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Kelly C, Zen Y, Heneghan MA. Post-Transplant Immunosuppression in Autoimmune Liver Disease. J Clin Exp Hepatol 2023; 13:350-359. [PMID: 36950491 PMCID: PMC10025678 DOI: 10.1016/j.jceh.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/10/2022] [Accepted: 07/04/2022] [Indexed: 02/17/2023] Open
Abstract
Autoimmune liver diseases (AILDs) are a group of conditions where immune-mediated liver damage can lead to the need for transplantation. Collectively, they account for almost a quarter of all liver transplants. Outcomes in terms of graft and patient survival for all liver transplants have improved markedly over decades with improvements in patient selection, surgical techniques and longer-term care and this is also seen in patients with AILDs. The current five- and ten-year survival rates post-transplant in autoimmune disease are excellent, at 88% and 78%, respectively. A key factor in maintaining good outcomes post liver transplant for these autoimmune conditions is the immunosuppression strategy. These patients have increased the rates of rejection, and autoimmune conditions can all recur in the graft ranging from 12 to 60% depending on the population studied. Immunosuppressive regimens are centred on calcineurin inhibitors, often combined with low dose corticosteroids, with or without the addition of antimetabolite therapy. There is no clear evidence-based immunosuppressive regimen for these conditions, and a tailored approach balancing the individuals' immunological profile against the risks of immunosuppression is often used. There are disease-specific considerations to optimised graft function including the role of ursodeoxycholic acid in both primary biliary cholangitis and primary sclerosing cholangitis and the role and timing of colectomy in primary sclerosing cholangitis in inflammatory bowel disease patients. However, unmet needs still exist in the management of AILDs post liver transplantation particularly in building the evidence base for optimal immunosuppression as well as mitigating the risk of recurrent disease.
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Key Words
- AIH, Autoimmune hepatitis
- AILD, Autoimmune liver disease
- CNI, Calcineurin inhibitors
- IBD, Inflammatory bowel disease
- LT, Liver transplantation
- PBC, Primary biliary cholangitis
- PSC, Primary sclerosing cholangitis
- autoimmune liver disease
- immunosuppression
- rAIH, Recurrent autoimmune hepatitis
- rPBC, Recurrent primary biliary cholangitis
- rPSC, Recurrent primary sclerosing cholangitis
- transplantation
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - Yoh Zen
- Institute of Liver Studies, Kings College Hospital, London, UK
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Meena BL, Verma N, De A, Taneja S, singh V. IgG4-Related Sclerosing Cholangitis with Cholecystitis Mimicking Cholangiocarcinoma: A Case Report. J Clin Exp Hepatol 2022; 12:1012-1016. [PMID: 35677498 PMCID: PMC9168706 DOI: 10.1016/j.jceh.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 05/26/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
IgG4-related diseases are rare multisystem disorders involving salivary glands, retroperitoneum, pancreas, biliary tract, and liver. Isolated biliary strictures and gall bladder involvement are rare in such patients, and presentation with cholangitis and weight loss can misguide the diagnosis toward malignancy. Here, we report an interesting case of IgG4-related biliary stricture with gall bladder involvement, presented with cholangitis and weight loss. The initial symptoms and imaging were guided toward the malignant possibilities of cholangiocarcinoma and pancreatic carcinoma. However, endosonography, serology, and histopathology clinched the diagnosis of IgG4-related disease. The patient was managed without any biliary intervention and with antibiotics, steroids, and steroid-sparing agents. There was a relapse of disease during the steroids taper that improved after hiking its doses. The disease responded with medical management on follow-up. We demonstrated the effectiveness of steroid-sparing agents to treat IgG4-related diseases, especially to avert the steroid-related adverse effects. This case highlights the possible mislead for the diagnosis and delayed management of IgG4 disease due to shared clinical features with hepatobiliary malignancies and the effectiveness of noninvasive measures of management.
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Key Words
- AIP, Autoimmune pancreatitis
- ANA, Antinuclear antibody
- CA 19-9, Carbohydrate antigen 19-9
- CT, Computed tomography
- EUS, endoscopic ultrasound
- FNAC, Fine needle aspiration cytology
- HISTORt, Histology, Imaging, Serology, treatment response, relapse
- HOP, Head of pancreas
- HPF, High power field
- IgG4 cholangitis
- IgG4 cholecystitis
- IgG4 disease
- IgG4HBD, IgG4-related hepatobiliary disease
- IgG4RD, IgG4-related disease
- IgG4SC, IgG4 sclerosing cholangitis
- MRCP, magnetic resonance cholangiopancreatography
- PSC, Primary sclerosing cholangitis
- RF, Rheumatoid factor
- RNA, Ribonucleic acid
- cholangiocarcinoma
- periampullary carcinoma
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Affiliation(s)
- Babu L. Meena
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Virendra singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Abstract
Chronic liver disease (CLD) is one of the leading causes of disability-adjusted life years in many countries. A recent understanding of nuclear bile acid receptor pathways has increased focus on the impact of crosstalk between the gut, bile acids, and liver on liver pathology. While conventionally used in cholestatic disorders and to dissolve gallstones, the discovery of bile acids' influence on the gut microbiome and human metabolism offers a unique potential for their utility in early and advanced liver diseases because of diverse etiologies. Based on these findings, preclinical studies using bile acid-based molecules have shown encouraging results at addressing liver inflammation and fibrosis. Emerging data also suggest that bile acid profiles change distinctively across various causes of liver disease. We summarize the current knowledge and evidence related to bile acids in health and disease and discuss culminated and ongoing therapeutic trials of bile acid derivatives in CLD. In the near future, further evidence in this area might help clinicians better detect and manage liver diseases.
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Key Words
- AD, Acute decompensation
- ALP, Alkaline phosphatase
- AMACR, α-methylacyl-CoA racemase (AMACR)
- ASBT, Apical sodium dependent bile salt transporter
- BA, Bile acid
- BSEP, Bile salt export pump
- BSH, Bile salt hydrolase
- CA, Cholic acid
- CDCA, Chenodeoxycholic acid
- CLD
- CLD, Chronic Liver Disease
- CTP, Child-Turcotte-Pugh
- CYP7A1, Cholesterol 7 α hydroxylase
- DCA, Deoxycholic acid
- DR5, Death receptor 5
- ELF, Enhanced Liver Fibrosis
- FGF-19, Fibroblast growth factor-19
- FGFR4, FGF receptor 4
- FXR, Farnesoid X receptor
- GCA, Glycocholic acid
- GDCA, Glycodeoxycholic acid
- GLP-1, Glucagon-like peptide1
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HVPG, Hepatic Venous Pressure Gradient
- LCA, Lithocholic acid
- LPS, Lipopolysaccharide
- MELD, Model for End-Stage Liver Disease (MELD)
- MRI-PDFF, Magnetic resonance imaging derived proton density fat fraction
- NAFLD
- NAFLD, Non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, Nonalcoholic steatohepatitis
- NTCP, Sodium taurocholate cotransporting polypeptide
- OCA, Obeticholic acid
- OST, Organic solute transporter
- PBC, Primary biliary cirrhosis
- PFIC, Progressive familial intrahepatic cholestasis
- PSC, Primary sclerosing cholangitis
- PXR, Pregnane X receptor
- SHP, Small heterodimer partner
- TBA, Total bile acids
- TGR5, Takeda G-protein coupled receptor 5
- TRAIL, TNF-related apoptosis-inducing ligand
- UDCA, Ursodeoxycholic acid
- UPLC-MS, Ultra-performance liquid chromatography with tandem mass spectrometry
- VDR, Vitamin D receptor
- bile acids
- cirrhosis
- microbiome
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Affiliation(s)
- Naba Farooqui
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Agrawal L, Jain S, Madhusudhan KS, Das P, Shalimar, Dash NR, Sahni P, Pal S. Sepsis Following Liver Biopsy in a Liver Transplant Recipient: Case Report and Review of Literature. J Clin Exp Hepatol 2021; 11:254-259. [PMID: 33746451 PMCID: PMC7953005 DOI: 10.1016/j.jceh.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
Percutaneous liver biopsy is a relatively safe procedure with low complication rates. Infections following liver biopsy are uncommon and can lead to a poor outcome. There are limited data on liver biopsy-related infections among liver transplant (LT) recipients. Also, there is a paucity of data regarding the use of prophylactic antibiotics in LT patients undergoing percutaneous liver biopsy. We report a case of systemic sepsis following percutaneous liver biopsy in a LT recipient with choledochojejunal anastomosis. This was followed by severe rejection and deterioration of liver function and recurrence of primary sclerosing cholangitis (PSC) to the extent that he has been listed for retransplantation. This case report emphasizes the potential risk of sepsis in LT recipients with bilioenteric anastomosis undergoing percutaneous liver biopsy. This increased risk may warrant periprocedural broad spectrum antibiotic prophylaxis, in this subgroup of patients.
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Key Words
- ALT, Alanine transaminase
- AST, Aspartate transaminase
- BD, Twice daily
- DDLT, Deceased donor liver transplant
- FFP, Fresh frozen plasma
- I.V., Intravenous
- LFTs, Liver function tests
- LT, Liver transplant
- MMF, Mycophenolate mofetil
- MRCP, Magnetic resonance cholangiopancreatography
- MRI, Magnetic resonance imaging
- MU, Million units
- OD, Once daily
- PSC, Primary sclerosing cholangitis
- PTBD, Percutaneous transhepatic biliary drainage
- TDS, Three times daily
- TLC, Total leucocyte count
- liver biopsy
- liver transplantation
- sepsis
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Affiliation(s)
- Lokesh Agrawal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sachin Jain
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kumble S. Madhusudhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterolgy, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Nihar R. Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Chauhan M, Alpers DH, Hamilton JP, Thuluvath PJ. If Hoofbeats are not From Horses, It Could be Zebras!! Isolated Hyper-alkaline Phosphatasemia. J Clin Exp Hepatol 2021; 11:619-622. [PMID: 34511824 PMCID: PMC8414313 DOI: 10.1016/j.jceh.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/05/2020] [Indexed: 12/12/2022] Open
Abstract
Alkaline phosphatase (AP) is a membrane bound enzyme and when it is elevated in blood, it is mostly due to either hepatobiliary or bone diseases. We report isolated intestinal hyperphosphatasemia (IAP) in two sisters. Both sisters presented with identical trends of isolated AP elevation. Both underwent extensive workup for liver diseases including cholangiograms, and none was identified. Subsequent isoenzyme electrophoresis showed that 45%-56% of the elevated AP was due to IAP. This elevation of the intestinal AP is consistent with a rare hereditary biochemical abnormality, benign familial intestinal hyperphosphatemia. This condition should be considered in the differential diagnosis of otherwise isolated serum AP levels to avoid unnecessary investigations.
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Affiliation(s)
- Mahak Chauhan
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
| | - David H. Alpers
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - James P. Hamilton
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul J. Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA,Department of Medicine, The University of Maryland School of Medicine, Baltimore, MD, USA,Address for correspondence: Paul J. Thuluvath, Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore MD, USA.
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Chaouali M, Carvalho A, Tezeghdenti A, Ben Azaiez M, Cunha C, Ghazouani E, Kochkar R. Cytotoxic T lymphocyte antigen-4 gene polymorphisms and susceptibility to type 1 autoimmune hepatitis in the Tunisian population. Genes Dis 2017; 5:256-262. [PMID: 30320190 PMCID: PMC6176120 DOI: 10.1016/j.gendis.2017.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 12/15/2017] [Indexed: 02/06/2023] Open
Abstract
Genetic factors and gene polymorphisms leading to the onset of autoimmune response in autoimmune hepatitis (AIH) are still not full elucidated. Since the CTLA-4 molecule is a key modulator of the lymphocytes responses we hypothezied that deficiencies or mutations in the gene encoding CTLA4 protein may be involved in AIH susceptibility and trigger the autoimmune response. We investigated 3 distinct polymorphic sites (+49A > G, CT60 G > A and -318C > T) of the CTLA4 gene in 50 AIH patients and 100 healthy controls using the KASP genotyping technology. A significant positive association with AIH susceptibility was found for the GG genotype in +49 position of the CTLA4 gene which was significantly higher in AIH patients compared to controls (28% vs 9%, p = 0.003, OR = 3.93 [1.56-9.88]). The CTLA4 A/A genotype in position CT60 was more significantly frequent in controls comparing to AIH patients and could be considered as a protective genotype for the tunisian patients. CTLA4 genotyping in position -318 did not show any statistically significant difference in genotype or allele distribution. The CTLA4 gene polymorphism in position +49 is associated to AIH susceptibility in the Tunisian population. Mutation in the CTLA4 gene may lead to a modification of the CTLA4 protein structure that could have functional relevance in AIH pathogenesis and onset.
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Key Words
- AIH, Autoimmune hepatitis
- AMA-M2, Anti-mitochondrial antibody-M2
- ANA, Anti-nuclear antibodies
- Autoimmune hepatitis
- CMV, Cytomegalovirus
- CTLA4 gene polymorphisms
- CTLA4, Cytotoxic T-lymphocyte antigen 4
- Cytotoxic T-lymphocyte antigen 4
- EBV, Epstein–Barr virus
- HLA, Human leucocyte antigen
- KASP PCR, Competitive allele-specific real-time PCR
- LKM1, Anti-Liver/Kidney Microsomal Antibodies Type 1
- PBC, Primary biliary cirrhosis
- PSC, Primary sclerosing cholangitis
- SLA, Antibodies against soluble liver antigen
- SMA, Smooth-muscle antibodies
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Affiliation(s)
- Marwa Chaouali
- Department of Immunology, Military Hospital of Tunis, Montfleury 1008, Tunis, Tunisia.,El Manar University, Laboratory of Mycology, Pathologies and Biomarkers 1092, Tunis, Tunisia
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar 4710-057, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Aymen Tezeghdenti
- Department of Immunology, Military Hospital of Tunis, Montfleury 1008, Tunis, Tunisia
| | - Mouna Ben Azaiez
- Department of Immunology, Military Hospital of Tunis, Montfleury 1008, Tunis, Tunisia
| | - Cristina Cunha
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar 4710-057, Braga, Portugal
| | - Ezzeddine Ghazouani
- Department of Immunology, Military Hospital of Tunis, Montfleury 1008, Tunis, Tunisia
| | - Radhia Kochkar
- Department of Immunology, Military Hospital of Tunis, Montfleury 1008, Tunis, Tunisia
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