Epidemiology of autoimmune liver disease in Korea: evidence from a nationwide real-world database

BACKGROUND

Autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) are all immune-mediated chronic inflammatory liver diseases. Autoimmune liver diseases are rare, making identification and treatment difficult. To improve clinical outcomes and enhance patient quality of life, we performed an epidemiological study of autoimmune liver diseases based on real-world comprehensive data.

RESULTS

We used National Health Insurance Service claims data in Korea from 2005 to 2019. Patients were identified using the International Classification of Disease 10th Revision code, and rare intractable disease codes assigned according to the strict diagnostic criteria. In the AIH cohort, 8,572 (83.9%) were females and the mean age at diagnosis was 56.3 ± 14.3 years. PBC also showed female dominance (83.3%) and the mean age was 57.8 ± 12.6 years. Patients with PSC showed no sex predominance and had a mean age of 57.8 ± 21.5 years. During the study period, there were 10,212, 6,784, and 888 AIH, PBC, and PSC patients, respectively. The prevalence of AIH, PBC, and PSC in 2019 were 18.4, 11.8, and 1.5 per 100,000 population, while the corresponding incidences were 2.3, 1.4, and 0.3 per 100,000 population, respectively. Analysis of sex-age-standardized data showed that the annual prevalence of these diseases is increasing. The 10-year survival rates were 89.8%, 74.9%, and 73.4% for AIH, PBC, and PSC, respectively.

CONCLUSIONS

The number of patients with autoimmune liver disease in South Korea is increasing over time. Further research on autoimmune liver disease is needed to fulfill unmet clinical needs.

Danhongqing formula alleviates cholestatic liver fibrosis by downregulating long non-coding RNA H19 derived from cholangiocytes and inhibiting hepatic stellate cell activation

OBJECTIVE

This study explores the mechanism of action of Danhongqing formula (DHQ), a compound-based Chinese medicine formula, in the treatment of cholestatic liver fibrosis.

METHODS

In vivo experiments were conducted using 8-week-old multidrug resistance protein 2 knockout (Mdr2-/-) mice as an animal model of cholestatic liver fibrosis. DHQ was administered orally for 8 weeks, and its impact on cholestatic liver fibrosis was evaluated by assessing liver function, liver histopathology, and the expression of liver fibrosis-related proteins. Real-time polymerase chain reaction, Western blot, immunohistochemistry and other methods were used to observe the effects of DHQ on long non-coding RNA H19 (H19) and signal transducer and activator of transcription 3 (STAT3) phosphorylation in the liver tissue of Mdr2-/- mice. In addition, cholangiocytes and hepatic stellate cells (HSCs) were cultured in vitro to measure the effects of bile acids on cholangiocyte injury and H19 expression. Cholangiocytes overexpressing H19 were constructed, and a conditioned medium containing H19 was collected to measure its effects on STAT3 protein expression and cell activation. The intervention effect of DHQ on these processes was also investigated. HSCs overexpressing H19 were constructed to measure the impact of H19 on cell activation and assess the intervention effect of DHQ.

RESULTS

DHQ alleviated liver injury, ductular reaction, and fibrosis in Mdr2-/- mice, and inhibited H19 expression, STAT3 expression and STAT3 phosphorylation. This formula also reduced hydrophobic bile acid-induced cholangiocyte injury and the upregulation of H19, inhibited the activation of HSCs induced by cholangiocyte-derived conditioned medium, and decreased the expression of activation markers in HSCs. The overexpression of H19 in a human HSC line confirmed that H19 promoted STAT3 phosphorylation and HSC activation, and DHQ was able to successfully inhibit these effects.

CONCLUSION

DHQ effectively alleviated spontaneous cholestatic liver fibrosis in Mdr2-/- mice by inhibiting H19 upregulation in cholangiocytes and preventing the inhibition of STAT3 phosphorylation in HSC, thereby suppressing cell activation. Please cite this article as: Li M, Zhou Y, Zhu H, Xu LM, Ping J. Danhongqing formula alleviates cholestatic liver fibrosis by downregulating long non-coding RNA H19 derived from cholangiocytes and inhibiting hepatic stellate cell activation. J Integr Med. 2024; 22(2): 188-198.

[Diagnosis and Treatment of Primary Biliary Cholangitis]

Primary biliary cholangitis (PBC) is an autoimmune disease prevalent in middle-aged women and characterized by chronic cholestasis. PBC is diagnosed when at least two of the following three criteria are met: elevated alkaline phosphatase, presence of PBC-specific autoantibodies such as the anti-mitochondrial antibody or PBC-specific anti-nuclear antibodies, and non-suppurative inflammation of the interlobular bile duct after excluding other causes including drugs and biliary obstruction. The first-line treatment for PBC is ursodeoxycholic acid (UDCA, 13-15 mg/kg/day). The response to UDCA is predictive of long-term prognosis and should be evaluated 6-12 months after the UDCA treatment. The second-line treatments for PBC recommended due to an inadequate response to UDCA include obeticholic acid and fibrates. Symptoms and complications, including pruritus, sicca syndrome, and osteoporosis, should be evaluated and appropriately managed.

[Epidemiology of Autoimmune Liver Disease]

Autoimmune liver disease is an important immune-mediated pathologic entity involving the liver and intrahepatic bile duct, including autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. Although it is necessary to ascertain its presence in acute or chronic liver disease without common causes, it is not easy to diagnose this disease straightforwardly because of its rarity. Recently, the incidence and prevalence of autoimmune hepatitis and primary biliary cholangitis have increased in several regions. In contrast, there is limited data dealing with the trend of the epidemiology of primary sclerosing cholangitis worldwide. Physicians should consider the epidemiologic characteristics of autoimmune liver disease because early diagnosis and proper treatment might prevent the progression of advanced liver disease. In addition, more sophisticated epidemiologic studies will be needed to elucidate the trend of these rare diseases nationwide.

Environmental risk factors and comorbidities of primary biliary cholangitis in Korea: a case-control study

BACKGROUND/AIMS

The risk factors for the development of primary biliary cholangitis (PBC) is unclear. This study aimed to investigate the risk factors associated with PBC in Korea through a questionnaire survey.

METHODS

Consecutively enrolled 103 PBC patients from six referral hospitals and 100 age- and sex-matched community controls participated in this study. A standardized questionnaire survey including demographics, lifestyle, individual and familial medical history and reproductive history was prospectively collected and analyzed.

RESULTS

The PBC patients had a mean age of 58.3 years and a female proportion of 86.4%. The age- and sex-matched controls had a similar educational level and economic status to the PBC patients. Among the lifestyle factors, the multivariable analysis showed smoking including both first-hand and second-hand (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.06 to 3.93), history of autoimmune diseases (OR, 2.46; 95% CI, 1.06 to 6.35), and family history of PBC (OR, 17.76; 95% CI, 1.77 to 2,418.74) were significantly associated with PBC, whereas alcohol intake was negatively associated with PBC. Among reproductive factors, the number of induced abortions was significantly associated with PBC, while the number of full-term deliveries was negatively associated with PBC.

CONCLUSION

A family history of PBC, accompanying autoimmune diseases, and smoking were significantly associated with PBC. More induced abortions and less full-term deliveries were associated with PBC in women. In contrast, mild to moderate alcohol intake was negatively associated with PBC. Further studies are warranted to validate the results of this study and to search for clues about the pathogenesis of PBC.

Daifan San intervenes in forkhead box P3 and the interleukin (IL)-23/IL-17A signaling pathway to help prevent and treat primary biliary cirrhosis

OBJECTIVE

To investigate the mechanism by which Daifan San (DFS) prevents and treats primary biliary cirrhosis (PBC) via the forkhead box P3 (FoxP3) and interleukin (IL)-23/IL-17A signaling pathways.

METHODS

Ninety C57BL/6 mice were randomly divided into the control, model, DFS low-dose, DFS middle-dose, DFS high-dose and ursodeoxycholic acid (UDCA) groups (n = 15 per group). A mouse model of PBC was induced using polyinosinic polycytidylic acids (poly I:C). Lymphocyte subset expression in the peripheral blood was analyzed via flow cytometry. The inflammatory cytokines and antimitochondrial autoantibody (AMA) levels were detected via enzyme-linked immunosorbent assays. The expressions and location of type I collagen, type III collagen, cytokeratin 19 and FoxP3 in the liver tissue were evaluated via immunohistochemistry. FoxP3, IL-23 and IL-17 expressions in the peripheral blood and liver tissue were evaluated via real-time polymerase chain reaction and western blotting.

RESULTS

IL-17, IL-23, IL-8, IL-33, TNF-a, and AMA expressions were significantly increased in the model group and decreased in the DFS and UDCA groups. Conversely, Treg cell and FoxP3 expressions were significantly decreased in the model group and increased in the DFS and UDCA groups. The IL-23/IL-17A signaling pathway was closely correlated with chronic inflammation of the bile duct in PBC and functional deletion of Treg cells, leading to reduced FoxP3 levels and mediating the loss of tolerance in PBC.

CONCLUSION

DFS may delay the occurrence and relieve the symptoms of PBC by downregulating IL-23/IL-17A signaling pathway expression and upregulating FoxP3 expression.

Association between three autoimmune diseases: vitiligo, primary biliary cirrhosis, and Sjögren's syndrome

Although the association of multiple autoimmune diseases has already been widely described, no reports of the association between vitiligo, primary biliary cirrhosis and Sjogren's syndrome were retrieved in the SciELO and PubMed databases. The authors describe the case of a female patient who was diagnosed with primary biliary cirrhosis and Sjogren's syndrome at age 54. At age 58, she developed vitiligo restricted to the face, associated with significant impairment of self-esteem and quality of life. Antinuclear antibody was negative at the onset of the condition, but became positive after phototherapy initiation. In general, the occurrence of multiple autoimmune diseases in the same patient is known as a mosaic of autoimmunity. However, specific mechanisms appear to interconnect primary biliary cirrhosis and Sjogren's syndrome, such as PDC-E2-mediated generalized epithelitis.

[Ursodeoxycholic acid combined with bezafibrate in the treatment of refractory primary biliary cholangitis: a meta-analysis]

Objective: To evaluate the efficacy, safety and remission rates of pruritus of bezafibrate and UDCA combination therapy in the treatment of refractory PBC. Methods: PubMed, Embase, The Cochrane Library databases, Science direct, Web of Science, CBM, WangFang Data, CNKI, VIP databases were searched to collect randomized controlled trials, crossover trials and self-control clinical trials of combination therapy of UDCA and bezafibrate with UDCA monotherapy for PBC up to June, 2018. RevMan 5.3 software was used for meta-analysis. Two evaluators independently screened the literature, extracted the data, and evaluated the risk of bias of relevant study. Results: Eleven studies, including 465 patients were included. Ursodeoxycholic acid combined with bezafibrate had greatly improved liver biochemical indicators (P < 0.01) and pruritus scores in patients with refractory primary biliary cholangitis (MD = -2.97, 95% CI: -4.34~ -1.60, P < 0.01). However, there was no statistically significant differences in adverse events (RR = 1.28, 95% CI: 0.96 to 1.70, P = 0.09), and mortality rate (RR = 2.58, 95% CI: 0.57 to 11.73, P = 0.22) between the two groups. Conclusion: Ursodeoxycholic acid combined with bezafibrate may improve the biochemical response and pruritus score of refractory PBC, but has no significant effect on adverse events and mortality rate.

Prognostic Value of Biochemical Response Models for Primary Biliary Cholangitis and the Additional Role of the Neutrophil-to-Lymphocyte Ratio

Background/Aims

Recently reported prognostic models for primary biliary cholangitis (PBC) have been shown to be effective in Western populations but have not been well-validated in Asian patients. This study aimed to compare the performance of prognostic models in Korean patients and to investigate whether inflammation-based scores can further help in prognosis prediction.

Methods

This study included 271 consecutive patients diagnosed with PBC in Korea. The following prognostic models were evaluated: the Barcelona model, the Paris-I/II model, the Rotterdam criteria, the GLOBE score and the UK-PBC score. The neutrophil-to-lymphocyte ratio (NLR) was analyzed with reference to its association with prognosis.

Results

For predicting liver transplant or death at the 5-year and 10-year follow-up examinations, the UK-PBC score (areas under the receiver operating characteristic curve [AUCs], 0.88 and 0.82) and GLOBE score (AUCs, 0.85 and 0.83) were significantly more accurate in predicting prognosis than the other scoring systems (all p＜0.05). There was no significant difference between the performance of the UK-PBC and GLOBE scores. In addition to the prognostic models, a high NLR (＞2.46) at baseline was an independent predictor of reduced transplant-free survival in the multivariate analysis (adjusted hazard ratio, 3.74; p＜0.01). When the NLR was applied to the prognostic models, it significantly differentiated the prognosis of patients.

Conclusions

The UK-PBC and GLOBE scores showed good prognostic performance in Korean patients with PBC. In addition, a high NLR was associated with a poorer prognosis. Including the NLR in prognostic models may further help to stratify patients with PBC.

[Research progress on risk factors for poor response of ursodeoxycholic acid in primary biliary cholangitis]

Primary biliary cholangitis (PBC) is an autoimmune-mediated chronic cholestatic liver disease. Ursodeoxycholic acid (UDCA) is a first-line drug approved by the Food and Drug Administration for the treatment of PBC. It can effectively improve serum biochemical indicators, delay histological progress, and prolong the survival of non-transplant patients. However, around 40% of patients with PBC have a poor response to UDCA with a poor outcome. Early identification of patients with poor biochemical responses and timely second-line treatment may alter the course of the disease. This article summarizes the risk factors for the poor response of UDCA in the PBC.

[Characteristics of IgH-CDR3 repertoire of peripheral B cells in a patient with primary biliary cholangitis: a preliminary study using high-throughput sequencing]

Objective: To analyze the characteristics of immunoglobulin heavy chain complementarity-determining region (IgH-CDR3) repertoire of peripheral B cells in a patient with primary biliary cholangitis (PBC) and to investigate the diversity of the immune system. Methods: Arm-PCR was used to amplify the IgH-CDR3 region of circulating B cells isolated from a PBC patient, and high-throughput sequencing was used to analyze the amplified product. The characteristics of immune repertoire were analyzed by bioinformatics. Results: In total, 329219 sequence reads were generated from the sample, with 325540 total CDR3 sequences and 72774 distinct CDR3 sequences, and the D50 of IGH-CDR3 was 7.7. The dominant CDR3 length of the sample was 45 nt (9.6%); the N addition with the highest frequency ranged from 13 to 14 nt (5.25%); the J trimming with the highest frequency was 0 nt (12.7%); the three most frequent V alleles were V4-59 (9.5%), V3-23 (8.1%), and V1-69 (6.4%). Conclusion: The diversity of IgH-CDR3 repertoire is relatively low in this patient with PBC, with several B-cell clonal expansions. The specificity needs to be further verified after increasing the sample size.

[Risk factors and therapeutic strategies for primary biliary cholangitis patients with poor prognosis]

With the progress in detection methods and the update of diagnostic and therapeutic concepts, more and more patients with primary biliary cholangitis (PBC) have been diagnosed and treated. A high proportion of PBC patients, however, progress to liver decompensation, with an increased risk of liver transplantation and death and a significant reduction in long-term survival. These patients need early diagnosis and urgent treatment. This article discusses how to identify the PBC patients with poor prognosis early from the aspects of biochemical response, disease features, and biomarkers, and reviews the progress in related complementary therapies and new drugs including Ocaliva, Fibrates, UDCA-derived drugs, and molecular targeted drugs.