cholangitis. JHEP Rep 2019; 2:100060. [PMID: 32039401 PMCID: PMC7005566 DOI: 10.1016/j.jhepr.2019.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/08/2019] [Accepted: 11/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background & Aims A DNA methylation (DNAm) signature derived from 353 CpG sites (the Horvath clock) has been proposed as an epigenetic measure of chronological and biological age. This epigenetic signature is accelerated in diverse tissue types in various disorders, including non-alcoholic steatohepatitis, and is associated with mortality. Here, we assayed whole blood DNAm to explore age acceleration in patients with primary sclerosing cholangitis (PSC). Methods Using the MethylationEPIC BeadChip (850K) array, DNAm signatures in whole blood were analyzed in 36 patients with PSC enrolled in a 96-week trial of simtuzumab (Ishak F0-1, n = 13; F5-6, n = 23). Age acceleration was calculated as the difference between DNAm age and chronological age. Comparisons between patients with high and low age acceleration (≥ vs. < the median) were made and Cox regression evaluated the association between age acceleration and PSC-related clinical events (e.g. decompensation, cholangitis, transplantation). Results Age acceleration was significantly higher in patients with PSC compared to a healthy reference cohort (median, 11.1 years, p <2.2 × 10-16). In PSC, demographics, presence of inflammatory bowel disease, and ursodeoxycholic acid use were similar between patients with low and high age acceleration. However, patients with high age acceleration had increased serum alkaline phosphatase, gamma glutamyltransferase, alanine aminotransferase, enhanced liver fibrosis test scores, and greater hepatic collagen and α-smooth muscle actin expression on liver biopsy (all p <0.05). Moreover, patients with high age acceleration had an increased prevalence of cirrhosis (89% vs. 39%; p = 0.006) and greater likelihood of PSC-related events (hazard ratio 4.19; 95% CI 1.15–15.24). Conclusion This analysis of blood DNAm profiles suggests that compared with healthy controls, patients with PSC – particularly those with cirrhosis - exhibit significant acceleration of epigenetic age. Future studies are required to evaluate the prognostic implications and effect of therapies on global methylation patterns and age acceleration in PSC. Lay summary An epigenetic clock based on DNA methylation has been proposed as a marker of age. In liver diseases such as non-alcoholic steatohepatitis, age acceleration based on this epigenetic clock has been observed. Herein, we show that patients with primary sclerosing cholangitis have marked age acceleration, which is further accentuated by worsening fibrosis. This measure of age acceleration could be a useful marker for prognostication or risk stratification in primary sclerosing cholangitis. A peripheral blood DNA methylation (DNAm) score identifies age acceleration in PSC patients vs. healthy controls. PSC patients with high age acceleration had significantly more PSC-related events than those with low age acceleration. These findings may enable stratification of at-risk PSC patients based on a DNAm score from peripheral blood.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- Aging
- BMI, body mass index
- DNAm, DNA methylation
- ELF, enhanced liver fibrosis
- FDR, false discovery rate
- GGT, gamma-glutamyltransferase
- IBD, inflammatory bowel disease
- IL, interleukin
- LOXL2, lysyl oxidase-like-2
- NASH, non-alcoholic steatohepatitis
- PSC, primary sclerosing cholangitis
- SMA, smooth muscle actin
- UDCA, ursodeoxycholic acid
- biomarker
- inflammatory bowel disease
- primary sclerosing cholangitis
- prognosis
- ursodeoxycholic acid
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Corresponding author. Address: Division of Gastroenterology & Hepatology, Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | | | | | | | | | | | - Aliya Gulamhusein
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis, Sacramento, CA, USA
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Trauner M, Gulamhusein A, Hameed B, Caldwell S, Shiffman ML, Landis C, Eksteen B, Agarwal K, Muir A, Rushbrook S, Lu X, Xu J, Chuang J, Billin AN, Li G, Chung C, Subramanian GM, Myers RP, Bowlus CL, Kowdley KV. The Nonsteroidal Farnesoid X Receptor Agonist Cilofexor (GS-9674) Improves Markers of Cholestasis and Liver Injury in Patients With Primary Sclerosing Cholangitis. Hepatology 2019; 70:788-801. [PMID: 30661255 PMCID: PMC6767458 DOI: 10.1002/hep.30509] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023]
Abstract
Primary sclerosing cholangitis (PSC) represents a major unmet medical need. In a phase II double-blind, placebo-controlled study, we tested the safety and efficacy of cilofexor (formerly GS-9674), a nonsteroidal farnesoid X receptor agonist in patients without cirrhosis with large-duct PSC. Patients were randomized to receive cilofexor 100 mg (n = 22), 30 mg (n = 20), or placebo (n = 10) orally once daily for 12 weeks. All patients had serum alkaline phosphatase (ALP) > 1.67 × upper limit of normal and total bilirubin ≤ 2 mg/dL at baseline. Safety, tolerability, pharmacodynamic effects of cilofexor (serum C4 [7α-hydroxy-4-cholesten-3-one] and bile acids), and changes in liver biochemistry and serum fibrosis markers were evaluated. Overall, 52 patients were randomized (median age 43 years, 58% male, 60% with inflammatory bowel disease, 46% on ursodeoxycholic acid). Baseline median serum ALP and bilirubin were 348 U/L (interquartile range 288-439) and 0.7 mg/dL (0.5-1.0), respectively. Dose-dependent reductions in liver biochemistry were observed. At week 12, cilofexor 100 mg led to significant reductions in serum ALP (median reduction -21%; P = 0.029 versus placebo), gamma-glutamyl transferase (-30%; P < 0.001), alanine aminotransferase (ALT) (-49%; P = 0.009), and aspartate aminotransferase (-42%; P = 0.019). Cilofexor reduced serum C4 compared with placebo; reductions in bile acids were greatest with 100 mg. Relative reductions in ALP were similar between ursodeoxycholic acid-treated and untreated patients. At week 12, cilofexor-treated patients with a 25% or more relative reduction in ALP had greater reductions in serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, tissue inhibitor of metalloproteinase 1, C-reactive protein, and bile acids than nonresponders. Adverse events were similar between cilofexor and placebo-treated patients. Rates of grade 2 or 3 pruritus were 14% with 100 mg, 20% with 30 mg, and 40% with placebo. Conclusion: In this 12-week, randomized, placebo-controlled study, cilofexor was well tolerated and led to significant improvements in liver biochemistries and markers of cholestasis in patients with PSC.
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Affiliation(s)
| | | | - Bilal Hameed
- University of CaliforniaSan Francisco School of MedicineSan FranciscoCA
| | | | | | | | | | | | | | | | | | - Jun Xu
- Gilead Sciences, Inc.Foster CityCA
| | | | | | | | | | | | | | | | - Kris V. Kowdley
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWA
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Bowlus CL, Yang GX, Liu CH, Johnson CR, Dhaliwal SS, Frank D, Levy C, Peters MG, Vierling JM, Gershwin ME. Therapeutic trials of biologics in primary biliary cholangitis: An open label study of abatacept and review of the literature. J Autoimmun 2019; 101:26-34. [DOI: 10.1016/j.jaut.2019.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/01/2019] [Accepted: 04/06/2019] [Indexed: 12/12/2022]
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50
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Trauner M, Nevens F, Shiffman ML, Drenth JPH, Bowlus CL, Vargas V, Andreone P, Hirschfield GM, Pencek R, Malecha ES, MacConell L, Shapiro D. Long-term efficacy and safety of obeticholic acid for patients with primary biliary cholangitis: 3-year results of an international open-label extension study. Lancet Gastroenterol Hepatol 2019; 4:445-453. [DOI: 10.1016/s2468-1253(19)30094-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/12/2022]
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