Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group

BACKGROUND & AIMS

Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment.

METHODS

A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis.

RESULTS

The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'.

CONCLUSIONS

These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints.

LAY SUMMARY

Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.

Long-acting Release Octreotide for Pediatric Upper Gastrointestinal Bleeding

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) secondary to portal hypertension (PHT), without endoscopic or surgical treatment options due to an ectopic or unidentified bleeding site or the patient's anatomic characteristics, is challenging in pediatric hepatology. The usual treatment in these cases includes intravenous Octreotide. Recently, the availability of long-acting release Octreo tide (OCT-LAR) for monthly intramuscular administration has become an interesting therapeutic alternative.

OBJECTIVE

To report the case of an infant with UGIB due to PHT who was successfully treated with OCT-LAR.

CLINICAL CASE

Eight-month-old patient with repeated episodes of UGIB due to extrahepatic portal vein malformation, requiring blood transfusions, and intravenous octreotide infusions. As neither endoscopic nor surgical treatment were feasible, we decided to start IM OCT- LAR monthly. After ten months of treatment, the patient did not present bleeding episodes. No medication-related events were observed.

CONCLUSION

We consider that this report could help in the management of similar pediatric patients with UGIB due to PHT without conventional therapeutic possibilities.

Prognostic factors in paediatric acute liver failure

OBJECTIVES

To study the aetiology, outcome and prognostic indicators in children with acute liver failure (ALF).

STUDY DESIGN

Retrospective chart review of 210 patients (107 males/103 females; median age: 5.33 years, range: 1-17.4). Patients were followed until discharge (group 1), death (group 2) or liver transplantation (LT; group 3). Data from group 1 were compared to data from the other two groups and King's College criteria were also assessed.

RESULTS

Final diagnoses were: 128 (61%) hepatitis A, 68 (32%) indeterminate and 14 (7%) others. The characteristics of patients who survived (n = 59), died (n = 61) and underwent LT (n = 90) were analysed. In multivariate analysis, prothrombin time and encephalopathy III/IV were the most significant parameters suggesting a high likelihood of death. When King's College criteria were applied on admission in patients with and without transplantation, the positive predictive values were 96% and 95%, and the negative predictive values were 82% and 82%, respectively.

CONCLUSIONS

Hepatitis A is the main cause of ALF in children in Argentina. Advanced encephalopathy and prolonged prothrombin time were significantly associated with death or need for LT. King's College criteria for predicting the outcome of ALF are applicable in children, including those with ALF due to hepatitis A infection.

[Autoimmune hepatitis in children. Initial presentation as fulminant hepatic failure]

There are few cases reported of autoimmune hepatitis (AIH) type 2 presenting as fulminant hepatic failure (FHF) in children. The purpose of this study was to report three girls with AIH type 2 that presented as FHF.

METHODS

Over a period of 12 years, 123 patients with AIH diagnosed based on international criteria, 9 (7%) were type 2.3 of them presented as FHF. Other etiologies (viral, metabolic and toxic) were ruled out. The treatment was started with prednisone (2 mg-kg-day) and azathioprine (2 mg-kg-day).

EVOLUTION

Patients 1 and 3 died while waiting for liver transplant (LT) at 72 and 48 hours after initiating medical treatment. Patient 2 underwent LT3 days after starting treatment, with excellent evolution at 3 years and 7 months of follow up.

CONCLUSIONS

1--AIH type 2 was very infrequent in our group. 2--33% of cases had initial presentation as FHF. 3--The course of the disease was aggressive, not responding to immunosuppressive therapy. The evolution was unfavorable in all patients. 4--LT is an alternative treatment for this severe disease.

Short-term cyclosporine induces a remission of autoimmune hepatitis in children

BACKGROUND/AIMS

The current immunosuppressive treatment of patients with autoimmune hepatitis consists of prednisone and azathioprine. High doses of prednisone used to obtain the remission of the disease are associated with serious adverse effects. To avoid harmful consequences of prednisone therapy, we proposed to treat patients with oral cyclosporine to obtain the remission of the inflammatory process.

METHODS

This is a pilot, multinational, multicenter, clinical trial involving children with autoimmune hepatitis. Thirty-two children were recruited, who according to international criteria were considered as having definite autoimmune hepatitis. Cyclosporine alone was administered for 6 months, followed by combined low doses of prednisone and azathioprine for 1 month, after which cyclosporine was discontinued. Biochemical remission of the disease was established by the follow-up of serum transaminase activity levels. Growth parameters and adverse effects of the treatment were recorded.

RESULTS

Two patients were withdrawn from the study: one for non-compliance and the other for liver failure which did not improve with cyclosporine. Of the 30 remaining patients, 25 normalized alanine aminotransferase activity levels by 6 months and all the patients by 1 year of treatment. Z-scores for height showed a trend towards improvement during treatment. Adverse effects of cyclosporine were mild and disappeared during weaning off the medication.

CONCLUSIONS

Cyclosporine induced the biochemical remission of the hepatic inflammatory/necrotic process in children with autoimmune hepatitis, with few and well-tolerated adverse effects.

[Anti-actin antibodies in acute viral hepatitis A in children]

Hepatitis A Virus (HAV) infection has been proposed as a possible trigger of autoimmune hepatitis type I. We have previously reported the presence of anti-actin antibodies en protracted hepatitis A. At present the presence of anti-actin antibodies in acute uncomplicated hepatitis A is unknown. The aim of this study was to evaluate the incidence and persistence of anti-actin antibodies un children with acute hepatitis A.

MATERIALS AND METHODS

38 patients, 21 female and 17 male, with mean age of 6.5 years (range 2-13 years) were included. All patients were anti HAV IgM positive. The patients were clinically controlled and laboratory determinations such as ALT/AST, gammaglobulin, gamma GT, nuclear, smooth muscle (anti-actin specificity) and liver-kidney-microsome type I (anti-LKM) antibodies, were evaluated at admission and at the first, third and fifth month. Anti-actin antibodies were determined by indirect immunofluorescense (IIF) on rat kidney, stomach and liver sections and also on monolayers of cultured fibroblasts. Titers higher than 1/40 were considered positive.

RESULTS

18 patients (47.3%) were anti-actin positive in the first determination (titers 1/40 and 1/80). In 4 patients (12.9%) these antibodies remained positive up to one month. All patients were negative 5 months after the onset of illness. ANA and anti-LKM were negative in all cases.

CONCLUSIONS

1) This data demonstrate the presence of anti-actin antibodies in children with uncomplicated HAV hepatitis. 2) The antibodies remained positive for a short period of time. 3) Titers were lower than in autoimmune hepatitis type I. 4) Taken together these results suggest that anti-actin antibodies would be an expression of non specific stimulation of lymphocyte B.

[Histologic factors as elements of prognostic value in biliary atresia]

Biliary atresia (BA) is one of the biliary tree anomaly more frequent. Occurs in about 0.8 to 1/10.000 live births. BA is defined as a progressive biliary tree. The prognosis depends on the age of the diagnosis and precocity surgery. We present the results of a retrospective analysis of 71 RA carried out at the Garrahan Hospital from 1987 to 1993. 47 were female and 24 were male. Age ranged from 45 to 120 days of life. This study involved a consecutive series of 58 patients with histopathologic study of Porta-hepatis (PH) and liver biopsy obtained during the Kasai. The purpose of this study was to determine the value of histological factors as type of PH and hepatocytic giant cell transformation (GCT). 82.8% had favorable type of PH and the CCT was mild in 84.5%. 72.4% had bad outcome and was independent of the type of PH. Neither of them were statistically significant with survive and evolution. In our service neither PH non CGT were predictors of a bad outcome. There were good outcome in 27.5%, died 37.9% and 10.3% undergo liver transplantation. The precocity in a diagnosis and surgical procedure before two months of age are the most important factors in correlation with survival. Others immunomorphologic factors must be studied in BA that explained the etiopathogenic process. Orthotopic liver transplantation is the successful therapy in children with BA.