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Pedersen MR, Mayo MJ. Advances in the evaluation and treatment of autoimmune hepatitis. Curr Opin Gastroenterol 2024; 40:126-133. [PMID: 38363233 DOI: 10.1097/mog.0000000000001014] [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: 02/17/2024]
Abstract
PURPOSE OF REVIEW The primary therapy of autoimmune hepatitis (AIH) has been established for over three decades. This review focuses on updates in the evaluation and management of patients with AIH. RECENT FINDINGS The evaluation of patients has recently been updated to include more definitive screening for other autoimmune diseases, including thyroid disease and celiac disease. Antibody detection by ELISA, an easier and more commonly available method, has been incorporated into the latest iteration of the AIH scoring system. Corticosteroids and AZA remain the backbone of AIH treatment, but there is growing evidence for mycophenolate mofetil as both first-line and second-line therapy, and growing inquiry into calcineurin inhibitors. Noninvasive markers of liver disease have now been validated in AIH, with the strongest evidence for VCTE in patients with minimal hepatic inflammation. SUMMARY Recent research of alternative immunosuppressant therapies, noninvasive markers of fibrosis, and updated society guidelines, have improved our ability to evaluate, treat, and follow patients with AIH.
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Affiliation(s)
- M R Pedersen
- Division of Digestive and Liver Disease, University of Texas Southwestern Medical Center, Harry Hines Blvd, Dallas, Texas, USA
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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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4
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Zapata M, Pagan-Torres H, Mayo MJ. Systemic Complications of Primary Biliary Cholangitis. Clin Liver Dis 2024; 28:115-128. [PMID: 37945153 DOI: 10.1016/j.cld.2023.07.004] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Chronic cholestasis is the hallmark clinical feature of primary biliary cholangitis. In addition to progressive liver damage, chronic cholestasis can lead to serious complications, many of which occur outside the liver. Bile acids are ligands for nuclear hormone receptors, and alterations in their concentration disrupt normal functioning of numerous different cell types. This article discusses the clinical presentation, pathophysiology, and management of pruritus (itching), fatigue, osteoporosis, hyperlipidemia, fat-soluble vitamin deficiencies, malignancies, cardiac dysfunction, bacterial cholangitis, cholemic (bile cast) nephropathy, and Sicca syndrome.
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Affiliation(s)
- Mariana Zapata
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA
| | - Hendrick Pagan-Torres
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA
| | - Marlyn J Mayo
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8887, USA.
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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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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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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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Mayo MJ, Carey E, Smith HT, Mospan AR, McLaughlin M, Thompson A, Morris HL, Sandefur R, Kim WR, Bowlus C, Levy C. Correction to: Impact of Pruritus on Quality of Life and Current Treatment Patterns in Patients with Primary Biliary Cholangitis. Dig Dis Sci 2023; 68:4064-4065. [PMID: 37555884 PMCID: PMC10516767 DOI: 10.1007/s10620-023-08050-9] [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: 08/10/2023]
Affiliation(s)
- Marlyn J. Mayo
- University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | | | | | | | | | | | | | | | | | - on behalf of the TARGET-PBC
Investigators
- University of Texas Southwestern Medical Center, Dallas, TX USA
- Mayo Clinic, Phoenix, AZ USA
- GlaxoSmithKline, Brentford, Middlesex UK
- Target RWE, Durham, NC USA
- GlaxoSmithKline, Collegeville, PA USA
- GlaxoSmithKline, RTP, Raleigh, NC USA
- Stanford University, Stanford, CA USA
- University of California, Davis, Sacramento, CA USA
- University of Miami, Miami, FL USA
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9
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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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Murillo Perez CF, Ioannou S, Hassanally I, Trivedi PJ, Corpechot C, van der Meer AJ, Lammers WJ, Battezzati PM, Lindor KD, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Gulamhusein A, Ponsioen CY, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Parés A, Londoño MC, Janssen HLA, Invernizzi P, Vuppalanchi R, Hirschfield GM, Hansen BE, Levy C. Optimizing therapy in primary biliary cholangitis: Alkaline phosphatase at six months identifies one-year non-responders and predicts survival. Liver Int 2023; 43:1497-1506. [PMID: 37157905 DOI: 10.1111/liv.15592] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/05/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Patients with primary biliary cholangitis (PBC) and insufficient response to ursodeoxycholic acid (UDCA), currently assessed after 1 year, are candidates for second-line therapy. The aims of this study are to assess biochemical response pattern and determine the utility of alkaline phosphatase (ALP) at six months as a predictor of insufficient response. METHODS UDCA-treated patients in the GLOBAL PBC database with available liver biochemistries at one year were included. POISE criteria were used to assess response to treatment, defined as ALP <1.67 × upper limit of normal (ULN) and normal total bilirubin at one year. Various thresholds of ALP at six months were evaluated to predict insufficient response based on negative predictive value (NPV) and that with nearest to 90% NPV was selected. RESULTS For the study, 1362 patients were included, 1232 (90.5%) female, mean age of 54 years. The POISE criteria were met by 56.4% (n = 768) of patients at one year. The median ALP (IQR) of those who met POISE criteria compared to those who did not was 1.05 × ULN (0.82-1.33) vs. 2.37 × ULN (1.72-3.69) at six months (p < .001). Of 235 patients with serum ALP >1.9 × ULN at six months, 89% did not achieve POISE criteria (NPV) after one year of UDCA. Of those with insufficient response by POISE criteria at one year, 210 (67%) had an ALP >1.9 × ULN at six months and thus would have been identified early. CONCLUSIONS We can identify patients for second-line therapy at six months using an ALP threshold of 1.9 × ULN, given that approximately 90% of these patients are non-responders according to POISE criteria.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Ioannou
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
| | | | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, Paris, France
| | | | - Willem J Lammers
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- IRCCS Negrar, Verona, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, IRCCS Humanitas Research Hospital, Department of Biomedical Sciences, Humanitas University, Rozzano (Milan), Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Cynthia Levy
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
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11
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Mayo MJ, Carey E, Smith HT, Mospan AR, McLaughlin M, Thompson A, Morris HL, Sandefur R, Kim WR, Bowlus C, Levy C. Impact of Pruritus on Quality of Life and Current Treatment Patterns in Patients with Primary Biliary Cholangitis. Dig Dis Sci 2023; 68:995-1005. [PMID: 35704252 PMCID: PMC10406656 DOI: 10.1007/s10620-022-07581-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Patients with primary biliary cholangitis (PBC) often suffer with pruritus. We describe the impact of pruritus on quality of life and how it is managed in a real-world cohort. METHODS TARGET-PBC is a longitudinal observational cohort of patients with PBC across the USA. Data include information from medical records for three years prior to the date of consent up to 5 years of follow-up. Enrolled patients were asked to complete patient-reported outcome surveys: PBC-40, 5-D itch, and the PROMIS fatigue survey. Kruskal-Wallis tests were used to compare differences in symptoms between groups. RESULTS A total of 211 patients with completed PRO surveys were included in the current study. PRO respondents were compared with non-respondents in the TARGET-PBC population and were broadly similar. Pruritus was reported in 170 patients (81%), with those reporting clinically significant pruritus (30%) scoring worse across each domain of the PBC-40 and 5-D itch, more frequently having cirrhosis, and having significantly greater levels of fatigue. Patients reporting clinically significant pruritus were more likely to receive treatment, but 33% had never received treatment (no itch = 43.9%, mild itch = 38.3%). CONCLUSIONS The prevalence of pruritus was high in this population, and those reporting clinically significant pruritus had a higher likelihood of having advanced disease and worse quality of life. However, this study found that pruritus in PBC is under-treated. This may be due in part to ineffectiveness of current treatments, poor tolerance, or the lack of FDA-approved medications for pruritus.
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Affiliation(s)
- Marlyn J. Mayo
- University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | | | | | | | | | | | | | | | - Christopher Bowlus
- University of California, Davis, Sacramento, CA USA
- University of Miami, Miami, FL USA
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12
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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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13
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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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14
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de Veer RC, Harms MH, Corpechot C, Thorburn D, Invernizzi P, Janssen HLA, Battezzati PM, Nevens F, Lindor KD, Floreani A, Ponsioen CY, Mayo MJ, Parés A, Mason AL, Kowdley KV, Trivedi PJ, Hirschfield GM, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lammers WJ, Hansen BE, van Buuren HR, van der Meer AJ. Liver transplant-free survival according to alkaline phosphatase and GLOBE score in patients with primary biliary cholangitis treated with ursodeoxycholic acid. Aliment Pharmacol Ther 2022; 56:1408-1418. [PMID: 36138566 PMCID: PMC9826062 DOI: 10.1111/apt.17226] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/06/2022] [Revised: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND After 1 year of ursodeoxycholic acid (UDCA), patients with primary biliary cholangitis (PBC) may have a normal GLOBE score despite high alkaline phosphatase (ALP) levels. AIM To assess the association between ALP and liver transplantation (LT)-free survival according to the GLOBE score METHODS: Among patients with a normal or elevated GLOBE score in the Global PBC cohort, the association between ALP after 1 year of UDCA and the risk of LT/death was assessed. The LT-free survival was compared with that of a matched general population. RESULTS After 1 year of UDCA, ALP was associated with the risk of LT/death (aHR 1.31, 95% CI 1.003-1.72, p = 0.048) among 2729 patients with a normal GLOBE score. The 10-year LT-free survival among these patients with an ALP >2.0 × ULN was 94.0% (95% CI 90.1-97.9) for those <50 years, and 82.6% (95% CI 76.5-88.7) for those ≥50 years, which was significantly lower (p = 0.040) and similar (p = 0.736) to that of the matched population, respectively. The 10-year LT-free survival in patients ≥50 years with normal GLOBE score and normal ALP (90.8%, 95% CI 87.7-93.9) was significantly higher (p = 0.022) than the matched population. Among 1045 patients with an elevated GLOBE score, ALP was associated with LT/death only in those <50 years (aHR 1.38, 95% CI 1.06-1.81, p = 0.016). CONCLUSION The LT-free survival of patients with PBC with a normal GLOBE score is optimal in case of normal ALP levels, also in relation to the general population. Despite their generally favourable prognosis, an elevated ALP level may still indicate a need for add-on therapy.
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Affiliation(s)
- Rozanne C. de Veer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maren H. Harms
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, European Reference Network on Hepatological Diseases (ERN Rare‐Liver)Saint‐Antoine Hospital, Assistance Publique ‐ Hôpitaux de Paris; Inserm UMR_S938, Saint‐Antoine Research Center, Sorbonne UniversityParisFrance
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive HealthThe Royal Free HospitalLondonUK
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Harry L. A. Janssen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada
| | | | - Frederik Nevens
- Department of HepatologyUniversity Hospitals LeuvenKU LeuvenLeuvenBelgium
| | - Keith D. Lindor
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA,Arizona State UniversityCollege of Health SolutionsPhoenixArizonaUSA
| | - Annarosa Floreani
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly,Scientific Institute for ResearchHospitalization and HealthcareNegrarVeronaItaly
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centreslocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marlyn J. Mayo
- Digestive and Liver diseases, UT Southwestern Medical CenterDallasTexasUSA
| | - Albert Parés
- Liver UnitHospital Clínic, CIBERehd, IDIBAPS, University of BarcelonaBarcelonaSpain
| | - Andrew L. Mason
- Division of Gastroenterology and HepatologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Kris V. Kowdley
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Palak J. Trivedi
- Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Gideon M. Hirschfield
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Tony Bruns
- Department of Internal Medicine IVJena University Hospital, Friedrich Schiller UniversityJenaGermany,Department of Internal Medicine IIIUniversity Hospital RWTH AachenAachenGermany
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Xavier Verhelst
- Department of Gastroenterology and HepatologyGhent University HospitalBelgium
| | - Willem J. Lammers
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Bettina E. Hansen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
| | - Henk R. van Buuren
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Adriaan J. van der Meer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
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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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16
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Mayo MJ. Mechanisms and molecules: What are the treatment targets for primary biliary cholangitis? Hepatology 2022; 76:518-531. [PMID: 35152430 DOI: 10.1002/hep.32405] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 11/22/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 12/22/2022]
Abstract
Treatment of primary biliary cholangitis (PBC) with ursodeoxycholic acid (UDCA) is not always sufficient to prevent progression to hepatic decompensation and/or need for liver transplant. Adjuvant therapy with obeticholic acid may provide additional biochemical improvements in some patients, but it is not well-tolerated by patients with significant itch or advanced cirrhosis. Thus, new and creative approaches to treating patients with PBC are important to identify. This review discusses major potential therapeutic targets in PBC and provides examples of some specific agents currently in development for the treatment of PBC. Targets are broadly classified into those which strive to modify bile, inflammation, cell survival, or fibrosis. In bile, shrinking the size of the bile acid pool or modifying the quality of the bile by making it more hydrophilic or enriched in phosphatidylcholine may ameliorate cholestatic injury. Biliary epithelial cell survival may be extended by fortifying the bicarbonate umbrella or improving cell membrane integrity. Autoimmunity and cholangitis have the potential to be improved via regulation of the immune system. Targeting cytokines, immune checkpoints, and anti-mitochondrial antibodies are examples of a more focused immunosuppression approach. Stem cell therapy and lymphocyte trafficking inhibition are more novel methods of broad immune regulation. Anti-fibrotic therapies are also potentially useful for preventing progression of PBC. The nuclear hormone receptors, farnesoid X receptor (FXR) and peroxisome proliferator-activated receptor (PPAR) regulate many of these pathways: cholestasis, inflammation, and fibrosis, which is why they are being enthusiastically pursued as potential therapeutic targets in PBC.
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Affiliation(s)
- Marlyn J Mayo
- Internal Medicine, University of Texas Southwestern University, Dallas, Texas, USA
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17
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Rich NE, Parvathaneni A, Sen A, Odewole M, Arroyo A, Mufti AR, Kerr TA, Grant L, Tujios SR, Mayo MJ, Lee WM, Yang JD, Yokoo T, Gopal P, Hoshida Y, Zhu H, Yopp AC, Marrero JA, Singal AG. High Neutrophil-Lymphocyte Ratio and Delta Neutrophil-Lymphocyte Ratio Are Associated with Increased Mortality in Patients with Hepatocellular Cancer. Dig Dis Sci 2022; 67:2666-2676. [PMID: 33939138 DOI: 10.1007/s10620-021-07001-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 02/19/2021] [Accepted: 04/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The neutrophil-lymphocyte ratio (NLR) has been proposed as a prognostic biomarker for cirrhosis and non-liver malignancies. We aimed to evaluate the prognostic value of NLR in a diverse cohort of patients with hepatocellular carcinoma (HCC). METHODS We performed a retrospective study of patients diagnosed with HCC between 2008 and 2017 at two large US health systems. We used Cox proportional hazard and multivariable ordinal logistic regression models to identify factors associated with overall survival and response to first HCC treatment, respectively. Primary variables of interest were baseline NLR and delta NLR, defined as the difference between pre- and post-treatment NLR. RESULTS Among 1019 HCC patients, baseline NLR was < 5 in 815 (80.0%) and ≥ 5 in 204 (20.0%). Patients with NLR ≥ 5 had a higher proportion of infiltrative tumors (36.2% vs 22.3%), macrovascular invasion (39.6% vs 25.5%), metastatic disease (20.6% vs 11.4%), and AFP > 200 ng/mL (45.6% vs 33.8%). Baseline NLR ≥ 5 was independently associated with higher mortality (median survival 4.3 vs 15.1 months; adjusted HR 1.70, 95%CI 1.41-2.06), with differences in survival consistent across BCLC stages. After adjusting for baseline covariates including NLR, delta NLR > 0.26 was also independently associated with increased mortality (HR 1.42, 95%CI 1.14-1.78). In a secondary analysis, high NLR was associated with lower odds of response to HCC treatment (20.2% vs 31.6%; adjusted OR 0.55, 95%CI 0.32-0.95). CONCLUSIONS In a large Western cohort of patients with HCC, high baseline NLR and delta NLR were independent predictors of mortality. IMPACT NLR is an inexpensive test that may be a useful component of future HCC prognostic models.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA.
| | - Aarthi Parvathaneni
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Ahana Sen
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Mobolaji Odewole
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Ana Arroyo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Thomas A Kerr
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Shannan R Tujios
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Ju Dong Yang
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center and Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Takeshi Yokoo
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yujin Hoshida
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Hao Zhu
- Children's Research Institute, UT Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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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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Pedersen MR, Greenan G, Arora S, Murali AR, Mayo MJ. Ursodeoxycholic Acid Decreases Incidence of Primary Biliary Cholangitis and Biliary Complications After Liver Transplantation: A Meta-Analysis. Liver Transpl 2021; 27:866-875. [PMID: 33185320 DOI: 10.1002/lt.25935] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 08/08/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
After liver transplantation (LT), the role of ursodeoxycholic acid (UDCA) is not well characterized. We examine the effect of UDCA after LT in the prophylaxis of biliary complications (BCs) in all-comers for LT and the prevention of recurrent primary biliary cholangitis (rPBC) in patients transplanted for PBC. Two authors searched PubMed/MEDLINE and Embase from January 1990 through December 2018 to identify all studies that evaluate the effectiveness of UDCA prophylaxis after LT for BCs in all LT recipients and rPBC after LT in patients transplanted for PBC. Odds ratios (ORs) were calculated for endpoints of the BC study. Pooled recurrence rates were calculated for rPBC. The study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A total of 15 studies were included, comprising 530 patients in the analysis for BCs and 1727 patients in the analysis for rPBC. UDCA was associated with decreased odds of BCs (OR, 0.70; 95% confidence interval [CI], 0.52-0.93; P = 0.01) and biliary stones and sludge (OR, 0.49; 95% CI, 0.24-0.77; P = 0.004). Prophylactic use of UDCA did not affect the odds of biliary stricture. For patients transplanted for PBC, the rate of rPBC was lower with the prophylactic use of UDCA (IR 16.7%; 95% CI, 0.114%-22.0%; I2 = 36.1%) compared with not using prophylactic UDCA (IR 23.1%; 95% CI, 16.9%-29.3%; I2 = 86.7%). UDCA after LT reduces the odds of BC and bile stones and sludge in all-comer LT recipients and reduces or delays the incidence of rPBC in patients transplanted for PBC. UDCA use after LT could be considered in all LT recipients to reduce the odds of BC and may be particularly beneficial for patients transplanted for PBC by reducing the incidence of rPBC.
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Affiliation(s)
- Mark R Pedersen
- Division of Digestive and Liver Diseases, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Garrett Greenan
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Sumant Arora
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
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Wong F, Pappas SC, Curry MP, Reddy KR, Rubin RA, Porayko MK, Gonzalez SA, Mumtaz K, Lim N, Simonetto DA, Sharma P, Sanyal AJ, Mayo MJ, Frederick RT, Escalante S, Jamil K. Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome. N Engl J Med 2021; 384:818-828. [PMID: 33657294 DOI: 10.1056/nejmoa2008290] [Citation(s) in RCA: 196] [Impact Index Per Article: 65.3] [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: 12/20/2022]
Abstract
BACKGROUND The vasoconstrictor terlipressin is used for type 1 hepatorenal syndrome (HRS-1) in many parts of the world and is part of the clinical practice guidelines in Europe. METHODS We conducted a phase 3 trial to confirm the efficacy and safety of terlipressin plus albumin in adults with HRS-1. The patients were randomly assigned in a 2:1 ratio to receive terlipressin or placebo for up to 14 days; in both groups, concomitant use of albumin was strongly recommended. The primary end point was verified reversal of HRS, defined as two consecutive serum creatinine measurements of 1.5 mg per deciliter or less at least 2 hours apart and survival without renal-replacement therapy for at least 10 days after the completion of treatment. Four prespecified secondary end points were analyzed with the Hochberg procedure to account for multiple comparisons. RESULTS A total of 300 patients underwent randomization - 199 were assigned to the terlipressin group and 101 to the placebo group. Verified reversal of HRS was reported in 63 patients (32%) in the terlipressin group and 17 patients (17%) in the placebo group (P = 0.006). With respect to the prespecified secondary end points, HRS reversal, defined as any serum creatinine level of 1.5 mg per deciliter or less during the first 14 days, was reported in 78 patients (39%) in the terlipressin group and 18 (18%) in the placebo group (P<0.001); HRS reversal without renal-replacement therapy by day 30, in 68 (34%) and 17 (17%), respectively (P = 0.001); HRS reversal among patients with systemic inflammatory response syndrome (84 patients in the terlipressin group and 48 patients in the placebo group), in 31 (37%) and 3 (6%), respectively (P<0.001); and verified reversal of HRS without recurrence by day 30, in 52 (26%) and 17 (17%), respectively (P = 0.08). At day 90, liver transplantations had been performed in 46 patients (23%) in the terlipressin group and 29 patients (29%) in the placebo group, and death occurred in 101 (51%) and 45 (45%), respectively. More adverse events, including abdominal pain, nausea, diarrhea, and respiratory failure, occurred with terlipressin than with placebo. Death within 90 days due to respiratory disorders occurred in 22 patients (11%) in the terlipressin group and 2 patients (2%) in the placebo group. CONCLUSIONS In this trial involving adults with cirrhosis and HRS-1, terlipressin was more effective than placebo in improving renal function but was associated with serious adverse events, including respiratory failure. (Funded by Mallinckrodt Pharmaceuticals; CONFIRM ClinicalTrials.gov number, NCT02770716.).
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Affiliation(s)
- Florence Wong
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - S Chris Pappas
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Michael P Curry
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - K Rajender Reddy
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Raymond A Rubin
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Michael K Porayko
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Stevan A Gonzalez
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Khalid Mumtaz
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Nicholas Lim
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Douglas A Simonetto
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Pratima Sharma
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Arun J Sanyal
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Marlyn J Mayo
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - R Todd Frederick
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Shannon Escalante
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
| | - Khurram Jamil
- From the Department of Medicine, University of Toronto, Toronto (F.W.); Orphan Therapeutics, Annandale (S.C.P.), and Mallinckrodt Pharmaceuticals, Bedminster (S.E., K.J.) - both in New Jersey; the Department of Medicine, Beth Israel Deaconess Medical Center, Boston (M.P.C.); the University of Pennsylvania, Philadelphia (K.R.R.); Piedmont Transplant Institute, Piedmont Healthcare, Atlanta (R.A.R.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (M.K.P.); the Department of Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth (S.A.G.), and the Department of Medicine, University of Texas Southwestern Medical Center, Dallas (M.J.M.) - both in Texas; Ohio State University, Columbus (K.M.); the Department of Medicine, University of Minnesota, Minneapolis (N.L.), and the Department of Medicine, Mayo Clinic, Rochester (D.A.S.) - both in Minnesota; the Department of Medicine, University of Michigan Medical Center, Ann Arbor (P.S.); Virginia Commonwealth University, Richmond (A.J.S.); and Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco (R.T.F.)
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21
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Harms MH, Hirschfield GM, Floreani A, Mayo MJ, Parés A, Liberman A, Malecha ES, Pencek R, MacConell L, Hansen BE. Obeticholic acid is associated with improvements in AST-to-platelet ratio index and GLOBE score in patients with primary biliary cholangitis. JHEP Rep 2020; 3:100191. [PMID: 33319187 PMCID: PMC7724188 DOI: 10.1016/j.jhepr.2020.100191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 03/25/2020] [Revised: 08/12/2020] [Accepted: 09/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Biochemical markers, including GLOBE score and aspartate aminotransferase-to-platelet ratio index (APRI), are used to stratify risk in patients with primary biliary cholangitis (PBC). This study aimed to evaluate the effects of obeticholic acid (OCA) on categorical shifts in GLOBE score, APRI, and both combined, based on data from POISE, a phase III placebo-controlled trial in patients with PBC who had an incomplete response or were intolerant to ursodeoxycholic acid. Methods In a post hoc analysis, baseline and Month 12 data from POISE were used to calculate the APRI and GLOBE score. Patients were stratified into 3 risk groups based on a combination of APRI (0.54) and GLOBE (0.3 or age-specific) thresholds. Results The analysis included 215 patients (47 low risk; 79 moderate risk; 89 high risk). Using the combined GLOBE score (threshold of 0.3) and APRI thresholds, there was improvement in ≥1 risk stage in 37% and 35% of patients in the OCA 5–10 mg and 10 mg groups, respectively, vs. 12% in the placebo group (both p <0.05). Progression occurred in 10% and 0% in the 5–10 mg and 10 mg groups vs. 37% in the placebo group. Results with GLOBE age-specific thresholds were similar. Conclusions Based on change in APRI and GLOBE score at 12 months, OCA treatment is associated with reduction in the predicted risk of liver-related complications in patients with PBC. Lay summary Primary biliary cholangitis (PBC) is a chronic disease affecting the liver. People who suffer from PBC are at risk of serious long-term complications. Information from certain blood tests can be used to estimate the likelihood of experiencing long-term complications. The results of this study showed that based on blood test results, people taking obeticholic acid, with or without ursodeoxycholic acid, for PBC were predicted to have a better outcome than those taking placebo. Clinical trials registration NCT01473524. Biochemical markers can help estimate risk of progression in patients with primary biliary cholangitis. Data from the POISE trial were used to calculate GLOBE score and aminotransferase-to-platelet ratio index. Obeticholic acid treatment was associated with a shift to lower risk of progression.
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Key Words
- AE, adverse event
- ALP, alkaline phosphatase
- APRI
- APRI, aspartate aminotransferase-to-platelet ratio index
- AST, aspartate aminotransferase
- Cholestasis
- DB, double-blind
- FXR, farnesoid X receptor
- IQR, inter-quartile range
- LLN, lower limit of normal
- LN, natural logarithm
- LT, liver transplant
- OCA, obeticholic acid
- OR, odds ratio
- PBC
- PBC, primary biliary cholangitis
- Risk stratification
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Albert Parés
- Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | | | | | | | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, ON, Canada.,IHPME, University of Toronto, Toronto, ON, Canada
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Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72:671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] [Citation(s) in RCA: 399] [Impact Index Per Article: 99.8] [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: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Cara L Mack
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David Adams
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David N Assis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nanda Kerkar
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, NY
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mohammad H Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
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Kerkar N, Mayo MJ. Autoimmune Hepatitis: Highlights for Liver Transplant Providers From the American Association for the Study of Liver Diseases 2019 Guidelines. Liver Transpl 2020; 26:973-976. [PMID: 32133751 DOI: 10.1002/lt.25740] [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: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Nanda Kerkar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Golisano Childrens Hospital at Strong, University of Rochester Medical Center, Rochester, NY
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, TX
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24
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Vierling JM, Kerkar N, Czaja AJ, Mack CL, Adams D, Assis DN, Manns MP, Mayo MJ, Nayfeh T, Majzoub AMM, Alzuabi MA, Ding J, Haffar S, Murad MH, Alsawas M. Immunosuppressive Treatment Regimens in Autoimmune Hepatitis: Systematic Reviews and Meta-Analyses Supporting American Association for the Study of Liver Diseases Guidelines. Hepatology 2020; 72:753-769. [PMID: 32500593 DOI: 10.1002/hep.31407] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 03/05/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
Affiliation(s)
- John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nanda Kerkar
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Cara L Mack
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Adams
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - David N Assis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | | | - Muayad A Alzuabi
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Jingyi Ding
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Samir Haffar
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Mouaz Alsawas
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
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25
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Harms MH, de Veer RC, Lammers WJ, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Trivedi PJ, Hirschfield GM, Pares A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Hansen BE, Buuren HRV, van der Meer AJ. Number needed to treat with ursodeoxycholic acid therapy to prevent liver transplantation or death in primary biliary cholangitis. Gut 2020; 69:1502-1509. [PMID: 31843787 PMCID: PMC7398464 DOI: 10.1136/gutjnl-2019-319057] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 05/09/2019] [Revised: 10/31/2019] [Accepted: 11/16/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The clinical benefit of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has never been reported in absolute measures. The aim of this study was to assess the number needed to treat (NNT) with UDCA to prevent liver transplantation (LT) or death among patients with PBC. METHODS The NNT was calculated based on the untreated LT-free survival and HR of UDCA with respect to LT or death as derived from inverse probability of treatment weighting-adjusted Cox proportional hazard analyses within the Global PBC Study Group database. RESULTS We included 3902 patients with a median follow-up of 7.8 (4.1-12.1) years. The overall HR of UDCA was 0.46 (95% CI 0.40 to 0.52) and the 5-year LT-free survival without UDCA was 81% (95% CI 79 to 82). The NNT to prevent one LT or death within 5 years (NNT5y) was 11 (95% CI 9 to 13). Although the HR of UDCA was similar for patients with and without cirrhosis (0.33 vs 0.31), the NNT5y was 4 (95% CI 3 to 5) and 20 (95% CI 14 to 34), respectively. Among patients with low alkaline phosphatase (ALP) (≤2× the upper limit of normal (ULN)), intermediate ALP (2-4× ULN) and high ALP (>4× ULN), the NNT5y to prevent one LT or death was 26 (95% CI 15 to 70), 11 (95% CI 8 to 17) and 5 (95% CI 4 to 8), respectively. CONCLUSION The absolute clinical efficacy of UDCA with respect to LT or death varied with baseline prognostic characteristics, but was high throughout. These findings strongly emphasise the incentive to promptly initiate UDCA treatment in all patients with PBC and may improve patient compliance.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rozanne C de Veer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Service d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Palak J Trivedi
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, Universita degli Studi di Padova, Padova, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology - location Academic Medical Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington, USA
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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26
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Murillo Perez CF, Harms MH, Lindor KD, van Buuren HR, Hirschfield GM, Corpechot C, van der Meer AJ, Feld JJ, Gulamhusein A, Lammers WJ, Ponsioen CY, Carbone M, Mason AL, Mayo MJ, Invernizzi P, Battezzati PM, Floreani A, Lleo A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Thorburn D, Trivedi PJ, Verhelst X, Parés A, Janssen HLA, Hansen BE. Goals of Treatment for Improved Survival in Primary Biliary Cholangitis: Treatment Target Should Be Bilirubin Within the Normal Range and Normalization of Alkaline Phosphatase. Am J Gastroenterol 2020; 115:1066-1074. [PMID: 32618657 DOI: 10.14309/ajg.0000000000000557] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [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: 12/11/2022]
Abstract
INTRODUCTION In primary biliary cholangitis (PBC), bilirubin and alkaline phosphatase (ALP) are widely established as independent predictors of prognosis. Current treatment goals do not aim for normalization of surrogate markers because their association with survival has not been defined. METHODS The patient cohort from the GLOBAL PBC Study Group was used, comprising of long-term follow-up data from European and North American centers. Ursodeoxycholic acid-treated and untreated patients with bilirubin levels ≤1 × upper limit of normal (ULN) at baseline or 1 year were included. The association of normal ALP with transplant-free survival was assessed in a subgroup with ALP ≤1.67 × ULN at 1 year. Optimal thresholds of bilirubin and ALP to predict liver transplantation (LT) or death were evaluated. RESULTS There were 2,281 patients included in the time zero cohort and 2,555 patients in the 1-year cohort. The bilirubin threshold with the highest ability to predict LT or death at 1 year was 0.6 × ULN (hazard ratio 2.12, 95% CI 1.69-2.66, P < 0.001). The 10-year survival rates of patients with bilirubin ≤0.6 × ULN and >0.6 × ULN were 91.3% and 79.2%, respectively (P < 0.001). The risk for LT or death was stable below the bilirubin levels of 0.6 × ULN, yet increased beyond this threshold. Ursodeoxycholic acid-induced reduction in bilirubin below this threshold was associated with an 11% improvement in 10-year survival. Furthermore, ALP normalization was optimal, with 10-year survival rates of 93.2% in patients with ALP ≤ 1 × ULN and 86.1% in those with ALP 1.0-1.67 × ULN. DISCUSSION Attaining bilirubin levels ≤0.6 × ULN or normal ALP are associated with the lowest risk for LT or death in patients with PBC. This has important implications for treatment targets.
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maren H Harms
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Centre de Re[Combining Acute Accent]fe[Combining Acute Accent]rence des Maladies Inflammatoires des VoiesBiliaires, Ho[Combining Circumflex Accent]pital Saint-Antoine, Paris, France
| | - Adriaan J van der Meer
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Pier Maria Battezzati
- Department of Health Sciences, Universita[Combining Grave Accent] degli Studi di Milano, Milan, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Humanitas Clinical Research Center IRCSS, Humanitas University, Rozzano (Milan), Italy
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, United Kingdom
| | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-3-reading-mayo a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-3-interview-mayo an interview with the author https://www.wileyhealthlearning.com/Activity/7058616/disclaimerspopup.aspx questions and earn CME.
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Affiliation(s)
- Mark R. Pedersen
- Division of Digestive and Liver DiseaseDepartment of Internal MedicineThe University of Texas Southwestern Medical CenterDallasTX
| | - Marlyn J. Mayo
- Division of Digestive and Liver DiseaseDepartment of Internal MedicineThe University of Texas Southwestern Medical CenterDallasTX
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Murillo Perez CF, Hirschfield GM, Corpechot C, Floreani A, Mayo MJ, van der Meer A, Ponsioen CY, Lammers WJ, Parés A, Invernizzi P, Carbone M, Maria Battezzati P, Nevens F, Kowdley KV, Thorburn D, Mason AL, Trivedi PJ, Lindor KD, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Janssen HLA, Hansen BE, Gulamhusein A. Fibrosis stage is an independent predictor of outcome in primary biliary cholangitis despite biochemical treatment response. Aliment Pharmacol Ther 2019; 50:1127-1136. [PMID: 31621931 DOI: 10.1111/apt.15533] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [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: 06/20/2019] [Revised: 07/10/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fibrosis stage predicts prognosis in patients with chronic liver disease independent of aetiology, although its precise role in risk stratification in patients with primary biliary cholangitis (PBC) remains undefined. AIM To assess the utility of baseline fibrosis stage in predicting long-term outcomes in the context of biochemical risk stratification METHODS: In a large and globally representative cohort of patients with PBC, liver biopsies performed from 1980 to 2014 were evaluated. The predictive ability of histologic fibrosis stage in addition to treatment response at 1 year (Toronto/Paris-II criteria), as well as non-invasive markers of fibrosis (AST/ALT ratio [AAR], AST to platelet ratio index [APRI], FIB-4), for transplant-free survival was assessed with Cox proportional-hazards models. RESULTS There were 1828 patients with baseline liver biopsy. Advanced histologic fibrosis (stage 3/4) was an independent predictor of survival in addition to non-invasive measures of fibrosis with the hazard ratios ranging from 1.59 to 2.73 (P < .001). Patients with advanced histologic fibrosis stage had worse survival despite biochemical treatment response, with a 10-year survival of 76.0%-86.6% compared to 94.5%-95.1% depending on the treatment response criteria used. Poor correlations were observed between non-invasive measures of fibrosis and histologic fibrosis stage. CONCLUSION Assessment of fibrosis stage grants prognostic value beyond biochemical treatment response at 1 year. This highlights the need to incorporate fibrosis stage in individual risk stratification in patients with PBC, partly to identify those that may derive benefit from novel therapies.
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Cheung AC, Lammers WJ, Murillo Perez CF, van Buuren HR, Gulamhusein A, Trivedi PJ, Lazaridis KN, Ponsioen CY, Floreani A, Hirschfield GM, Corpechot C, Mayo MJ, Invernizzi P, Battezzati PM, Parés A, Nevens F, Thorburn D, Mason AL, Carbone M, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lindor KD, Lleo A, Poupon R, Janssen HLA, Hansen BE. Effects of Age and Sex of Response to Ursodeoxycholic Acid and Transplant-free Survival in Patients With Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2019; 17:2076-2084.e2. [PMID: 30616022 DOI: 10.1016/j.cgh.2018.12.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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: 07/17/2018] [Revised: 12/07/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) predominantly affects middle-aged women; there are few data on disease phenotypes and outcomes of PBC in men and younger patients. We investigated whether differences in sex and/or age at the start of ursodeoxycholic acid (UDCA) treatment are associated with response to therapy, based on biochemical markers, or differences in transplant-free survival. METHODS We performed a longitudinal retrospective study of 4355 adults in the Global PBC Study cohort, collected from 17 centers across Europe and North America. Patients received a diagnosis of PBC from 1961 through 2014. We evaluated the effects of sex and age on response to UDCA treatment (based on GLOBE score) and transplant-free survival using logistic regression and Cox regression analyses, respectively. RESULTS Male patients were older at the start of treatment (58.3±12.1 years vs 54.3±11.6 years for women; P<.0001) and had higher levels of bilirubin and lower circulating platelet counts (P<.0001). Younger patients (45 years or younger) had increased serum levels of transaminases than older patients (older than 45 years). Patients older than 45 years at time of treatment initiation had increased odds of a biochemical response to UDCA therapy, based on GLOBE score, compared to younger patients. The greatest odds of response to UDCA were observed in patients older than 65 years (odds ratio compared to younger patients 45 years or younger, 5.48; 95% CI, 3.92-7.67; P<.0001). Risk of liver transplant or death (compared to a general population matched for age, sex, and birth year) decreased significantly with advancing age: hazard ratio for patients 35 years or younger, 14.59 (95% CI, 9.66-22.02) vs hazard ratio for patients older than 65 years, 1.39 (95% CI, 1.23-1.57) (P<.0001). On multivariable analysis, sex was not independently associated with response or transplant-free survival. CONCLUSION In longitudinal analysis of 4355 adults in the Global PBC Study, we associated patient age, but not sex, with response to UDCA treatment and transplant-free survival. Younger age at time of treatment initiation is associated with increased risk of treatment failure, liver transplant, and death.
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Affiliation(s)
- Angela C Cheung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Marlyn J Mayo
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Albert Parés
- Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, CIBERehd, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, United Kingdom
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Ana Lleo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Raoul Poupon
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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30
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Harms MH, van Buuren HR, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Hirschfield GM, Parés A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Lammers WJ, Hansen BE, van der Meer AJ. Ursodeoxycholic acid therapy and liver transplant-free survival in patients with primary biliary cholangitis. J Hepatol 2019; 71:357-365. [PMID: 30980847 DOI: 10.1016/j.jhep.2019.04.001] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [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: 11/22/2018] [Revised: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The clinical efficacy of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) remains subject to debate as definitive randomized controlled trials are lacking. We aimed to determine whether UDCA prolongs liver transplant (LT)-free survival in patients with PBC. METHODS This international cohort study included patients from the Global PBC Study Group database, originating from 8 countries in Europe and North America. Both UDCA-treated and untreated patients were included. LT and death were assessed as a combined endpoint through Cox regression analyses, with inverse probability treatment weighting (IPTW). RESULTS In the 3,902 patients included, the mean (SD) age was 54.3 (11.9) years, 3,552 patients (94.0%) were female, 3,529 patients (90.4%) were treated with UDCA and 373 patients (9.6%) were not treated. The median (interquartile range) follow-up was 7.8 (4.1-12.1) years. In total, 721 UDCA-treated patients and 145 untreated patients died or underwent LT. After IPTW, the 10-year cumulative LT-free survival was 79.7% (95% CI 78.1-81.2) among UDCA-treated patients and 60.7% (95% CI 58.2-63.4) among untreated patients (p <0.001). UDCA was associated with a statistically significant reduced risk of LT or death (hazard ratio 0.46, 95% CI 0.40-0.52; p <0.001). The hazard ratio remained statistically significant in all stages of disease. Patients classified as inadequate biochemical responders after 1 year of UDCA had a lower risk of LT or death than patients who were not treated (adjusted hazard ratio 0.56; 95% CI 0.45-0.69; p <0.001). CONCLUSION The use of UDCA improves LT-free survival among patients with PBC, regardless of the disease stage and the observed biochemical response. These findings support UDCA as the current universal standard of care in PBC. LAY SUMMARY In this international multicenter study of 3,902 patients with primary biliary cholangitis, we found that treatment with ursodeoxycholic acid is associated with prolonged liver transplant-free survival. This association was significant, irrespective of sex, age, or disease stage. The survival benefit remained statistically significant in patients with an incomplete biochemical response to ursodeoxycholic acid therapy.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Keith D Lindor
- Arizona State University, College of Health Solutions, Phoenix, AZ, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada; Birmingham NIHR Biomedical Research Centre, and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, WA, USA
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Hirschfield GM, Chazouillères O, Drenth JP, Thorburn D, Harrison SA, Landis CS, Mayo MJ, Muir AJ, Trotter JF, Leeming DJ, Karsdal MA, Jaros MJ, Ling L, Kim KH, Rossi SJ, Somaratne RM, DePaoli AM, Beuers U. Effect of NGM282, an FGF19 analogue, in primary sclerosing cholangitis: A multicenter, randomized, double-blind, placebo-controlled phase II trial. J Hepatol 2019; 70:483-493. [PMID: 30414864 DOI: 10.1016/j.jhep.2018.10.035] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [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: 08/30/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an inflammatory, cholestatic and progressively fibrotic liver disease devoid of effective medical intervention. NGM282, an engineered, non-tumorigenic FGF19 analogue, potently regulates CYP7A1-mediated bile acid homeostasis. We assessed the activity and safety of NGM282 in patients with PSC. METHODS In this double-blind, placebo-controlled phase II trial, 62 patients who had PSC confirmed by cholangiography or biopsy and an elevated alkaline phosphatase (ALP) >1.5 × the upper limit of normal were randomly assigned 1:1:1 to receive NGM282 1 mg, 3 mg or placebo once daily for 12 weeks. The primary outcome was the change in ALP from baseline to week 12. Secondary and exploratory outcomes included changes in serum biomarkers of bile acid metabolism and fibrosis. Efficacy analysis was by intention-to-treat. RESULTS At 12 weeks, there were no significant differences in the mean change from baseline in ALP between the NGM282 and placebo groups, and therefore, the primary endpoint was not met. However, NGM282 significantly reduced levels of 7alpha-hydroxy-4-cholesten-3-one (a marker of hepatic CYP7A1 activity, LS mean differences -6.2 ng/ml (95% CI -10.7 to -1.7; p = 0.008) and -9.4 ng/ml (-14.0 to -4.9; p <0.001) in the NGM282 1 mg and 3 mg groups, respectively, compared with placebo) and bile acids. Importantly, fibrosis biomarkers that predict transplant-free survival, including Enhanced Liver Fibrosis score and Pro-C3, were significantly improved following NGM282 treatment. Most adverse events were mild to moderate in severity, with gastrointestinal symptoms more frequent in the NGM282 treatment groups. CONCLUSIONS In patients with PSC, NGM282 potently inhibited bile acid synthesis and decreased fibrosis markers, without significantly affecting ALP levels. LAY SUMMARY We present for the first time, the clinical and laboratory effects of a first-in-class, engineered analogue of the endocrine hormone FGF19 in patients with primary sclerosing cholangitis (PSC). By incorporating non-invasive markers of fibrosis, beyond standard liver injury markers, we show that NGM282 impacted on fibrosis turnover and hepatic inflammation without changing alkaline phosphatase. Our findings demonstrate the complexities of using highly potent rational agents in PSC, and furthermore challenge the dogma about what the appropriate endpoints should be for trials in PSC.
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Affiliation(s)
- Gideon M Hirschfield
- 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; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada.
| | - Olivier Chazouillères
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology and Gastroenterology Department, Saint-Antoine University Hospital, Assistance Publique-Hopitaux de Paris, and INSERM UMR S938, Sorbonne University, Paris, France
| | - Joost P Drenth
- Department of Gastroenterology and Hepatology, Radboud UMC, Nijmegen, the Netherlands
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | | | - Charles S Landis
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, United States
| | - Marlyn J Mayo
- University Texas Southwestern Medical Center, Dallas, United States
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, United States
| | - James F Trotter
- Texas Digestive Disease Consultants, Clinical Research, Southlake, United States
| | | | | | | | - Lei Ling
- NGM Biopharmaceuticals, South San Francisco, United States
| | - Kathline H Kim
- NGM Biopharmaceuticals, South San Francisco, United States
| | | | | | - Alex M DePaoli
- NGM Biopharmaceuticals, South San Francisco, United States
| | - Ulrich Beuers
- Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Mayo MJ, Pockros PJ, Jones D, Bowlus CL, Levy C, Patanwala I, Bacon B, Luketic V, Vuppalanchi R, Medendorp S, Dorenbaum A, Kennedy C, Novak P, Gu J, Apostol G, Hirschfield GM. A Randomized, Controlled, Phase 2 Study of Maralixibat in the Treatment of Itching Associated With Primary Biliary Cholangitis. Hepatol Commun 2019; 3:365-381. [PMID: 30859149 PMCID: PMC6396374 DOI: 10.1002/hep4.1305] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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: 08/21/2018] [Accepted: 11/14/2018] [Indexed: 12/19/2022] Open
Abstract
Primary biliary cholangitis (PBC) is typically associated with elevated serum bile acid levels and pruritus, but pruritus is often refractory to treatment with existing therapies. This phase 2 study assessed the efficacy and safety of maralixibat, a selective, ileal, apical, sodium‐dependent, bile acid transporter inhibitor, in adults with PBC and pruritus. Adults with PBC and pruritus who had received ursodeoxycholic acid (UDCA) for ≥6 months or were intolerant to UDCA were randomized 2:1 to maralixibat (10 or 20 mg/day) or placebo for 13 weeks in combination with UDCA (when tolerated). The primary outcome was change in Adult Itch Reported Outcome (ItchRO™) average weekly sum score (0, no itching; 70, maximum itching) from baseline to week 13/early termination (ET). The study enrolled 66 patients (maralixibat [both doses combined], n = 42; placebo, n = 24). Mean ItchRO™ weekly sum scores decreased from baseline to week 13/ET with maralixibat (–26.5; 95% confidence interval [CI], –31.8, –21.2) and placebo (–23.4; 95% CI, –30.3, –16.4). The difference between groups was not significant (P = 0.48). In the maralixibat and placebo groups, adverse events (AEs) were reported in 97.6% and 70.8% of patients, respectively. Gastrointestinal disorders were the most frequently reported AEs (maralixibat, 78.6%; placebo, 50.0%). Conclusion: Reductions in pruritus did not differ significantly between maralixibat and placebo. However, a large placebo effect may have confounded assessment of pruritus. Lessons learned from this rigorously designed and executed trial are indispensable for understanding how to approach trials assessing pruritus as the primary endpoint and the therapeutic window of bile acid uptake inhibition as a therapeutic strategy in PBC.
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Affiliation(s)
- Marlyn J Mayo
- Digestive and Liver Diseases University of Texas Southwestern Medical Center Dallas TX
| | - Paul J Pockros
- Scripps Clinic and Scripps Translational Science Institute La Jolla CA
| | - David Jones
- Institute of Cellular Medicine Newcastle University Newcastle upon Tyne United Kingdom
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology University of California Davis School of Medicine Sacramento CA
| | - Cynthia Levy
- Division of Hepatology University of Miami Miller School of Medicine Miami FL
| | - Imran Patanwala
- Royal Liverpool University Hospital and University of Liverpool Liverpool United Kingdom
| | - Bruce Bacon
- Division of Gastroenterology and Hepatology Saint Louis University School of Medicine St. Louis MO
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University School of Medicine Richmond VA.,McGuire Research Institute, McGuire VA Medical Center Richmond VA
| | | | | | | | | | - Patricia Novak
- Lumena Pharmaceuticals San Diego CA (one of the Shire group of companies)
| | | | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease University Health Network, University of Toronto Toronto Canada
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Mayo MJ, Wigg AJ, Leggett BA, Arnold H, Thompson AJ, Weltman M, Carey EJ, Muir AJ, Ling L, Rossi SJ, DePaoli AM. NGM282 for Treatment of Patients With Primary Biliary Cholangitis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial. Hepatol Commun 2018; 2:1037-1050. [PMID: 30202819 PMCID: PMC6128239 DOI: 10.1002/hep4.1209] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [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: 02/14/2018] [Accepted: 05/16/2018] [Indexed: 01/07/2023] Open
Abstract
Patients with primary biliary cholangitis (PBC) who had an inadequate response to ursodiol have few treatment options. Alkaline phosphatase (ALP) and bilirubin levels correlate with the risk of liver transplant or death in PBC patients. Fibroblast growth factor (FGF) 19 is a hormone that acts directly in the liver to regulate bile acid synthesis. We evaluated NGM282, an engineered analogue of FGF19, for the treatment of PBC. In this 28-day, double-blind, placebo-controlled phase 2 trial, 45 PBC patients who had an inadequate response to ursodiol were randomly assigned 1:1:1 to receive subcutaneous daily doses of either NGM282 at 0.3 mg (n = 14), 3 mg (n = 16), or placebo (n = 15). The primary endpoint was a change in ALP from baseline after 28 days of treatment. At day 28, ALP was significantly reduced with NGM282 treatment at both 0.3 mg (least-squares mean -51.0 IU/L [standard error (SE) 15.4]) and 3 mg (-66.0 IU/L [SE 16.0]) versus placebo (3.3 IU/L [SE 14.8]), with least-squares mean differences of -54.3 IU/L (95% confidence interval -104.2 to -4.5; P = 0.0149) and -69.3 IU/L (95% confidence interval -120.5 to -18.3; P = 0.0030), respectively. Fifty percent (7 of 14) of patients receiving NGM282 0.3 mg and 46% (6 of 13) of those receiving NGM282 3mg achieved 15% or greater reduction in ALP levels from baseline, compared with 7% (1 of 15) of patients receiving placebo. NGM282 also significantly reduced serum concentrations of transaminases and immunoglobulins. Most adverse events were grade 1 (mild) to grade 2 (moderate) in severity, with gastrointestinal disorders more frequent in the NGM282 treatment groups. No worsening of pruritus was observed with NGM282 treatment. Conclusion: NGM282 administered for 28 days resulted in significant improvements in ALP and transaminase levels compared with placebo, with an acceptable safety profile in patients with PBC. (Hepatology Communications 2018; 00:000-000).
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Affiliation(s)
- Marlyn J Mayo
- University of Texas Southwestern Medical Center Dallas Texas
| | - Alan J Wigg
- Flinders Medical Center Adelaide South Australia Australia
| | - Barbara A Leggett
- Royal Brisbane and Women's Hospital and School of Medicine University of Queensland Brisbane Queensland Australia
| | | | | | | | | | | | - Lei Ling
- NGM Biopharmaceuticals Inc. South San Francisco California
| | | | - Alex M DePaoli
- NGM Biopharmaceuticals Inc. South San Francisco California
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Murillo Perez CF, Goet JC, Lammers WJ, Gulamhusein A, van Buuren HR, Ponsioen CY, Carbone M, Mason A, Corpechot C, Invernizzi P, Mayo MJ, Battezzati PM, Floreani A, Pares A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Thorburn D, Hirschfield G, LaRusso NF, Lindor KD, Zachou K, Poupon R, Trivedi PJ, Verhelst X, Janssen HLA, Hansen BE. Milder disease stage in patients with primary biliary cholangitis over a 44-year period: A changing natural history. Hepatology 2018; 67:1920-1930. [PMID: 29220537 DOI: 10.1002/hep.29717] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 07/17/2017] [Revised: 11/21/2017] [Accepted: 12/02/2017] [Indexed: 01/03/2023]
Abstract
UNLABELLED Changes over time in the presenting features and clinical course of patients with primary biliary cholangitis are poorly described. We sought to describe temporal trends in patient and disease characteristics over a 44-year period across a large international primary biliary cholangitis cohort of 4,805 patients diagnosed between 1970 and 2014, from 17 centers across Europe and North America. Patients were divided into five cohorts according to their year of diagnosis: 1970-1979 (n = 143), 1980-1989 (n = 858), 1990-1999 (n = 1,754), 2000-2009 (n = 1,815), and ≥2010 (n = 235). Age at diagnosis, disease stage, response to ursodeoxycholic acid, and clinical outcomes were compared. Mean age at diagnosis increased incrementally by 2-3 years per decade from 46.9 ± 10.1 years in the 1970s to 57.0 ± 12.1 years from 2010 onward (P < 0.001). The female to male ratio (9:1) and antimitochondrial antibody positivity (90%) were not significantly variable. The proportion of patients presenting with mild biochemical disease (according to Rotterdam staging) increased from 41.3% in the 1970s to 72.2% in the 1990s (P < 0.001) and remained relatively stable thereafter. Patients with a mild histological stage at diagnosis increased from 60.4% (1970-1989) to 76.5% (1990-2014) (P < 0.001). Correspondingly, response to ursodeoxycholic acid according to Paris-I criteria increased; 51.7% in the 1970s and 70.5% in the 1990s (P < 0.001). Recent decades were also characterized by lower decompensation rates (18.5% in the 1970s to 5.8% in the 2000s, P < 0.001) and higher 10-year transplant-free survival (48.4%, 68.7%, 79.7%, and 80.1% for each respective cohort; P < 0.001). CONCLUSION In recent decades, a pattern of primary biliary cholangitis presentation consistent with an older age at diagnosis alongside reduced disease severity has been noted; the observed trends may be explained by an increase in routine testing of liver function and/or a changing environmental trigger. (Hepatology 2018;67:1920-1930).
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Insitute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jorn C Goet
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, TX
| | | | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Gideon Hirschfield
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | | | | | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Palak J Trivedi
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Levy C, Bowlus CL, Carey E, Crawford JM, Deane K, Mayo MJ, Kim WR, Fried MW. A real-world observational cohort of patients with primary biliary cholangitis: TARGET-primary biliary cholangitis study design and rationale. Hepatol Commun 2018; 2:484-491. [PMID: 29761165 PMCID: PMC5944592 DOI: 10.1002/hep4.1173] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 09/15/2017] [Revised: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 12/13/2022] Open
Abstract
Primary biliary cholangitis (PBC) is a rare chronic cholestatic liver disease that may progress to biliary cirrhosis if left untreated. The first‐line therapy for PBC is ursodeoxycholic acid (UDCA). Unfortunately, 1 of 3 patients does not respond to UDCA. These patients are at risk for developing clinical events, including cirrhosis, complications of portal hypertension, hepatocellular carcinoma, liver transplant, or death. Recently, the U.S. Food and Drug Administration approved obeticholic acid to be used in certain patients with PBC. Off‐label therapies are also used, and several other therapies are currently under evaluation. Real‐world effectiveness of newly approved and off‐label therapies remains unknown. TARGET‐PBC is a 5‐year, longitudinal, observational study of patients with PBC that will evaluate the effectiveness of clinical practice interventions and provide practical information unobtainable in registration trials. Enrollment will take place at both academic and community sites. In addition to consenting to medical records review, participants will be asked to provide an annual blood sample and complete patient reported outcome surveys at predetermined intervals. Any available liver biopsies will be digitally preserved. Conclusion: Key study outcomes will be the evaluation of the safety and effectiveness of PBC interventions and the assessment of disease progression under real‐world conditions. (Hepatology Communications 2018;2:484‐491)
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Affiliation(s)
- Cynthia Levy
- Department of Medicine University of Miami Miami FL
| | | | | | | | | | - Marlyn J Mayo
- University of Texas Southwestern Medical Center Dallas TX
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Duraiswamy S, Sheffield JS, Mcintire D, Leveno K, Mayo MJ. Updated Etiology and Significance of Elevated Bilirubin During Pregnancy: Changes Parallel Shift in Demographics and Vaccination Status. Dig Dis Sci 2017; 62:517-525. [PMID: 27586034 DOI: 10.1007/s10620-016-4282-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 10/20/2015] [Accepted: 08/16/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The most common cause of jaundice during pregnancy in the United States (US) is still attributed to viral hepatitis, despite the dramatic drop in incidence of viral hepatitis in the US. OBJECTIVE We hypothesized that viral hepatitis is no longer a frequent etiology of jaundice among the pregnant population in the US and sought to identify the contemporary causes of elevated bilirubin during pregnancy as well as to quantify the associated risk to the mother and fetus. STUDY DESIGN Clinical data from all pregnant women who delivered an infant between 2005 and 2011 at a single hospital in Dallas, Texas, were ascertained using prospectively collected computerized databases. Women with elevated total bilirubin (>1.2 mg/dl) were analyzed to determine the cause of hyperbilirubinemia and maternal and fetal outcomes. RESULTS Out of a total of 80,857 consecutive deliveries, there were 397 (0.5 %) pregnancies with hyperbilirubinemia. The most common etiology was gallstones (98/397 = 25 %), followed by preeclampsia/eclampsia/HELLP (94/397 = 24 %) and intrahepatic cholestasis of pregnancy (53/397 = 13 %). Adverse infant outcomes, including stillbirths, fetal malformations, neonatal deaths, and small for gestational age births, were more common in the women with hyperbilirubinemia during pregnancy, but there were no maternal deaths. CONCLUSIONS Acute viral hepatitis is no longer a common cause of jaundice in pregnant women in the US. In the current era, gallstones and preeclampsia-related disorders are the most common causes of jaundice in pregnant women. Disorders that cause elevated maternal bilirubin during pregnancy are associated with increased risk for the fetus.
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Affiliation(s)
- Sangeethapriya Duraiswamy
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9151, USA
| | - Jeanne S Sheffield
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald Mcintire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kenneth Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9151, USA.
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Hirschfield GM, Gershwin ME, Strauss R, Mayo MJ, Levy C, Zou B, Johanns J, Nnane IP, Dasgupta B, Li K, Selmi C, Marschall HU, Jones D, Lindor K. Ustekinumab for patients with primary biliary cholangitis who have an inadequate response to ursodeoxycholic acid: A proof-of-concept study. Hepatology 2016; 64:189-99. [PMID: 26597786 DOI: 10.1002/hep.28359] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [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: 08/11/2015] [Accepted: 11/18/2015] [Indexed: 12/21/2022]
Abstract
UNLABELLED The interleukin (IL)-12 signaling cascade has been associated with primary biliary cholangitis (PBC). This multicenter, open-label, proof-of-concept study evaluated the anti-IL12/23 monoclonal antibody, ustekinumab (90 mg subcutaneous at weeks 0 and 4, then every 8 weeks through week 20), in adults with PBC and an inadequate response to ursodeoxycholic acid therapy (i.e., alkaline phosphatase [ALP] >1.67× upper limit of normal [ULN] after ≥6 months). ALP response was defined as a >40% decrease from baseline and ALP remission as ALP normalization (if baseline ALP 1.67×-2.8× ULN) or <1.67× ULN (if baseline ALP >2.8× ULN). Changes in Enhanced Liver Fibrosis (ELF) scores and serum bile acids were also assessed. At baseline, patients had median disease duration of 3.2 years, median ELF score of 9.8, and highly elevated total bile acid concentration (median, 43.3 μmol/L); 13 of 20 (65%) patients had baseline ALP >3× ULN. Although steady-state serum ustekinumab concentrations were reached by week 12, no patient achieved ALP response or remission. Median percent ALP reduction from baseline to week 28 was 12.1%. ELF score decreased slightly from baseline to week 28 (median reduction: 0.173), and total serum bile acid concentrations decreased from baseline to week 28 (median reduction: 8.8 μmol/L). No serious infections or discontinuations resulting from adverse events were reported through week 28. One patient had a serious upper gastrointestinal hemorrhage considered unrelated to test agent by the investigator. CONCLUSION Open-label ustekinumab therapy, though associated with a modest decrease in ALP after 28 weeks of therapy, did not otherwise appreciably change ALP and overt proof-of-concept was not established as per prespecified primary endpoint of proposed efficacy. No new ustekinumab safety signals were observed. (Hepatology 2016;64:189-199).
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Affiliation(s)
- Gideon M Hirschfield
- National Institute of Health Research (NIHR) Biomedical Research Unit (BRU) and Center for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - M Eric Gershwin
- Division of Rheumatology, Allergy & Immunology, The University of California School of Medicine, Davis, CA
| | | | | | | | - Bin Zou
- Janssen Research & Development, LLC, Spring House, PA
| | - Jewel Johanns
- Janssen Research & Development, LLC, Spring House, PA
| | - Ivo P Nnane
- Janssen Research & Development, LLC, Spring House, PA
| | | | - Katherine Li
- Janssen Research & Development, LLC, Spring House, PA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, Milan, Italy.,BIOMETRA Department, University of Milan, Milan, Italy
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - David Jones
- Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, United Kingdom
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Aday AW, Mayo MJ, Elliott A, Rockey DC. The Beneficial Effect of Beta-Blockers in Patients With Cirrhosis, Portal Hypertension and Ascites. Am J Med Sci 2016; 351:169-76. [PMID: 26897272 DOI: 10.1016/j.amjms.2015.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 07/07/2015] [Accepted: 10/21/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with cirrhosis and portal hypertensive complications have reduced survival. As such, it has been suggested that nonselective beta-blocker therapy in patients with advanced ascites is harmful. The aim of this study was, therefore, to determine the risk of mortality in patients with cirrhosis and ascites taking nonselective beta-blocker therapy for the prevention of variceal hemorrhage. MATERIALS AND METHODS This study was a retrospective analysis of 2,419 patients with cirrhosis and portal hypertension admitted to Parkland Memorial Hospital (a university-affiliated county teaching hospital) from 2003-2010. Patients were subdivided into those with varices only, ascites only and those with both varices and ascites. The primary outcome measure for this study was all-cause in-hospital mortality. RESULTS Overall, 68 of 1,039 (6.5%) patients taking beta-blockers died during their hospitalization, while 223 of 1,380 (16.2%) patients not taking beta-blockers died (P < 0.001). Beta-blocker use was also assessed in specific cohorts; mortality was 21.1% in patients with severe ascites with varices who were not taking beta-blockers compared with 8.9% in patients who were taking beta-blockers (P = 0.05). Overall, fewer patients taking beta-blockers died compared with those not taking beta-blockers in patients with varices only (6.4% versus 12.1%) and those with ascites with or without varices (6.6% versus 18.1%) (P < 0.001). CONCLUSIONS Mortality was lower in patients with cirrhosis and portal hypertension taking nonselective beta-blockers than in those not taking beta-blockers. The use of nonselective beta-blockers provided a significant survival benefit in patients with all grades of ascites, including those with severe ascites.
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Affiliation(s)
- Ariel W Aday
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital, Parkland Health and Hospital System, Dallas, Texas
| | - Marlyn J Mayo
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital, Parkland Health and Hospital System, Dallas, Texas
| | - Alan Elliott
- Department of Statistical Science, Southern Methodist University, Dallas, Texas
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
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Trivedi PJ, Lammers WJ, van Buuren HR, Parés A, Floreani A, Janssen HLA, Invernizzi P, Battezzati PM, Ponsioen CY, Corpechot C, Poupon R, Mayo MJ, Burroughs AK, Nevens F, Mason AL, Kowdley KV, Lleo A, Caballeria L, Lindor KD, Hansen BE, Hirschfield GM. Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicentre international study. Gut 2016; 65:321-9. [PMID: 25567117 DOI: 10.1136/gutjnl-2014-308351] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [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: 09/01/2014] [Accepted: 12/08/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Hepatocellular carcinoma (HCC) is an infrequent yet critical event in primary biliary cirrhosis (PBC); however, predictive tools remain ill-defined. Our objective was to identify candidate risk factors for HCC development in patients with PBC. DESIGN Risk factor analysis was performed in over 15 centres from North America and Europe spanning >40 years observation period using Cox proportional hazards assumptions, logistic regression, and Kaplan-Meier estimates. RESULTS Of 4565 patients with PBC 123 developed HCC, yielding an incidence rate (IR) of 3.4 cases/1000 patient-years. HCC was significantly more common in men (p<0.0001), and on univariate analysis factors at PBC diagnosis associated with future HCC development were male sex (unadjusted HR 2.91, p<0.0001), elevated serum aspartate transaminase (HR 1.24, p<0.0001), advanced disease (HR 2.72, p=0.022), thrombocytopenia (HR 1.65, p<0.0001), and hepatic decompensation (HR 9.89, p<0.0001). As such, non-treatment with ursodeoxycholic acid itself was not associated with cancer development; however, 12-month stratification by biochemical non-response (Paris-I criteria) associated significantly with future risk of HCC (HR 4.52, p<0.0001; IR 6.6 vs 1.4, p<0.0001). Non-response predicted future risk in patients with early stage disease (IR 4.7 vs 1.2, p=0.005), advanced disease (HR 2.79, p=0.02; IR 11.2 vs 4.4, p=0.033), and when restricting the analysis to only male patients (HR 4.44, p<0.001; IR 18.2 vs 5.4, p<0.001). On multivariable analysis biochemical non-response remained the most significant factor predictive of future HCC risk (adjusted HR 3.44, p<0.0001). CONCLUSIONS This uniquely powered, internationally representative cohort robustly demonstrates that 12-month biochemical non-response is associated with increased future risk of developing HCC in PBC. Such risk stratification is relevant to patient care and development of new therapies.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU) and Centre for Liver Research, University of Birmingham, Birmingham, UK Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgical, Oncological and Gastroenterological, University of Padua, Padua, Italy
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Toronto Center for Liver Diseases, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
| | - Christophe Corpechot
- Center de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Raoul Poupon
- Center de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Marlyn J Mayo
- Department of Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA Liver Care Network, Swedish Medical Center, Seattle, Washington, USA
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA Arizona State University, Phoenix, Arizona, USA
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU) and Centre for Liver Research, University of Birmingham, Birmingham, UK Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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Lammers WJ, Hirschfield GM, Corpechot C, Nevens F, Lindor KD, Janssen HLA, Floreani A, Ponsioen CY, Mayo MJ, Invernizzi P, Battezzati PM, Parés A, Burroughs AK, Mason AL, Kowdley KV, Kumagi T, Harms MH, Trivedi PJ, Poupon R, Cheung A, Lleo A, Caballeria L, Hansen BE, van Buuren HR. Development and Validation of a Scoring System to Predict Outcomes of Patients With Primary Biliary Cirrhosis Receiving Ursodeoxycholic Acid Therapy. Gastroenterology 2015; 149:1804-1812.e4. [PMID: 26261009 DOI: 10.1053/j.gastro.2015.07.061] [Citation(s) in RCA: 275] [Impact Index Per Article: 30.6] [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: 04/16/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Approaches to risk stratification for patients with primary biliary cirrhosis (PBC) are limited, single-center based, and often dichotomous. We aimed to develop and validate a better model for determining prognoses of patients with PBC. METHODS We performed an international, multicenter meta-analysis of 4119 patients with PBC treated with ursodeoxycholic acid at liver centers in 8 European and North American countries. Patients were randomly assigned to derivation (n = 2488 [60%]) and validation cohorts (n = 1631 [40%]). A risk score (GLOBE score) to predict transplantation-free survival was developed and validated with univariate and multivariable Cox regression analyses using clinical and biochemical variables obtained after 1 year of ursodeoxycholic acid therapy. Risk score outcomes were compared with the survival of age-, sex-, and calendar time-matched members of the general population. The prognostic ability of the GLOBE score was evaluated alongside those of the Barcelona, Paris-1, Rotterdam, Toronto, and Paris-2 criteria. RESULTS Age (hazard ratio = 1.05; 95% confidence interval [CI]: 1.04-1.06; P < .0001); levels of bilirubin (hazard ratio = 2.56; 95% CI: 2.22-2.95; P < .0001), albumin (hazard ratio = 0.10; 95% CI: 0.05-0.24; P < .0001), and alkaline phosphatase (hazard ratio = 1.40; 95% CI: 1.18-1.67; P = .0002); and platelet count (hazard ratio/10 units decrease = 0.97; 95% CI: 0.96-0.99; P < .0001) were all independently associated with death or liver transplantation (C-statistic derivation, 0.81; 95% CI: 0.79-0.83, and validation cohort, 0.82; 95% CI: 0.79-0.84). Patients with risk scores >0.30 had significantly shorter times of transplant-free survival than matched healthy individuals (P < .0001). The GLOBE score identified patients who would survive for 5 years and 10 years (responders) with positive predictive values of 98% and 88%, respectively. Up to 22% and 21% of events and nonevents, respectively, 10 years after initiation of treatment were correctly reclassified in comparison with earlier proposed criteria. In subgroups of patients aged <45, 45-52, 52-58, 58-66, and ≥66 years, age-specific GLOBE-score thresholds beyond which survival significantly deviated from matched healthy individuals were -0.52, 0.01, 0.60, 1.01 and 1.69, respectively. Transplant-free survival could still be accurately calculated by the GLOBE score with laboratory values collected at 2-5 years after treatment. CONCLUSIONS We developed and validated scoring system (the GLOBE score) to predict transplant-free survival of ursodeoxycholic acid-treated patients with PBC. This score might be used to select strategies for treatment and care.
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Affiliation(s)
- Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Arizona State University, College of Health Solutions, Phoenix, Arizona
| | - Harry L A Janssen
- Liver Clinic, Toronto Western and General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Pier M Battezzati
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andrew K Burroughs
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, United Kingdom
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington
| | - Teru Kumagi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Palak J Trivedi
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Angela Cheung
- Liver Clinic, Toronto Western and General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Mayo MJ. Predicting Outcomes of Primary Biliary Cholangitis Using the GLOBE Score. Gastroenterol Hepatol (N Y) 2015; 11:842-844. [PMID: 27134602 PMCID: PMC4849514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Marlyn J Mayo
- Associate Professor Internal Medicine University of Texas Southwestern Medical Center Dallas, Texas
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Lammers WJ, van Buuren HR, Hirschfield GM, Janssen HLA, Invernizzi P, Mason AL, Ponsioen CY, Floreani A, Corpechot C, Mayo MJ, Battezzati PM, Parés A, Nevens F, Burroughs AK, Kowdley KV, Trivedi PJ, Kumagi T, Cheung A, Lleo A, Imam MH, Boonstra K, Cazzagon N, Franceschet I, Poupon R, Caballeria L, Pieri G, Kanwar PS, Lindor KD, Hansen BE. Levels of alkaline phosphatase and bilirubin are surrogate end points of outcomes of patients with primary biliary cirrhosis: an international follow-up study. Gastroenterology 2014; 147:1338-49.e5; quiz e15. [PMID: 25160979 DOI: 10.1053/j.gastro.2014.08.029] [Citation(s) in RCA: 297] [Impact Index Per Article: 29.7] [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: 04/17/2014] [Revised: 07/31/2014] [Accepted: 08/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Noninvasive surrogate end points of long-term outcomes of patients with primary biliary cirrhosis (PBC) are needed to monitor disease progression and evaluate potential treatments. We performed a meta-analysis of individual patient data from cohort studies to evaluate whether patients' levels of alkaline phosphatase and bilirubin correlate with their outcomes and can be used as surrogate end points. METHODS We performed a meta-analysis of data from 4845 patients included in 15 North American and European long-term follow-up cohort studies. Levels of alkaline phosphatase and bilirubin were analyzed in different settings and subpopulations at different time points relative to the clinical end point (liver transplantation or death). RESULTS Of the 4845 patients, 1118 reached a clinical end point. The median follow-up period was 7.3 years; 77% survived for 10 years after study enrollment. Levels of alkaline phosphatase and bilirubin measured at study enrollment (baseline) and each year for 5 years were strongly associated with clinical outcomes (lower levels were associated with longer transplant-free survival). At 1 year after study enrollment, levels of alkaline phosphatase that were 2.0 times the upper limit of normal (ULN) best predicted patient outcome (C statistic, 0.71) but not significantly better than other thresholds. Of patients with alkaline phosphatase levels ≤ 2.0 times the ULN, 84% survived for 10 years compared with 62% of those with levels >2.0 times the ULN (P < .0001). Absolute levels of alkaline phosphatase 1 year after study enrollment predicted patient outcomes better than percentage change in level. One year after study enrollment, a bilirubin level 1.0 times the ULN best predicted patient transplant-free survival (C statistic, 0.79). Of patients with bilirubin levels ≤ 1.0 times the ULN, 86% survived for 10 years after study enrollment compared with 41% of those with levels >1.0 times the ULN (P < .0001). Combining levels of alkaline phosphatase and bilirubin increased the ability to predict patient survival times. We confirmed the predictive value of alkaline phosphatase and bilirubin levels in multiple subgroups, such as patients who had not received treatment with ursodeoxycholic acid, and at different time points after study enrollment. CONCLUSIONS Levels of alkaline phosphatase and bilirubin can predict outcomes (liver transplantation or death) of patients with PBC and might be used as surrogate end points in therapy trials.
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Affiliation(s)
- Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, England
| | - Harry L A Janssen
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Marlyn J Mayo
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pier M Battezzati
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Andrew K Burroughs
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, England
| | - Kris V Kowdley
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Palak J Trivedi
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, England
| | - Teru Kumagi
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Angela Cheung
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Mohamad H Imam
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kirsten Boonstra
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Irene Franceschet
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Giulia Pieri
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, England
| | - Pushpjeet S Kanwar
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Nelson DB, Duraiswamy S, McIntire DD, Mayo MJ, Leveno KJ. Does preeclampsia involve the pancreas? A report of original research. J Matern Fetal Neonatal Med 2014; 28:836-8. [DOI: 10.3109/14767058.2014.935325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Selmi C, Cavaciocchi F, Lleo A, Cheroni C, De Francesco R, Lombardi SA, De Santis M, Meda F, Raimondo MG, Crotti C, Folci M, Zammataro L, Mayo MJ, Bach N, Shimoda S, Gordon SC, Miozzo M, Invernizzi P, Podda M, Scavelli R, Martin MR, Seldin MF, Lasalle JM, Gershwin ME. Genome-wide analysis of DNA methylation, copy number variation, and gene expression in monozygotic twins discordant for primary biliary cirrhosis. Front Immunol 2014; 5:128. [PMID: 24734033 PMCID: PMC3975093 DOI: 10.3389/fimmu.2014.00128] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/13/2014] [Indexed: 01/12/2023] Open
Abstract
Primary biliary cirrhosis (PBC) is an uncommon autoimmune disease with a homogeneous clinical phenotype that reflects incomplete disease concordance in monozygotic (MZ) twins. We have taken advantage of a unique collection consisting of genomic DNA and mRNA from peripheral blood cells of female MZ twins (n = 3 sets) and sisters of similar age (n = 8 pairs) discordant for disease. We performed a genome-wide study to investigate differences in (i) DNA methylation (using a custom tiled four-plex array containing tiled 50-mers 19,084 randomly chosen methylation sites), (ii) copy number variation (CNV) (with a chip including markers derived from the 1000 Genomes Project, all three HapMap phases, and recently published studies), and/or (iii) gene expression (by whole-genome expression arrays). Based on the results obtained from these three approaches we utilized quantitative PCR to compare the expression of candidate genes. Importantly, our data support consistent differences in discordant twins and siblings for the (i) methylation profiles of 60 gene regions, (ii) CNV of 10 genes, and (iii) the expression of 2 interferon-dependent genes. Quantitative PCR analysis showed that 17 of these genes are differentially expressed in discordant sibling pairs. In conclusion, we report that MZ twins and sisters discordant for PBC manifest particular epigenetic differences and highlight the value of the epigenetic study of twins.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis , Davis, CA , USA
| | - Francesca Cavaciocchi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; BIOMETRA Department, University of Milan , Milan , Italy
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center , Milan , Italy
| | | | | | - Simone A Lombardi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; BIOMETRA Department, University of Milan , Milan , Italy
| | - Francesca Meda
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Maria Gabriella Raimondo
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Chiara Crotti
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Marco Folci
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Luca Zammataro
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | | | - Nancy Bach
- Mt. Sinai University , New York, NY , USA
| | - Shinji Shimoda
- Clinical Research Center, National Nagasaki Medical Center , Nagasaki , Japan
| | | | - Monica Miozzo
- Department of Pathophysiology and Transplantation, University of Milan , Milan , Italy ; Division of Pathology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center , Milan , Italy
| | - Mauro Podda
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | | | - Michelle R Martin
- Genome Center and M.I.N.D. Institute, University of California Davis , Davis, CA , USA
| | - Michael F Seldin
- Department of Biochemistry and Molecular Medicine, University of California at Davis, Davis, CA, USA; Department of Internal Medicine, University of California at Davis, Davis, CA, USA
| | - Janine M Lasalle
- Genome Center and M.I.N.D. Institute, University of California Davis , Davis, CA , USA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis , Davis, CA , USA
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45
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Selmi C, Cavaciocchi F, Lleo A, Cheroni C, De Francesco R, Lombardi SA, De Santis M, Meda F, Raimondo MG, Crotti C, Folci M, Zammataro L, Mayo MJ, Bach N, Shimoda S, Gordon SC, Miozzo M, Invernizzi P, Podda M, Scavelli R, Martin MR, Seldin MF, Lasalle JM, Gershwin ME. Genome-wide analysis of DNA methylation, copy number variation, and gene expression in monozygotic twins discordant for primary biliary cirrhosis. Front Immunol 2014. [PMID: 24734033 PMCID: PMC4132258 DOI: 10.3389/fimmu.2014.00371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Indexed: 12/17/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is an uncommon autoimmune disease with a homogeneous clinical phenotype that reflects incomplete disease concordance in monozygotic (MZ) twins. We have taken advantage of a unique collection consisting of genomic DNA and mRNA from peripheral blood cells of female MZ twins (n = 3 sets) and sisters of similar age (n = 8 pairs) discordant for disease. We performed a genome-wide study to investigate differences in (i) DNA methylation (using a custom tiled four-plex array containing tiled 50-mers 19,084 randomly chosen methylation sites), (ii) copy number variation (CNV) (with a chip including markers derived from the 1000 Genomes Project, all three HapMap phases, and recently published studies), and/or (iii) gene expression (by whole-genome expression arrays). Based on the results obtained from these three approaches we utilized quantitative PCR to compare the expression of candidate genes. Importantly, our data support consistent differences in discordant twins and siblings for the (i) methylation profiles of 60 gene regions, (ii) CNV of 10 genes, and (iii) the expression of 2 interferon-dependent genes. Quantitative PCR analysis showed that 17 of these genes are differentially expressed in discordant sibling pairs. In conclusion, we report that MZ twins and sisters discordant for PBC manifest particular epigenetic differences and highlight the value of the epigenetic study of twins.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis , Davis, CA , USA
| | - Francesca Cavaciocchi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; BIOMETRA Department, University of Milan , Milan , Italy
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center , Milan , Italy
| | | | | | - Simone A Lombardi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy ; BIOMETRA Department, University of Milan , Milan , Italy
| | - Francesca Meda
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Maria Gabriella Raimondo
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Chiara Crotti
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Marco Folci
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | - Luca Zammataro
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | | | - Nancy Bach
- Mt. Sinai University , New York, NY , USA
| | - Shinji Shimoda
- Clinical Research Center, National Nagasaki Medical Center , Nagasaki , Japan
| | | | - Monica Miozzo
- Department of Pathophysiology and Transplantation, University of Milan , Milan , Italy ; Division of Pathology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center , Milan , Italy
| | - Mauro Podda
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center , Milan , Italy
| | | | - Michelle R Martin
- Genome Center and M.I.N.D. Institute, University of California Davis , Davis, CA , USA
| | - Michael F Seldin
- Department of Biochemistry and Molecular Medicine, University of California at Davis, Davis, CA, USA; Department of Internal Medicine, University of California at Davis, Davis, CA, USA
| | - Janine M Lasalle
- Genome Center and M.I.N.D. Institute, University of California Davis , Davis, CA , USA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis , Davis, CA , USA
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Abstract
Primary biliary cirrhosis and primary sclerosing cholangitis share some clinical features with autoimmune hepatitis, but when features of autoimmune hepatitis are present, prognosis can be affected and immunosuppressive treatment warranted. The presence of severe interface hepatitis in primary biliary cirrhosis portends a worse prognosis and should prompt evaluation for possible autoimmune hepatitis overlap and treatment with immunosuppression. Specific models to identify which subjects benefit most from the addition of immunosuppression need to be developed. Drug-induced liver injury and IgG4 disease may masquerade as autoimmune hepatitis or primary sclerosing cholangitis and are important to consider in the differential diagnosis of the overlap or variant syndromes.
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Affiliation(s)
- Marlyn J Mayo
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9151, USA.
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47
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Mitchell MM, Lleo A, Zammataro L, Mayo MJ, Invernizzi P, Bach N, Shimoda S, Gordon S, Podda M, Gershwin ME, Selmi C, LaSalle JM. Epigenetic investigation of variably X chromosome inactivated genes in monozygotic female twins discordant for primary biliary cirrhosis. Epigenetics 2011; 6:95-102. [PMID: 20864813 DOI: 10.4161/epi.6.1.13405] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is an autoimmune chronic cholestatic liver disease with a strong genetic susceptibility due to the high concordance in monozygotic (MZ) twins and a striking female predominance. Women with PBC manifest an enhanced X monosomy rate in peripheral lymphocytes and we thus hypothesized an X chromosome epigenetic component to explain PBC female prevalence. While most genes on the female inactive X chromosome are silenced by promoter methylation following X chromosome inactivation (XCI), approximately 10% of X- linked genes exhibit variable escape from XCI in healthy females. This study was designed to test the hypothesis that susceptibility to PBC is modified by one or more X-linked gene with variable XCI status. Peripheral blood mRNA and DNA samples were obtained from a unique cohort of MZ twin sets discordant and concordant for PBC. Transcript levels of the 125 variable XCI status genes was determined by quantitative RT-PCR analysis and two genes (CLIC2 and PIN4) were identified as consistently downregulated in the affected twin of discordant pairs. Both CLIC2 and PIN4 demonstrated partial and variable methylation of CpG sites within 300 bp of the transcription start site that did not predict the XCI status. Promoter methylation of CLIC2 manifested no significant difference between samples and no significant correlation with transcript levels. PIN4 methylation showed a positive trend with transcription in all samples but no differential methylation was observed between discordant twins. A genetic polymorphism affecting the number of CpG sites in the PIN4 promoter did not impact methylation or transcript levels in a heterozygous twin pair and showed a similar frequency in independent series of unrelated PBC cases and controls. Our results suggest that epigenetic factors influencing PBC onset are more complex than methylation differences at X-linked promoters and variably 3 inactivated X-linked genes may be characterized by partial promoter methylation and biallelic transcription.
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Affiliation(s)
- Michelle M Mitchell
- Medical Microbiology and Immunology, University of California at Davis, CA, USA
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48
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Silveira MG, Brunt EM, Heathcote J, Gores GJ, Lindor KD, Mayo MJ. American Association for the Study of Liver Diseases endpoints conference: design and endpoints for clinical trials in primary biliary cirrhosis. Hepatology 2010; 52:349-59. [PMID: 20578151 DOI: 10.1002/hep.23637] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [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: 12/11/2022]
Affiliation(s)
- Marina G Silveira
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Tang SJ, Rodriguez-Frias E, Singh S, Mayo MJ, Jazrawi SF, Sreenarasimhaiah J, Lara LF, Rockey DC. Acute pancreatitis during pregnancy. Clin Gastroenterol Hepatol 2010; 8:85-90. [PMID: 19747985 DOI: 10.1016/j.cgh.2009.08.035] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [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: 01/28/2009] [Revised: 08/19/2009] [Accepted: 08/24/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute pancreatitis is rare during pregnancy; limited data are available about maternal and fetal outcomes. We investigated the effects of acute pancreatitis during pregnancy on fetal outcome. METHODS This retrospective cohort study, performed at a single academic center, included consecutive pregnant women who presented with (n = 96) or developed acute pancreatitis in the hospital (n = 7) in 2000-2006 (mean age, 26 y). Patient histories and clinical data were collected from medical records. RESULTS Of the 96 patients with spontaneous pancreatitis, 4 had complications: 1 patient in the first trimester had acute peripancreatic fluid collection, and 3 patients in the third trimester developed disseminated vascular coagulation (DIC). None of these patients achieved term pregnancy, and 1 of the patients with DIC died. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 patients with acute pancreatitis; post-ERCP pancreatitis was diagnosed in 4 patients (a total of 11 patients developed ERCP-associated pancreatitis). Term pregnancy was achieved in 73 patients (80.2%). Patients who developed pancreatitis in the first trimester had the lowest percentage of term pregnancy (60%) and highest risks of fetal loss (20%) and preterm delivery (16%). Of the patients with pancreatitis in the second and third trimesters, only one had fetal loss. Fetal malformations were not observed. CONCLUSIONS The majority of pregnant patients with acute pancreatitis did not have complications; most adverse fetal outcomes (fetal loss and preterm delivery) occurred during the first trimester. Acute pancreatitis, complicated by DIC, occurred most frequently in the third trimester and was associated with poor fetal and maternal outcomes.
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Affiliation(s)
- Shou-Jiang Tang
- Department of Gastroenterology, Hepatology & Endoscopy, Trinity Mother Frances Hospitals and Clinics, Tyler, Texas, USA.
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Abstract
BACKGROUND Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being unidimensional, for example only measuring intensity without impact on quality of life, or only measuring scratching activity. None has actually been demonstrated to be able to detect change over time, which is essential to using them as an outcome measure of response to an intervention. The 5-D itch scale was developed as a brief but multidimensional questionnaire designed to be useful as an outcome measure in clinical trials. The five dimensions are degree, duration, direction, disability and distribution. OBJECTIVES To study the 5-D with respect to validity, reliability and response to change. METHODS The 5-D was administered to 234 individuals with chronic pruritus due to liver disease (n = 63), kidney disease (n = 36), dermatological disorders (n = 56), HIV/AIDS (n = 28) and burn injuries (n = 51). The 5-D was administered at baseline and after a 6-week follow-up period. A subset of 50 untreated patients was retested after 3 days to assess test-retest reliability. RESULTS The 5-D score correlated strongly with a visual analogue score: r = 0.727 at baseline (P < 0.0001), r = 0.868 at the 3-day repeat (P < 0.0001), and r = 0.892 at the 6-week follow-up (P < 0.0001). There was no change in mean 5-D score between day 1 and day 3 in untreated individuals (intraclass correlation coefficient = 0.96, P < 0.0001). The 5-D did, however, detect significant changes in pruritus over the 6-week follow-up period (P < 0.0001). Subanalysis of the different patient groups revealed similar response patterns and scores, with the exception of lower total scores for the burn victims due to lower scores on the distribution domain because they itched only at the site of their burn. CONCLUSIONS The 5-D, therefore, is a reliable, multidimensional measure of itching that has been validated in patients with chronic pruritus to able to detect changes over time. The 5-D should be useful as an outcome measure in clinical trials.
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Affiliation(s)
- S Elman
- University of Wisconsin School of Medicine, Madison, WI, USA
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