[Post-COVID-19 severe cholangiopathy: report of 6 cases]

Coronavirus disease 2019 (COVID-19) is a predominantly respiratory tract infection with the capacity to affect other organs. Liver chemistry abnormalities are a frequent manifestation of COVID-19 but are usually transient. We describe the clinical course and most relevant findings of 6 patients who developed a cholangiopathy after severe COVID-19. The mean age of the patients, 4 men and 2 women, was 56 years and the mean time from COVID-19 diagnosis to diagnosis of cholangiopathy was 138 days. The features most important were the increase of alkaline phosphatase and destructuring and beading of the intrahepatic bile duct in magnetic resonance imaging. Cholangiopathy after severe COVID-19 constitutes a novel entity with unique features and potential for progressive biliary injury and secondary biliary cirrhosis. Further studies are required to understand this disease.

[Primary Biliary Cholangitis Diagnosed with Spontaneous Bacterial Peritonitis after Gastrectomy for Gastric Cancer-A Case Report]

Spontaneous bacterial peritonitis is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source. The diagnosis is established by a positive ascitic fluid bacterial culture and an ascitic fluid absolute polymorphonuclear leukocyte(PMN)count≥250 cells/μL. Here we report the case of 81-year-old female patient who was diagnosed with spontaneous bacterial peritonitis after gastrectomy for gastric cancer. The laparoscopic distal gastrectomy and D1+ lymph node dissection were performed for Stage Ⅰ gastric cancer, and the postoperative course was uneventful. The patient presented with abdominal pain and was hospitalized again on the third day from the discharge. Computed tomography showed an accumulation of ascites, and the ascitic fluid polymorphonuclear leukocyte count was 9,973 cells/μL. The patient was diagnosed with spontaneous bacterial peritonitis, and antibacterial agent was performed. Abdominal pain and accumulation of ascites had been improved, and the ascitic fluid polymorphonuclear leukocyte count had decreased clearly. The patient discharged on the 57th day from the operation. Spontaneous bacterial peritonitis after gastrectomy for gastric cancer was rare. We report this rare case, along with a discussion of the literature.

Clinical impact of antibodies to Sp100 on a bacterial infection in patients with primary biliary cholangitis

BACKGROUND

A specific antinuclear antibody for primary biliary cholangitis (PBC) is anti-Sp100, which was recognized as a serological marker of concurrent urinary tract infection. We sought to determine the clinical characteristics of PBC patients who had anti-Sp100.

PATIENTS AND METHODS

Fifty-one patients with PBC and 10 healthy controls (HCs) were enrolled. Anti-Sp100 were determined with an ELISA method. Lipopolysaccharide-binding protein (LBP) was measured as a serological hallmark for bacterial infection. The correlations of anti-Sp100 with demographic, laboratory, and pathological parameters were investigated.

RESULTS

Six of the 51 (11.8%) PBC patients had anti-Sp100, whereas none of the HCs did. There was no significant difference in the frequency of antimitochondrial antibodies (AMAs) between PBC patients with and without anti-Sp100 (67% vs. 82%, p = 0.5839). Biochemical and immunological parameters were not associated with the emergence of anti-Sp100 in these patients. The clinical stage by Scheuer classification was not correlated with the existence of anti-Sp100. No significant difference in the serum LBP levels was found between PBC patients with and without anti-Sp-100, although serum LBP levels were significantly higher in PBC patients with anti-Sp100 than in HCs (8.30 ± 2.24 ng/ml, vs. 5.12 ± 2.48 ng/ml, p = 0.0022). The frequency of granuloma formation was higher in the liver specimens of PBC patients with anti-Sp100 than in those without anti-Sp100 (67% vs 29%, p = 0.0710).

CONCLUSION

anti-Sp100 does not become a complementary serological marker for PBC in AMA-negative patients. A bacterial infection may trigger the production of anti-Sp100. Another factor is required to initiate the autoantibody production.

Omega-3 Polyunsaturated Fatty Acid: A Pharmaco-Nutraceutical Approach to Improve the Responsiveness to Ursodeoxycholic Acid

Ursodeoxycholic acid (UDCA) is the first line therapy for the treatment of cholestatic and autoimmune liver diseases. Its clinical use is currently limited by a significant proportion of non-responder patients. Polyunsaturated fatty acids (n-3 PUFAs) possess important anti-inflammatory properties and protect liver cells against bile acid (BA)-induced toxicity. The present study was designed to rapidly evaluate whether combining n-3 PUFAs (i.e., eicosapentaenoic [EPA] and docosahexaenoic [DHA] acids) to UDCA would provide additional benefits when compared to the drug alone. The parameters evaluated were (i) the expression of genes governing BA synthesis, transport, and metabolism; (ii) the prevention of BA-induced apoptosis and endoplasmic reticulum (ER)-stress; and (iii) the control of BA- and LPS-dependent inflammation. In the absence of n-3 PUFAs, most of the parameters investigated were unaffected by UDCA or were only altered by the higher dose (500 µM) of the drug. By contrast, in the presence of EPA/DHA (50/50 µM), all parameters showed a strongly improved response and the lowest UDCA dosage (50 µM) provided equal or better benefits than the highest dose used alone. For example, the combination EPA/DHA + UDCA 50 µM caused comparable down-regulation of the CYP7A1 gene expression and of the BA-induced caspase 3 activity as observed with UDCA 500 µM. In conclusion, these results suggest that the addition of n-3 PUFAs to UDCA may improve the response to the drug, and that such a pharmaco-nutraceutical approach could be used in clinic to open the narrow therapeutic dose of UDCA in cholestatic liver diseases.

Incorporating mucosal-associated invariant T cells into the pathogenesis of chronic liver disease

Mucosal-associated invariant T (MAIT) cells have been described in liver and non-liver diseases, and they have been ascribed antimicrobial, immune regulatory, protective, and pathogenic roles. The goals of this review are to describe their biological properties, indicate their involvement in chronic liver disease, and encourage investigations that clarify their actions and therapeutic implications. English abstracts were identified in PubMed by multiple search terms, and bibliographies were developed. MAIT cells are activated by restricted non-peptides of limited diversity and by multiple inflammatory cytokines. Diverse pro-inflammatory, anti-inflammatory, and immune regulatory cytokines are released; infected cells are eliminated; and memory cells emerge. Circulating MAIT cells are hyper-activated, immune exhausted, dysfunctional, and depleted in chronic liver disease. This phenotype lacks disease-specificity, and it does not predict the biological effects. MAIT cells have presumed protective actions in chronic viral hepatitis, alcoholic hepatitis, non-alcoholic fatty liver disease, primary sclerosing cholangitis, and decompensated cirrhosis. They have pathogenic and pro-fibrotic actions in autoimmune hepatitis and mixed actions in primary biliary cholangitis. Local factors in the hepatic microenvironment (cytokines, bile acids, gut-derived bacterial antigens, and metabolic by-products) may modulate their response in individual diseases. Investigational manipulations of function are warranted to establish an association with disease severity and outcome. In conclusion, MAIT cells constitute a disease-nonspecific, immune response to chronic liver inflammation and infection. Their pathological role has been deduced from their deficiencies during active liver disease, and future investigations must clarify this role, link it to outcome, and explore therapeutic interventions.

An Autopsy Case of Primary Biliary Cholangitis with Histological Submassive Hepatic Necrosis Caused by Acute Hepatitis E Virus Infection

A 59-year-old woman who had been diagnosed with cirrhotic primary biliary cholangitis (PBC) 5 years earlier was admitted for severe jaundice (total bilirubin: 30.1 mg/dL). We suspected that her cirrhotic PBC had deteriorated acutely for some reason. Her general condition deteriorated quickly, and she passed away on day 18 of admission. Hepatitis E virus (HEV)-IgA antibodies were positive, and Genotype 3b HEV involvement was confirmed from a blood sample taken on admission. Histopathological findings revealed cirrhosis and submassive loss and necrosis of hepatocytes. Clinicians should consider the possibility of acute HEV infection as a trigger for acute PBC exacerbation.

Relationship between osteoporosis, sarcopenia, vertebral fracture, and osteosarcopenia in patients with primary biliary cholangitis

AIM

Bone disorders are serious complications in patients with primary biliary cholangitis (PBC), especially in postmenopausal female patients. Given that osteoporosis interrelates closely with sarcopenia, the concept of osteosarcopenia (coexistence of the two complications) has been established. This study aimed to investigate the relationship between osteoporosis, sarcopenia, vertebral fracture, and osteosarcopenia in PBC patients.

METHODS

This study involved 117 consecutive PBC patients (21 males and 96 females). Bone mineral density (BMD) was measured with dual-energy X-ray absorptiometry. Sarcopenia was diagnosed according to the Japan Society of Hepatology assessment criteria.

RESULTS

Of the 117 patients, 33 (28.2%), 27 (23.1%), 21 (17.9%), and 18 (15.4%) had osteoporosis, sarcopenia, vertebral fracture, and osteosarcopenia, respectively. Multivariate analysis identified sarcopenia as a significant, independent risk factor associated with osteoporosis in all and female patients [odds ratio (OR) = 4.126, P = 0.018; OR = 6.510, P = 0.001, respectively], and vice versa (OR = 3.420, P = 0.040; OR = 4.012, P = 0.026, respectively). The skeletal muscle mass index and handgrip strength were significantly correlated with the BMD of the lumbar spine, femoral neck, and total hip (r = 0.46-0.59, P < 0.001). Patients with osteosarcopenia had significantly higher prevalence of vertebral fracture (10/18; 55.6%) than those without both osteoporosis and sarcopenia (5/75; 6.7%).

CONCLUSION

We demonstrated the prevalence of osteoporosis, sarcopenia, vertebral fracture, and osteosarcopenia in PBC, and noted that these complications interrelated closely with each other. Comprehensive assessment and treatment strategies for bone and muscle disorders are essential for PBC patients.

Effects of Primary Biliary Cholangitis on Quality of Life and Health Care Costs in the United Kingdom

BACKGROUND & AIMS

There have been few high-quality studies of the costs, preference-based health-related quality of life (HRQoL) and cost effectiveness of treatments for primary biliary cholangitis (PBC). We aimed to estimate the marginal effects of PBC complications and symptoms, accounting for treatment, on HRQoL and the annual cost of health care in the United Kingdom (UK). These are essential components for evaluation of cost effectiveness and this information will aid in evaluation of new treatments.

METHODS

Questionnaires were mailed to 4583 participants in the UK-PBC research cohort and data were collected on HRQoL and use of the National Health Service (NHS) in the UK from 2015 through 2016. HRQoL was measured using the EQ-5D-5L instrument. The annual cost of resource use was calculated using unit costs obtained from NHS sources. We performed econometric analyses to determine the effects of treatment, symptoms, complications, liver transplantation status, and patient characteristics on HRQoL and annual costs.

RESULTS

In an analysis of data from 2240 participants (over 10% of all UK PBC patients), we found that PBC symptoms have a considerable effect on HRQoL. Ursodeoxycholic acid therapy was associated with significantly higher HRQoL regardless of response status. Having had a liver transplant and ascites were also independently associated with reduced HRQoL. Having had a liver transplant (US$4294) and esophageal varices (US$3401) were the factors with the two greatest mean annual costs to the NHS. Symptoms were not independently associated with cost but were associated with reduction in HRQoL for patients, indicating the lack of effective treatments for PBC symptoms.

CONCLUSIONS

In an analysis of data from 2240 participants in the UK PBC, we found that HRQoL and cost estimates provide greater insight into the relative importance of PBC-related symptoms and complications. These findings provide estimates for health technology assessments of new treatments for PBC.

Anti-mitochondrial Antibodies in Patients with Dilated Cardiomyopathy

Objective It has been reported that anti-mitochondrial antibodies (AMAs) recognize mitochondrial antigens and are associated with some diseases involving multiple organs, such as primary biliary cholangitis, Sjögren syndrome, Hashimoto's thyroiditis, systemic sclerosis, interstitial pneumoniae, dilated cardiomyopathy, and tubulointerstitial nephritis. In the current study, we examined the prevalence of AMAs in patients with dilated cardiomyopathy (DCM) and their clinical characteristics. Methods We enrolled 270 patients with DCM. We measured serum AMAs and analyzed the associated factors. Out of the 270 patients, positive AMAs were detected in 3 patients (1.1%; mean age, 68 years old; 2 men). These three patients had a significantly higher prevalence of primary biliary cholangitis and myopathy and levels of alanine alkaline phosphatase than those who were negative for said antibodies. There were no significant differences in the levels of B-type natriuretic peptide, aspartate transaminase, and left ventricular ejection fraction between these groups of patients. During the follow-up period, two of the three patients died due to respiratory failure. The other patient survived but experienced type II respiratory failure. Conclusion The prevalence of AMAs in 270 DCM patients was only 1.1%, and these patients suffered from respiratory failure.

Mold Exposure and Mitochondrial Antibodies

CONTEXT

Some studies have reported that airborne levels of mold above 150-1000 spores per cubic meter are sufficient to cause a wide range of human health problems. In trying to understand the mechanism of injury to the mitochondria that trigger an autoimmune response, researchers have learned that pyruvate carboxylase is a major site of antigenicity for antimitochondrial antibodies (AMA). Antibodies to mitochondria are found in over 90% of patients with primary biliary cirrhosis and are occasionally found in patients with other autoimmune diseases.

OBJECTIVES

This study intended to examine the prevalence of antimitochondrial antibodies (AMA) in a population of patients exposed to molds, mycotoxins, and other toxins.

DESIGN

The research team described 6 case studies.

SETTING

The study occurred at an environmental- and occupational-medicine health clinic.

PARTICIPANTS

Six patients at the clinic were the participants. These 6 patients represented 6.9% of a cohort of 87 patients who received autoimmune testing during that period.

OUTCOME MEASURES

Participants received blood tests for autoimmune, metabolic, hormonal, and nutritional parameters, including AMA.

RESULTS

Six patients with a documented history of exposure to indoor mold, mycotoxin, and water damage had elevated levels of AMA.

CONCLUSIONS

The fact that high levels of AMA in the 6 patients were all associated with mold and moisture exposure appears to be significant. Exposure to water- and mold-damaged indoor environments might damage mitochondria and trigger autoimmunity. Long term follow-up is needed to determine what may develop in these patients.

Quality of life among patients with autoimmune hepatitis in remission: A comparative study

Health-related quality of life (HRQOL) is lower in individuals with autoimmune hepatitis (AIH) than in the general population. However, previous evaluations of HRQOL for AIH have included a broad range of disease activities. The aim of this study was to clarify HRQOL among patients with AIH in remission.We assessed HRQOL in patients with AIH in remission, patients with chronic hepatitis C (CHC) with eradicated hepatitis C virus (HCV) and patients with primary biliary cholangitis (PBC) using the Japanese version of the Chronic Liver Disease Questionnaire (CLDQ).Participants comprised 62 patients with AIH in remission, 39 patients with CHC with eradicated HCV and 66 patients with PBC. Median ages of patients were 63, 69, and 64 years, respectively. Overall score (5.6 vs 5.9, P = .02) and fatigue (5.2 vs 5.6, P = .01) and worry (5.6 vs 6.0, P = .01) domain scores of the CLDQ were significantly lower in patients with AIH in remission than in CHC with eradicated HCV, and similar to scores except for the systemic symptoms domain in patients with PBC. Disease duration was associated with lower scores on systemic symptoms and activity domains of the CLDQ in patients with AIH in remission.Patients with AIH in remission show impaired HRQOL associated with disease duration.

[Analysis of clinical features and prognosis in patients with primary Sjögren's syndrome and autoimmune liver disease]

OBJECTIVE

To analyze the clinical features and prognosis in patients with primary Sjögren's syndrome (pSS) and autoimmune liver diseases (ALD).

METHODS

A retrospective analysis of clinical manifestation and prognosis was performed in patients with ALD or without ALD during the three years (February 2014 to December 2017).

RESULTS

Totally, 203 patients with pSS were included in this study, 68 patients had ALD (31 patients with autoimmune hepatitis, 37 patients with primary biliary cholangitis), while 135 patients did not have ALD. There were no differences between the two groups regarding age, gender, clinical manifestations, such as dry mouth, dry eyes, pain, fatigue, lymphadenopathy, glandular swelling, cutaneous involvement, lung involvement, and renal involvement, and the incidence rate of other autoimmune diseases, such as autoimmune thyroid disease, rheumatoid arthritis, and vasculitis. There were also no differences in the titer of antinuclear antibody (ANA), the positive rates of anti-Sjögren's syndrome A antibody (SSA), SSA52, and anti-Sjögren's syndrome B antibody (SSB), and at the levels of erythrocyte sedimentation rate and C-reactive protein between the two groups. Most importantly, the pSS patients with ALD had a shorter disease course, a higher positive rate of anti-mitochondrial M2 antibody (AMA-M2) and anti-centromere antibody, a higher level of IgG and IgM, a lower level of complement 3, and a decreased number of blood cells. They also had a higher level of liver related serum index, such as alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase and total bilirubin, direct bilirubin, indirect bilirubin, a higher incidence rate of liver cirrhosis, an increased death incident (the mortality was 13.24% in the pSS patients with ALD, while 2.96% in the controls, P=0.013), and a worse prognosis. Binary Logistic regression analysis revealed that liver cirrhosis, the EULAR Sjögren's syndrome disease activity index (ESSDAI) scores and the level of total bilirubin were the prognostic factors of mortality in the pSS patients with ALD. The survival curve was estimated by the Kaplan-Meier method. It demonstrated that the pSS patients with ALD had a lower survival rate when compared with the controls.

CONCLUSION

The patients with both pSS and ALD will suffer from a more severe disease and a higher death incident. We should pay more attention to these patients and provide a better symptomatic treatment for them during clinical practice.

Autoimmune hepatitis, primary sclerosing cholangitis, and inflammatory bowel disease. Sequential overlap syndrome: a twist to the mosaic of autoimmunity

Autoimmune liver diseases can overlap resulting in a new entity, phenotypically different from those pathologies that converge, and that demonstrates the complexity of our immune system. Sequential overlap syndrome is the consecutive presentation, separated by a variable period of time, of two liver autoimmune diseases, mostly autoimmune hepatitis and primary biliary cholangitis. This syndrome constitutes a challenge both in its diagnosis and in its treatment given the exceptional nature of its presentation. The theory of a mosaic of autoimmunity is proposed to describe this phenomenon.

Current Trends of Essential Trace Elements in Patients with Chronic Liver Diseases

Essential trace elements play crucial roles in the maintenance of health, since they are involved in many metabolic pathways. A deficiency or an excess of some trace elements, including zinc, selenium, iron, and copper, frequently causes these metabolic disorders such as impaired glucose tolerance and dyslipidemia. The liver largely regulates most of the metabolism of trace elements, and accordingly, an impairment of liver functions can result in numerous metabolic disorders. The administration or depletion of these trace elements can improve such metabolic disorders and liver dysfunction. Recent advances in molecular biological techniques have helped to elucidate the putative mechanisms by which liver disorders evoke metabolic abnormalities that are due to deficiencies or excesses of these trace elements. A genome-wide association study revealed that a genetic polymorphism affected the metabolism of a specific trace element. Gut dysbiosis was also responsible for impairment of the metabolism of a trace element. This review focuses on the current trends of four trace elements in chronic liver diseases, including chronic hepatitis, liver cirrhosis, nonalcoholic fatty liver disease, and autoimmune liver diseases. The novel mechanisms by which the trace elements participated in the pathogenesis of the chronic liver diseases are also mentioned.

Reevaluating Goals of Therapy in Primary Biliary Cholangitis: Is Good Enough Is Not Good Enough Anymore?

Primary biliary cholangitis (PBC) is an autoimmune-mediated inflammatory cholestatic liver disease, which can progress to cirrhosis. This issue of The American Journal of Gastroenterology features the results of the GLOBAL PBC Study Group evaluating patients with PBC over a 10-year period. Although biochemical response was evaluated in previous studies, this study showed that bilirubin levels ≤0.6 upper limit of normal or normal levels of alkaline phosphatase are associated with the lowest risk for liver transplantation or death in patients with PBC.

[A case of fibrinogen storage disease with primary biliary cholangitis]

A 66-year-old woman was diagnosed as primary biliary cholangitis (PBC) and was previously hospitalized for ascites and jaundice. She came to our hospital for further examination of the liver by needle biopsy, which showed interface hepatitis that mainly comprised lymphocytes and inflammatory infiltrates in the bile duct in the portal area. On the other hand, numerous intracytoplasmic inclusions that were positive for fibrinogen immunostaining were seen in the lobular area. Finally, we histologically diagnosed as PBC with fibrinogen storage disease (FSD). FSD is rare disease that leads to liver damage caused by abnormal fibrinogen storage in the endoplasmic reticulum of hepatocytes, with only four cases reported in Japan until now.

Letter: histology is relevant for risk stratification in primary biliary cholangitis

LINKED CONTENT

This article is linked to Murillo Perez et al paper. To view this article, visit https://doi.org/10.1111/apt.15533.

The role of immunohistochemical staining with CK7 in the differential diagnosis of autoimmune hepatitis

INTRODUCTION

Although the immunohistochemical staining with cytokeratin 7 (CK7) is an adjuvant method for identifying various components of the intrahepatic biliary system, the expression of CK7 does not occur in hepatocytes. In the literature, some studies suggest that a group of cells having dual morphologic and immunophenotypic characteristics of bile duct epithelium and hepatocytes, referred to as progenitor stem cells, was stained positive with CK7.

MATERIALS AND METHODS

In this study, we examined a total of 219 cases diagnosed with autoimmune hepatitis, chronic hepatitis B, chronic hepatitis C, and primary biliary cholangitis between 2005 and 2017 in Uludağ University, Faculty of Medicine, Department of Medical Pathology.

RESULTS

The comparisons of AIH cases with HepB, HepC and PBC cases demonstrated that the immunoreactivity to CK7 was significantly higher in the AIH group (p < 0.005) compared to the groups of HepB and HepC, whereas no significant differences were found between the AIH and PBC groups.

CONCLUSIONS

In our study, it was concluded that the immunoreactivity to CK7 could be used as an adjuvant treatment to the clinicopathologic assessment in distinguishing between the AIH cases and chronic viral hepatitis. However, since CK7 immunoreactive hepatocytes were widely detected also in patients with chronic viral hepatitis, and there was no statistically significant difference between the PBC and AIH cases, it has been established that the inclusion of CK7 immunoreactivity into the diagnostic histopathological criteria for AIH would not be convenient (Tab. 1, Fig. 1, Ref. 22).

[Characteristics of initial diagnosis in autoimmune liver disease: an 18-year, retrospective single-center study]

Objective: To analyze the chorological changes of diagnosis in patients with autoimmune liver disease (AILD) and related factors for early diagnosis. Methods: A total of 581 patients with age ranged from 16 to 81 were retrospectively analyzed, who were admitted to Tianjin Medical University General Hospital with AILD during January 2000 to December 2017. Age at diagnosis, diagnostic method and cirrhosis at diagnosis were compared in different groups according to admission period as 2000-2005, 2006-2011, 2012-2017. Results: The diagnostic rate of AILD showed an upward trend during the past near two decades. The proportion of AILD patients diagnosed via health examination was increasing year by year mainly by elevated transaminases (P<0.001). The mean age at diagnosis in our AILD patients were younger at present, especially in men (P=0.044). The proportion of cirrhosis at diagnosis was gradually reduced in three different periods respectively [77.78%(21/27), 41.58% (79/190), 25.00%(91/364), P<0.001], which were coincident in patients with autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) (P<0.001). The shrinking trend of cirrhosis at diagnosis was significantly correlated with the increasing application of health examination (r=-0.549, P<0.001). Conclusions: Extensive application of health examination expands the diagnostic rate of AILD. During the past 18 years, more young patients are diagnosed with AILD. The proportion of severe cases such as cirrhosis at diagnosis is decreasing. Screening of immunological examinations in patients with abnormal transaminases is needed and critical to the early diagnosis of asymptomatic AILD.

[Study the role of lysosome-associated membrane protein type 2A for immune-mediated liver injury of primary biliary cholangitis]

Objective: To investigate the role of lysosome-associated membrane protein type 2A (LAMP-2A) for immune-mediated liver injury of primary biliary cholangitis (PBC). Methods: The association between LAMP-2A expression and PBC was examined by immunohistochemistry and electron microscopy in liver tissue samples from patients with PBC. Furthermore, the immunological damage of LAMP-2A overexpression on mouse liver was observed by adeno-associated virus (AAV) overexpression technique. The expression level of mRNA was analyzed by Student's t-test. The data were graphed and analyzed statistically using graphpad prism 5 (GraphPad Software).A value of p < 0.05 was considered statistically significant. Results: The expression of LAMP-2A in liver tissue of PBC patients was increased, and the autophagosome formation was observed in hepatocytes. C57BL/6 mice were injected into the caudal vein with LAMP-2A AAV for 6 weeks. The formation of autophagosomes in mouse hepatocytes was increased significantly. The expression of related molecules was abnormal; simultaneously, the degree of lymphocyte infiltration in the liver tissue of mice was significantly higher than the control group. Conclusion: An overexpression of LAMP-2A in the liver of patients with PBC may induce and/or promote the hepatic inflammatory response, especially the portal inflammatory infiltrate.

The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines

Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.

Editorial: scoring systems in primary biliary cholangitis - time to make a move

Linked Content

This article is linked to Yang et al papers. To view these articles visit https://doi.org/10.1111/apt.14010 and https://doi.org/10.1111/apt.13927.

Scientific publications on primary biliary cirrhosis from 2000 through 2010: an 11-year survey of the literature

Background

Primary biliary cirrhosis (PBC) is a chronic liver disease characterized by intrahepatic bile-duct destruction, cholestasis, and fibrosis. It can lead to cirrhosis and eventually liver failure. PBC also shows some regional differences with respect to incidence and prevalence that are becoming more pronounced each year. Recently, researchers have paid more attention to PBC. To evaluate the development of PBC research during the past 11 years, we determined the quantity and quality of articles on this subject. We also compared the contributions of scientists from the US, UK, Japan, Italy, Germany, and China.

Methods

The English-language papers covering PBC published in journals from 2000 through 2010 were retrieved from the PubMed database. We recorded the number of papers published each year, analyzed the publication type, and calculated the accumulated, average impact factors (IFs) and citations from every country. The quantity and quality of articles on PBC were compared by country. We also contrasted the level of PBC research in China and other countries.

Results

The total number of articles did not significantly increase during the past 11 years. The number of articles from the US exceeded those from any other country; the publications from the US also had the highest IFs and the most citations. Four other countries showed complex trends with respect to the quantity and quality of articles about PBC.

Conclusion

The researchers from the US have contributed the most to the development of PBC research. They currently represent the highest level of research. Some high-level studies, such as RCTs, meta-analyses, and in-depth basic studies should be launched. The gap between China and the advanced level is still enormous. Chinese investigators still have a long way to go.

[Case of fanconi syndrome positive for anti-M2 antibodies revealed by severe hypokalemia and multiple bone fracture]

A 38-year-old female developed pain in the right leg in 2006. In 2007, the diagnosis of femoral head necrosis was made based on MR images, and femoral head prosthetic replacement was performed. In April 2009, she visited a local hospital for low back pain, and was referred to our department due to electrolyte abnormalities on hemanalysis. Since marked hypokalemia (K=2.5 mEq/L), hypophosphatemia, hyperchloric metabolic acidosis, proteinuria, and urinary blood sugar suggested Fanconi syndrome, she was admitted for close examination. Bone survey showed a marked decrease in the amount of bone particularly in the four limbs and fracture at the proximal 1/3 of the left ulnar bone. In the lumbar spine, scoliosis and vertebral deformity were observed. Since impaired P re-absorption and unselected aminoaciduria and osteomalacia were also present, the diagnosis of Fanconi syndrome was made. On admission, ventricular tachycardia developed due to hypokalemia, requiring immediate electrolyte correction. For differentiation from acquired Fanconi syndrome, various examinations were performed. No apparent cause was found except for the positive antimitochondrial antibody-M2 (anti-M2). In this case, no data suggested liver dysfunction, and subsequent liver biopsy also showed no significant pathological findings pointing to PBC. We encountered a patient with Fanconi syndrome positive for anti-M2. This case may attract interest, particularly in the mechanism of nephropathy due to anti-M2, and therefore, this case is reported with a literature review.

Osteoporosis in primary biliary cirrhosis: a randomized trial of the efficacy and feasibility of estrogen/progestin

The optimal therapy for the prevention and treatment of osteoporosis in primary biliary cirrhosis (PBC) is unknown. Hormone replacement therapy (HRT) prevents osteoporosis, but may promote cholestasis. We performed a double-blind, randomized, placebo-controlled trial of transdermal estrogen/progestin in postmenopausal women with PBC. The 24-month study enrolled 31 patients, but trial uptake was limited and treatment arm dropout was significant. Placebo-treated patients had a higher percentage loss in femoral neck bone mineral density than actively treated patients (-3.76 +/- 1.37% versus 0.21 +/- 1.01%, respectively, P = .058). New fractures occurred in 2 patients on placebo, and in no patients on treatment. The mean monthly increase in bilirubin was not significantly different between groups, but individual data suggest HRT may worsen cholestasis. In conclusion, women with PBC have strong feelings about HRT, and recruitment for this intervention is difficult. Transdermal estrogen/progestin likely provides protection against bone loss in PBC patients, but may worsen cholestasis.