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Oliveira EMG, Amaral ACDC, Oliveira PMC, Lanzoni VP, Perez RM, Narciso-Schiavon JL, Whale RC, Carvalho-Filho RJ, Silva AEB, Ferraz MLCG. Clinical Characteristics of Genuine Acute Autoimmune Hepatitis. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:173-181. [PMID: 38757065 PMCID: PMC11095594 DOI: 10.1159/000531018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/17/2023] [Indexed: 05/18/2024]
Abstract
Introduction Autoimmune hepatitis (AIH) has a spectrum of symptoms ranging from asymptomatic disease to acute severe hepatitis, chronic hepatitis, and decompensated cirrhosis. The acute presentation is not rare and could represent genuine acute AIH (GAAIH) or acute exacerbation of chronic autoimmune hepatitis. We aimed to identify the prevalence, clinical features, and prognostic factors associated with GAAIH and compare these cases with acute exacerbation of chronic AIH. Methods This cross-sectional observational study evaluated patients with acute AIH presentation, defined as total bilirubin >5 times the upper limit of normality (xULN) and/or alanine aminotransferase >10 xULN, and no prior history of liver disease. Histology findings of acute disease defined GAAIH. Bivariate analyses were performed to identify factors associated with the GAAIH, when compared with acute exacerbation of chronic AIH. Results Seventy-two patients with acute presentation of AIH were included and six (8.3%) of them presented GAAIH. Comparative analysis between patients with GAAIH and patients with acute exacerbation of chronic AIH revealed that prothrombin activity (96% [74-100] vs. 61% [10-100]; p = 0.003) and albumin levels (3.9 ± 0.2 g/dL vs. 3.4 ± 0.5 g/dL; p < 0.001) were higher in patients with GAAIH. The International Autoimmune Hepatitis Group score was higher in patients with acute exacerbation of chronic AIH (18.5 [8-23] vs. 16.5 [15-17]; p = 0.010). Compared to 15.2% of acute exacerbation of chronic AIH, complete therapeutic response to treatment was achieved in 67.7% of cases with GAAIH (p = 0.018). Conclusions GAAIH was rare (8.3%), and patients with this presentation exhibited more preserved liver function tests, suggesting that most cases presenting with loss of function are acute exacerbation of chronic AIH. Additionally, patients with GAAIH had a better complete therapeutic response, suggesting a more preserved liver function at presentation, and early diagnosis has a positive therapeutic implication.
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Affiliation(s)
- Elze Maria Gomes Oliveira
- Division of Gastroenterology, Federal University of Sao Paulo, Sao Paulo, Brazil
- Centro Universitário Lusíada, Santos, Brazil
| | | | | | | | - Renata Mello Perez
- Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Janaína Luz Narciso-Schiavon
- Division of Gastroenterology, Department of Internal Medicine, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Raul Carlos Whale
- Division of Gastroenterology, Federal University of Sao Paulo, Sao Paulo, Brazil
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Clouston AD, Gouw ASH, Tiniakos D, Bedossa P, Brunt EM, Callea F, Dienes HP, Goodman ZD, Hubscher SG, Kakar S, Kleiner DE, Lackner C, Park YN, Roberts EA, Schirmacher P, Terracciano L, Torbenson M, Wanless IR, Zen Y, Burt AD. Severe acute liver disease in adults: Contemporary role of histopathology. Histopathology 2024. [PMID: 38773813 DOI: 10.1111/his.15212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/24/2024]
Abstract
Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).
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Affiliation(s)
- Andrew D Clouston
- Centre for Liver Disease Research, School of Medicine (Southern), University of Queensland, Princess Alexandra Hospital, Ipswich, Australia
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dina Tiniakos
- Department of Pathology, Aretaieion Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Elizabeth M Brunt
- Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Hans-Peter Dienes
- Institute of Pathology, Meduniwien, Medical University of Vienn, Wien, Austria
| | - Zachary D Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Stefan G Hubscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Young N Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eve A Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Luigi Terracciano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ian R Wanless
- Department of Pathology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alastair D Burt
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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3
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Fawzy A, Sutton H, Vandriel SM, Sonnenberg M, Kamath BM. Outcomes and management in paediatric autoimmune hepatitis presenting as acute liver failure: Individual patient data meta-analysis. Liver Int 2024. [PMID: 38700362 DOI: 10.1111/liv.15943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND AIMS Autoimmune hepatitis (AIH) in children presenting in acute liver failure (ALF) can be fatal and often requires liver transplantation (LTx). This individual patient data meta-analysis (IPD) aims to examine management and outcomes of this population, given the lack of large cohort studies on paediatric AIH first presenting as ALF (AIH-ALF). METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses of IPD statement using PubMed and Excerpta Medica dataBASE, and included English studies published between 2000 and 2020. The study included patients under 21 years of age, diagnosed with type 1 or 2 AIH and presenting with ALF. Data extracted included clinical and biochemical characteristics, interventions, and outcomes. RESULTS Three hundred and thirty eligible patients from 61 studies were identified, with an additional five patients from our institution. The majority were female (66.8%), with a median age of 10. Overall, 59.7% achieved native liver survival (NLS), 35% underwent LTx, and 5% died before LTx. The use of corticosteroids with non-steroid immunomodulators increased the likelihood of NLS by 2.5-fold compared to corticosteroids alone. AIH-1 was associated with 3.3-fold odds for NLS, compared to AIH-2. However, on multivariate analysis, only AIH-1 was identified as an independent predictor for NLS (OR 3.8 [95% CI 1.03-14.2], p = .04). CONCLUSION While corticosteroids and non-steroid immunomodulators treatment may offer enhanced probability of achieving NLS, treatment regimens for AIH-ALF may need to consider patient-specific factors, especially AIH type. This highlights the potential for NLS in AIH-ALF and suggest a need to identify biomarkers which predict the need for combination immunosuppression to avoid LTx.
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Affiliation(s)
- Aly Fawzy
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harry Sutton
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Shannon M Vandriel
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Mikayla Sonnenberg
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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4
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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] [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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5
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Bansal N, Rastogi M, Agrawal K, Vij V, Srivastava A. Acute liver failure histopathology: A 5-year retrospective study. Indian J Gastroenterol 2024; 43:468-474. [PMID: 38713344 DOI: 10.1007/s12664-024-01588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Acute liver failure (ALF) is a rare, life-threatening disease of diverse etiology. It is defined as severe acute liver injury for fewer than 26 weeks' duration with encephalopathy and impaired synthetic function (international normalized ratio [INR] of 1.5 or higher) in a patient without cirrhosis or pre-existing liver disease. The diagnosis rests mainly on the clinical ground with wide range of pathological features. The present study seeks to explore the diverse histological patterns observed in cases for ALF and assess their usefulness in determining the underlying causes for the condition. METHODOLOGY A retrospective cross-sectional study was conducted among patients of ALF who underwent liver transplant and transjugular liver biopsy over a five-year period. From 1082 explant liver and 2446 liver biopsies, 22 cases of ALF (10 explants and 12 liver biopsies) were included in the study. Clinical and laboratory details were retrieved and histological findings were reviewed. RESULT Age ranged from 10 to 72 years (mean age, 40 years). There was a female predominance with a male:female ratio of 1:1.7. The commonest cause for ALF was virus-induced hepatocellular damage in 36.3% (eight patients), followed by autoimmune hepatitis in 22.7% (five patients), drug-induced liver injury (DILI) in 18.1% (four patients), cryptogenic in 13.6% (three patients) and ischemic injury secondary to large vein thrombosis in 9.0% (two) patients. The histological patterns identified were categorized into six categories. A more comprehensive morphological evaluation was conducted specifically for cases of ALF associated with autoimmune hepatitis (AIH) and compared with other cases of ALF. CONCLUSION In summary, our present study illustrates a morphological overlap in various patterns for the purpose of etiological assessment. In cases of AIH ALF, the presence of portal plasma cell infiltrate and central perivenulitis were identified as significant histological features to guide diagnosis.
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Kochhar S, Assis DN, Mack C, Izurieta HS, Muratori L, Munoz A, Nordenberg D, Gidudu JF, Blau EF, Vierling JM. Autoimmune hepatitis: Brighton Collaboration case definition and guidelines for data collection, analysis, and presentation of immunisation safety data. Vaccine 2024; 42:1812-1825. [PMID: 38368225 DOI: 10.1016/j.vaccine.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 02/19/2024]
Abstract
This report introduces a Brighton Collaboration (BC) case definition for autoimmune hepatitis (AIH), which has been classified as a priority adverse event of special interest (AESI), as there were possible cases seen following COVID-19 vaccination. The case definition was developed by a group of subject matter and BC process experts to facilitate safety data comparability across pre- and post-licensure clinical trials, as well as pharmacovigilance activities in multiple settings with diverse resources and healthcare access. The usual BC case definition development process was followed in an expedited manner, and took two months to complete, including finalising the manuscript for publication, instead of the usual 1 year development time. It includes a systematic review of the literature and an expert consensus to define levels of diagnostic certainty for AIH, and provides specific guidelines for data collection and analysis. Histology, serological and biochemical tests and exclusion of alternate diagnosis were considered necessary to define the levels of certainty (definitive, probable and possible). AEFI reports of suspected AIH were independently classified by the WG members to test its useability and these classifications were used to finalise the case definition. The document underwent peer review by external AIH experts and a Reference Group of vaccine safety stakeholders in high-, low- and middle-income countries to ensure case definition useability, applicability, and scientific integrity. The expedited process can be replicated for development of other standardised case definitions for priority AESIs for endemics and epidemics. While applicable to cases reported following immunisation, the case definition is independent of lapsed time following vaccination and, as such, can also be used to determine background incidence for vaccinated and unvaccinated control groups in studies of causal association. While use of this case definition is also appropriate for the study of safety of other products including drugs, it is not meant to guide clinical case management.
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Affiliation(s)
- Sonali Kochhar
- Department of Global Health, University of Washington, Seattle, WA, USA; Global Healthcare Consulting, New Delhi, India.
| | - David N Assis
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.
| | - Cara Mack
- Medical College of Wisconsin, Children's Wisconsin, Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Milwaukee, WI, USA.
| | | | - Luigi Muratori
- DIMEC Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy.
| | - Alma Munoz
- Instituto de Salud Pública, Santiago, Chile.
| | - Dale Nordenberg
- Thriive, 250 - 25th Street, West Vancouver, BC V7V 4J1, USA.
| | - Jane F Gidudu
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Erin F Blau
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, USA.
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7
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Ferronato M, Lalanne C, Quarneti C, Panico ML, Guidi M, Lenzi M, Muratori L. The evolving phenotype of autoimmune hepatitis across the millennium: The 40-year experience of a referral centre in Italy. Liver Int 2024; 44:791-798. [PMID: 38230826 DOI: 10.1111/liv.15829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/28/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND AIMS During recent years, there have been major insight into the pathogenesis, diagnosis and treatment of autoimmune hepatitis (AIH). We aim to evaluate modifications of the clinical-epidemiological phenotype of AIH patients from 1980 to our days. METHODS Single-centre, tertiary care retrospective study on 507 consecutive Italian patients with AIH. Patients were divided into four subgroups according to the decade of diagnosis: 1981-1990, 1991-2000, 2001-2010 and 2011-2020. We assessed clinical, laboratory and histological features at diagnosis, response to treatment and clinical outcomes. Acute presentation is defined as transaminase levels >10-fold the upper limit and/or bilirubin >5 mg/dL. Complete response is defined as the normalization of transaminases and IgG after 12 months. Clinical progression is defined as the development of cirrhosis in non-cirrhotic patients and hepatic decompensation/hepatocellular carcinoma development in compensated cirrhosis. RESULTS Median age at diagnosis increased across decades (24, 31, 39, 52 years, p < .001). Acute onset became more common (39.6%, 44.4%, 47.7%, 59.5%, p = .019), while cirrhosis at diagnosis became less frequent (36.5%, 16.3%, 10.8%, 8.7%, p < .001). Complete response rates rose (11.1%, 49.4%, 72.7% 76.2%, p < .001) and clinical progression during follow-up decreased (54.3%, 29.9%, 16.9%, 11.2%, p < .001). Anti-nuclear antibodies positivity increased (40.7%, 52.0%, 73.7%, 79.3%, p < .001), while IgG levels/upper limit progressively decreased (1.546, 1.515, 1.252, 1.120, p < .001). Liver-related death and liver transplantation reduced from 17.1% to 2.1% (p < .001). CONCLUSIONS In the new millennium, the typical AIH patient in Italy is older at diagnosis, more often presents with acute hepatitis, cirrhosis is less frequent and response to treatment is more favourable.
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Affiliation(s)
- Marco Ferronato
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudine Lalanne
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Quarneti
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Luisa Panico
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Guidi
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Lenzi
- DIMEC, Università di Bologna, Bologna, Italy
| | - Luigi Muratori
- DIMEC, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- European Reference Network for Hepatological Disease (ERN RARE-LIVER), Department of Medicine Martinistraße, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Zhou YJ, Jin QF, Wang C, Zhang XJ, Liu H, Bao J. Onset of acute severe autoimmune hepatitis after severe acute respiratory syndrome coronavirus 2 infection: a case report. J Int Med Res 2024; 52:3000605241233450. [PMID: 38502002 PMCID: PMC10953009 DOI: 10.1177/03000605241233450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 01/29/2024] [Indexed: 03/20/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can trigger autoimmune inflammation in the liver, leading to acute autoimmune hepatitis (AIH). We herein report a case involving a 39-year-old woman with a 23-day history of yellow skin and urine. Using the revised original scoring system of the International AIH Group, we definitively diagnosed the patient with acute severe AIH (AS-AIH). She began treatment with 80 mg/day intravenous methylprednisolone, which was gradually reduced and followed by eventual transition to oral methylprednisolone. The patient finally achieved a biochemical response after 30 days of therapy, and liver transplantation was avoided. Clinicians should be aware that the onset of AS-AIH after SARS-CoV-2 infection differs from the onset of conventional AIH with respect to its clinical and pathological features. Early diagnosis and timely glucocorticoid treatment are crucial in improving outcomes.
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Affiliation(s)
- Yi-Jun Zhou
- Department of Hepatology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Qiao-Fei Jin
- Department of Hepatology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chen Wang
- Department of Hepatology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xiao-Jing Zhang
- Department of Hepatology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Hong Liu
- Department of Pathology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jianfeng Bao
- Department of Hepatology, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Malakar S, Mohindra S, Mishra P, Kothalkar S, Shirol VV, Borah G, Shamsul Hoda U, Shah N, Balankhe K, Pande G, Ghoshal UC. Implications of Gender on the Outcome in Patients With Autoimmune Hepatitis. Cureus 2024; 16:e55477. [PMID: 38571851 PMCID: PMC10989211 DOI: 10.7759/cureus.55477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is uncommon and predominantly affects females. Data on AIH from India are scanty. We retrospectively analyzed the spectrum and outcome of adults with AIH and compared it between male and female patients. METHODS AIH was diagnosed using a simplified AIH score. For suspected seronegative AIH, the revised score was used. Standard therapies for AIH and portal hypertension were administered and response was assessed at six months. Relapse rates and five-year mortality were also evaluated. RESULTS Of the 157 patients with AIH, 85 (male: female 25: 60) were included in the study. The median age at diagnosis was 46 (interquartile range (IQR) 32-55.5) years in males vs 45 (IQR 34.2-54) years in females (p=0.91). A similar proportion of male and female patients presented with cirrhosis, acute severe AIH, or AIH-related acute on chronic liver failure (ACLF); Extra-hepatic autoimmune diseases were less common in male patients (16% vs 35.5% p=0.02). Other laboratory and histological features were comparable in both groups. During the median follow-up period of 51 months (IQR 45-67 months). The biochemical and clinical response at six months were seen in 64% of male patients and 63.3% of female patients (p= 0.57). Of patients, 75% relapsed in the male AIH group (12 of 16 patients) after initial remission compared to 42% in the female group (p=0.02). Five-year mortality was 14.1%, and no patient developed hepatocellular carcinoma. CONCLUSION Male and female patients with AIH have similar clinical, biochemical, and histological profiles. More male patients relapsed after an initial response to therapy.
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Affiliation(s)
- Sayan Malakar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Piyush Mishra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Srikanth Kothalkar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Vivek V Shirol
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Gourav Borah
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Umair Shamsul Hoda
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Nishant Shah
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Kartik Balankhe
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Gaurav Pande
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
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Mercado LA, Gil-Lopez F, Chirila RM, Harnois DM. Autoimmune Hepatitis: A Diagnostic and Therapeutic Overview. Diagnostics (Basel) 2024; 14:382. [PMID: 38396421 PMCID: PMC10887775 DOI: 10.3390/diagnostics14040382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune hepatitis is an immune-mediated inflammatory condition of the liver of undetermined cause that affects both sexes, all ages, races, and ethnicities. Its clinical presentation can be very broad, from having an asymptomatic and silent course to presenting as acute hepatitis, cirrhosis, and acute liver failure potentially requiring liver transplantation. The diagnosis is based on histological abnormalities (interface hepatitis), characteristic clinical and laboratory findings (increased aspartate aminotransferase, alanine aminotransferase, and serum IgG concentration), and the presence of one or more characteristic autoantibodies. The large heterogeneity of these clinical, biochemical, and histological findings can sometimes make a timely and proper diagnosis a difficult task. Treatment seeks to achieve remission of the disease and prevent further progression of liver disease. First-line therapy includes high-dose corticosteroids, which are later tapered to decrease side effects, and azathioprine. In the presence of azathioprine intolerance or a poor response to the standard of care, second-line therapy needs to be considered, including mycophenolate mofetil. AIH remains a diagnostic and therapeutic challenge, and a further understanding of the pathophysiological pathways of the disease and the implementation of randomized controlled trials are needed.
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Affiliation(s)
- Lydia A. Mercado
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Fernando Gil-Lopez
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Razvan M. Chirila
- Department of General Internal Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
| | - Denise M. Harnois
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Shiffman ML. Autoimmune Hepatitis: Epidemiology, Subtypes, and Presentation. Clin Liver Dis 2024; 28:1-14. [PMID: 37945151 DOI: 10.1016/j.cld.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Autoimmune hepatitis (AIH) is a chronic immunologic disorder in which the immune system targets the liver. The disease has a genetic basis and this accounts for the epidemiologic variation observed in serologic testing and clinical presentation across different populations. The incidence of AIH increases with age into the 70s and seems to be increasing in prevalence. Most patients test positive for antinuclear antibody, ASMA, or anti-LKM but about 20% of patients do not have these serologic markers. At clinical presentation, patients may be asymptomatic, symptomatic, have acute liver failure, or decompensated cirrhosis.
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Affiliation(s)
- Mitchell L Shiffman
- Bon Secours Liver Institute of Richmond, Bon Secours Mercy Health, 5855 Bremo Road, Suite 509, Richmond, VA 23226, USA; Bon Secours Liver Institute of Hampton Roads, Bon Secours Mercy Health, 12720 Mc Manus Boulevard, Suite 313, Newport News, VA, 23602, USA.
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12
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Flikshteyn B, Amer K, Tafesh Z, Pyrsopoulos NT. Diagnosis of Autoimmune Hepatitis. Clin Liver Dis 2024; 28:37-50. [PMID: 37945161 DOI: 10.1016/j.cld.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Autoimmune hepatitis (AIH) presents a diagnostic challenge because it is relatively rare and heterogenous in presentation. This article presents the currently adopted approach to AIH diagnosis and explores the challenges with accurately identifying this disease entity. AIH offers no pathognomonic findings, instead relies on clinical presentation, serology, and histology to make the diagnosis. Diagnostic scoring systems support clinical judgment and serve as valuable tools in diagnosis and research. Histological analysis remains the cornerstone of diagnosis and to this day biopsy is essential to make the diagnosis.
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Affiliation(s)
- Ben Flikshteyn
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA.
| | - Kamal Amer
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA
| | - Zaid Tafesh
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA
| | - Nikolaos T Pyrsopoulos
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA
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13
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Enciso J, Vasavada-Patel R, Lien K. A Rare Presentation of Drug-Induced Autoimmune Hepatitis and the Role of Male Enhancement Supplements. Cureus 2024; 16:e51770. [PMID: 38322090 PMCID: PMC10844770 DOI: 10.7759/cureus.51770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Autoimmune hepatitis (AIH) is a condition characterized by an autoimmune response resulting in chronic inflammatory liver disease. Its presentation is marked by significant increases in serum immunoglobulins and the production of active autoantibodies that target liver tissue. AIH is often associated with other autoimmune disorders, which can lead to overlapping clinical syndromes. However, alternative theories propose that exposure to specific environmental triggers can initiate this autoimmune cascade. We present the case of a 45-year-old male who sought evaluation for abdominal discomfort and was subsequently diagnosed with drug-induced AIH (DIAIH) following prolonged use of an over-the-counter male-enhancing supplement.
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Affiliation(s)
- Juan Enciso
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Ruhi Vasavada-Patel
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Kyle Lien
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
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14
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Chowdhry M, Sharma A, Agrawal S, Vohra R, Kumar K, Goyal N, Kumar V A, Jerath N, Malhotra S, Sibal A, Mishra M. Efficacy of therapeutic plasma exchange in pediatric cases of acute liver failure as an extracorporeal liver support system. Transfus Apher Sci 2023; 62:103835. [PMID: 37996345 DOI: 10.1016/j.transci.2023.103835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Acute liver failure in the pediatric population is often accompanied by deranged metabolism, severe encephalopathy and coagulopathy. A liver transplant is the most viable option for the management of such patients. Therapeutic plasma exchange (TPE) is helpful in improving the liver biochemistry profile, thereby, increasing their likelihood of undergoing a liver transplant METHOD: The study was conducted over a period of 3 years (January 2018 to December 2021). Indications mainly consisted of ALF with hepatic encephalopathy, worsening liver parameters in spite of medical management, and candidacy for undergoing a liver transplant. Plasma exchange was performed daily or alternatively until the patient recovered, succumbed, or was stable enough to undergo a transplant. Biochemical parameters serum bilirubin, ALT, AST serum ammonia serum urea, serum creatinine were recorded before and after TPE sessions. RESULTS The study group comprised 14 patients of which a total of 28 TPE was performed. There were a total of 5 cases of cryptogenic ALF, 4 of Wilson disease, 2 cases each of infection-related ALF and autoimmune hepatitis, and a single case of drug-induced hepatitis. A total of 5 out of 14 patients underwent a liver transplant and amongst the 9 who did not undergo a transplant, 4 patients expired due to septic shock syndrome; the remaining 5 were discharged in a stable condition following TPE sessions. The disease-free survival was 78.9% and the transplant-free survival was 35.71%. CONCLUSION TPE plays a crucial role in improving the biochemistry profile of the liver in children with liver failure.
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Affiliation(s)
- Mohit Chowdhry
- Department of Transfusion Medicin & Transplant Immunology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India.
| | - Ankita Sharma
- Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Soma Agrawal
- Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Rohit Vohra
- Department of Pediatric, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Karunesh Kumar
- Department of Pediatric Gastroenterology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Neerav Goyal
- Department of Liver transplant and hepatic-biliary-pancreatic Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Arun Kumar V
- Department of Liver transplant and hepatic-biliary-pancreatic Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Nameet Jerath
- Department of Pediatric, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Smita Malhotra
- Department of Pediatric Gastroenterology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Anupam Sibal
- Department of Pediatric Gastroenterology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
| | - Manoj Mishra
- Department of Transplant Immunology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, New Delhi 110076, India
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15
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Stravitz RT, Fontana RJ, Karvellas C, Durkalski V, McGuire B, Rule JA, Tujios S, Lee WM. Future directions in acute liver failure. Hepatology 2023; 78:1266-1289. [PMID: 37183883 PMCID: PMC10521792 DOI: 10.1097/hep.0000000000000458] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Abstract
Acute liver failure (ALF) describes a clinical syndrome of rapid hepatocyte injury leading to liver failure manifested by coagulopathy and encephalopathy in the absence of pre-existing cirrhosis. The hallmark diagnostic features are a prolonged prothrombin time (ie, an international normalized ratio of prothrombin time of ≥1.5) and any degree of mental status alteration (HE). As a rare, orphan disease, it seemed an obvious target for a multicenter network. The Acute Liver Failure Study Group (ALFSG) began in 1997 to more thoroughly study and understand the causes, natural history, and management of ALF. Over the course of 22 years, 3364 adult patients were enrolled in the study registry (2614 ALF and 857 acute liver injury-international normalized ratio 2.0 but no encephalopathy-ALI) and >150,000 biosamples collected, including serum, plasma, urine, DNA, and liver tissue. Within the Registry study sites, 4 prospective substudies were conducted and published, 2 interventional ( N -acetylcysteine and ornithine phenylacetate), 1 prognostic [ 13 C-methacetin breath test (MBT)], and 1 mechanistic (rotational thromboelastometry). To review ALFSG's accomplishments and consider next steps, a 2-day in-person conference was held at UT Southwestern Medical Center, Dallas, TX, entitled "Acute Liver Failure: Science and Practice," in May 2022. To summarize the important findings in the field, this review highlights the current state of understanding of ALF and, more importantly, asks what further studies are needed to improve our understanding of the pathogenesis, natural history, and management of this unique and dramatic condition.
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Affiliation(s)
| | | | | | - Valerie Durkalski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jody A. Rule
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Shannan Tujios
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - William M. Lee
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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16
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Nastasio S, Mosca A, Alterio T, Sciveres M, Maggiore G. Juvenile Autoimmune Hepatitis: Recent Advances in Diagnosis, Management and Long-Term Outcome. Diagnostics (Basel) 2023; 13:2753. [PMID: 37685291 PMCID: PMC10486972 DOI: 10.3390/diagnostics13172753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023] Open
Abstract
Juvenile autoimmune hepatitis (JAIH) is severe immune-mediated necro-inflammatory disease of the liver with spontaneous progression to cirrhosis and liver failure if left untreated. The diagnosis is based on the combination of clinical, laboratory and histological findings. Prothrombin ratio is a useful prognostic factor to identify patients who will most likely require a liver transplant by adolescence or early adulthood. JAIH treatment consists of immune suppression and should be started promptly at diagnosis to halt inflammatory liver damage and ultimately prevent fibrosis and progression to end-stage liver disease. The risk of relapse is high especially in the setting of poor treatment compliance. Recent evidence however suggests that treatment discontinuation is possible after a prolonged period of normal aminotransferase activity without the need for liver biopsy prior to withdrawal.
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy;
| | - Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
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17
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Beech C, Liu C, Zhang X. Pathology of Acute and Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:581-593. [PMID: 37380284 DOI: 10.1016/j.cld.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Liver failure can develop as either acute liver failure in the absence of preexisting liver disease, or as acute-on-chronic liver failure in a patient with underlying chronic liver disease or cirrhosis. A timely liver biopsy is helpful to distinguish acute and chronic liver disease, identify precipitating factors, provide prognostic information based on pathologic changes, and aid in making appropriate decisions for patient management. This article will discuss the pathologic features of acute and acute-on-chronic liver failure. Developing an appreciation for the histopathologic patterns of injury observed in these entities is essential for a practical understanding of the diagnostic process.
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Affiliation(s)
- Cameron Beech
- Department of Pathology, ARUP Laboratories, University of Utah, Salt Lake City, UT 84112, USA
| | - Chen Liu
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520-8023, USA.
| | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520-8023, USA.
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18
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Sharma S, Agarwal S, Saraya A, Choudhury AK, Saigal S, Soin AS, Shukla A, Sahu MK, Lesmana LA, Lesmana RC, Shah SN, Hu J, Tan SS, Jothimani D, Rela M, Ghazinyan HL, Amrapurkar DN, Eapen CE, Goel A, Payawal DA, Hamid S, Butt AS, Zhongping D, Singh V, Duseja A, Sood A, Midha V, Al Mahtab M, Kim DJ, Ning Q, Kulkarni AV, Rao PN, Lee GH, Treeprasertsuk S, Shaojie X, Karim MF, Sollano JD, Kalista KF, Gani RA, Prasad VGM, Sarin SK. Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure. Hepatol Int 2023; 17:989-999. [PMID: 36790652 DOI: 10.1007/s12072-023-10482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND AIMS Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment. METHODS Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90 days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [- 6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2 weeks. RESULTS Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0 years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90 day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2 weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3 days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ - 1.2, could identify non-responders at day 3 (concomitant- 75% vs either - 42%, p < 0.001). CONCLUSION Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.
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Affiliation(s)
- Sanchit Sharma
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110026, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110026, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110026, India.
| | - Ashok Kumar Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta, Medicity, Gurugram, Haryana, India
| | - A S Soin
- Department of Hepatology, Medanta, Medicity, Gurugram, Haryana, India
| | - Akash Shukla
- Department of Gastroenterology, LTMMC, Mumbai, Maharashtra, India
| | - Manoj K Sahu
- Department of Hepatology, IMS and SUM Hospital, Bhubneshwar, Odhisha, India
| | | | | | - Samir N Shah
- Department of Hepatology, Global Hospital, Mumbai, India
| | - Jinhua Hu
- Department of Medicine, 302 Military Hospital, Bejing, China
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Bata Cabs, Selangor, Malaysia
| | - Dinesh Jothimani
- Department of Liver Transplant and Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohammed Rela
- Department of Liver Transplant and Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Hasmik L Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
| | | | - C E Eapen
- Department of Hepatology, Christan Medical College, Vellore, India
| | - Ashish Goel
- Department of Hepatology, Christan Medical College, Vellore, India
| | | | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Amna S Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Duan Zhongping
- Translational Hepatology Institute Capital Medical University, Beijing You' an Hospital, Beijing, China
| | | | - Ajay Duseja
- Department of Hepatology, PGIMER, Chandigarh, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Qin Ning
- Department of Medicine, Tongji Hospital, Tongji Medical College, Wuhan, China
| | | | - P N Rao
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Guan Huei Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore
| | | | - Xin Shaojie
- Medical School of Chinese PLA, Beijing, China
| | - Md Fazal Karim
- Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Kemal Fariz Kalista
- Division of Hepatobiliary, Cipto Mangunkusuamo Hospital, University of Indonesia, Jakarta, Indonesia
| | - Rino Alvani Gani
- Division of Hepatobiliary, Cipto Mangunkusuamo Hospital, University of Indonesia, Jakarta, Indonesia
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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KASL clinical practice guidelines for management of autoimmune hepatitis 2022. Clin Mol Hepatol 2023; 29:542-592. [PMID: 37137334 PMCID: PMC10366804 DOI: 10.3350/cmh.2023.0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
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20
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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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21
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Enke T, Livingston S, Rule J, Stravitz T, Rakela J, Bass N, Reuben A, Tujios S, Larson A, Sussman N, Durkalski V, Lee W, Ganger D. Autoimmune hepatitis presenting as acute liver failure: A 20-year retrospective review of North America. Liver Transpl 2023; 29:570-580. [PMID: 36825579 PMCID: PMC10192052 DOI: 10.1097/lvt.0000000000000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/12/2023] [Indexed: 02/25/2023]
Abstract
Autoimmune hepatitis is a common cause of acute liver failure. Treatment includes steroids for acute liver injury and liver transplantation in those who fail to respond or develop acute liver failure. The aim of this study is to further characterize acute liver failure secondary to autoimmune hepatitis and identify variables that predict 21-day transplant-free survival. This study included adults hospitalized with acute liver failure enrolled in the Acute Liver Failure Study Group Registry between 1998 and 2019 from 32 centers within the US. The etiology of all cases was reviewed by the Adjudication Committee, and all cases identified as autoimmune hepatitis were included. Acute liver injury was defined as an INR ≥2.0 without encephalopathy and acute liver failure as INR ≥ 1.5 with encephalopathy. Laboratory and clinical data were reviewed. Variables significantly associated with 21-day transplant-free survival were used to develop a multivariable logistic regression model. A total of 193 cases of acute liver failure secondary to autoimmune hepatitis were identified and reviewed. There were 161 patients (83.4%) diagnosed with acute liver failure on enrollment, and 32 (16.6%) developed acute liver failure during hospitalization. At 21 days, 115 (59.6%) underwent liver transplantation, 28 (14.5%) had transplant-free survival, and 46 (23.8%) died before liver transplantation. Higher admission values of bilirubin, INR, and coma grade were associated with worse outcomes. A prognostic index incorporating bilirubin, INR, coma grade, and platelet count had a concordance statistic of 0.84. Acute liver failure secondary to autoimmune hepatitis is associated with a high short-term mortality. We developed a model specifically for autoimmune hepatitis that may be helpful in predicting 21-day transplant-free survival and early identification of patients in need of expedited liver transplant evaluation.
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Affiliation(s)
| | | | - Jody Rule
- University of Texas Southwestern Medical Center
| | | | | | - Nathan Bass
- University of California San Francisco Medical Center
| | | | | | | | | | | | - William Lee
- University of Texas Southwestern Medical Center
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22
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Autoimmune Hepatitis and Fibrosis. J Clin Med 2023; 12:jcm12051979. [PMID: 36902767 PMCID: PMC10004701 DOI: 10.3390/jcm12051979] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Autoimmune hepatitis (AIH) is a chronic immune-inflammatory disease of the liver, generally considered a rare condition. The clinical manifestation is extremely varied and can range from paucisymptomatic forms to severe hepatitis. Chronic liver damage causes activation of hepatic and inflammatory cells leading to inflammation and oxidative stress through the production of mediators. This results in increased collagen production and extracellular matrix deposition leading to fibrosis and even cirrhosis. The gold standard for the diagnosis of fibrosis is liver biopsy; however, there are serum biomarkers, scoring systems, and radiological methods useful for diagnosis and staging. The goal of AIH treatment is to suppress fibrotic and inflammatory activities in the liver to prevent disease progression and achieve complete remission. Therapy involves the use of classic steroidal anti-inflammatory drugs and immunosuppressants, but in recent years scientific research has focused on several new alternative drugs for AIH that will be discussed in the review.
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23
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Abstract
Autoimmune hepatitis is an inflammatory disease of the liver of unknown cause that may progress to liver cirrhosis and end stage liver failure if diagnosis is overlooked and treatment delayed. The clinical presentation is often that of acute hepatitis, sometimes very severe; less frequently, it can be insidious or completely asymptomatic. The disease can affect people of any age and is more common in women; its incidence and prevalence seem to be on the rise worldwide. An abnormal immune response targeting liver autoantigens and inducing persistent and self-perpetuating liver inflammation is the pathogenic mechanism of the disease. A specific set of autoantibodies, increased IgG concentrations, and histological demonstration of interface hepatitis and periportal necrosis are the diagnostic hallmarks of autoimmune hepatitis. Prompt response to treatment with corticosteroids and other immunomodulatory drugs is almost universal and supports the diagnosis. The aims of treatment are to induce and maintain long term remission of liver inflammation. Treatment can often even reverse liver fibrosis, thus preventing progression to advanced cirrhosis and its complications. Most patients need lifelong maintenance therapy, and repeated follow-up in experienced hands improves the quality of care and quality of life for affected patients.
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Affiliation(s)
- Luigi Muratori
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
| | - Marco Lenzi
- DIMEC, Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- European Reference Network for Hepatological Diseases (ERN RARE-LIVER)
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Pan JJ, Fontana RJ. CAQ Corner: Acute liver failure management and liver transplantation. Liver Transpl 2022; 28:1664-1673. [PMID: 35574981 PMCID: PMC9796044 DOI: 10.1002/lt.26503] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Jason J. Pan
- Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan Medical CenterAnn ArborMichiganUSA
| | - Robert J. Fontana
- Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan Medical CenterAnn ArborMichiganUSA
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Autoimmune Hepatitis with Acute Presentation: Clinical, Biochemical, and Histological Features of 126 Patients. Can J Gastroenterol Hepatol 2022; 2022:6470847. [PMID: 36199980 PMCID: PMC9529506 DOI: 10.1155/2022/6470847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Autoimmune hepatitis (AIH) is a chronic liver disease with a relevant inflammatory component and an unknown etiology. Evidence for clinical characteristics and risk factors in large cohorts of patients with acute AIH (AAIH) is lacking. We clinically characterized patients with AAIH, the prevalence of a combined adverse outcome (death or liver transplantation (LT)), and its risk factors. METHODS A retrospective study of adult patients diagnosed with AAIH at three centers (Santiago, Chile; 2000-2018) was conducted. Clinical and laboratory characteristics were obtained. A liver biopsy was performed for all patients. Descriptive statistics and logistic regression models were used. RESULTS A total of 126 patients were admitted; 77% were female, 33 (26.2%) had a severe presentation, and 14 (11.1%) had a fulminant presentation. Overall, 24 patients (19.0%) lacked typical autoantibodies, and 26.2% had immunoglobulin G levels in the normal range. The most frequent histological findings were plasma cells (86.5%), interface hepatitis (81.7%), and chronic hepatitis (81.0%). Rosettes were uncommon (35.6%). Advanced fibrosis was present in 27% of patients. Combined adverse outcomes occurred in 7.9% of cases, all fulminant with histological cholestasis. Alkaline phosphatase, bilirubin, and prothrombin less than 50% were independent risk factors for in-hospital death or LT (p value <0.05). Although corticosteroid treatment was associated with better outcomes (OR 0.095, p value = 0.013), more severe patients were less likely to receive this therapy. Discussion. In this large cohort of patients with AAIH, clinical characteristics differ from those reported in patients with chronic AIH. Fulminant hepatitis, histological cholestasis, alkaline phosphatase, bilirubin, and prothrombin were associated with death/LT.
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Abstract
Abbreviated pathogenesis and clinical course of the acute liver failure syndrome. The pathogenesis and clinical course of the syndrome of acute liver failure (ALF) differs depending upon the etiology of the primary liver injury. In turn, the severity of the liver injury and resulting synthetic failure is often the primary determinant of whether a patient is referred for emergency liver transplantation. Injuries by viral etiologies trigger the innate immune system via pathogen-associated molecular patterns (PAMPs), while toxin-induced (and presumably ischemia-induced) injuries do so via damage-associated molecular patterns (DAMPs). The course of the clinical syndrome further depends upon the relative intensity and composition of cytokine release, resulting in an early proinflammatory phenotype (SIRS) and later compensatory anti-inflammatory response phenotype (CARS). The outcomes of overwhelming immune activation are the systemic (extrahepatic) features of ALF (cardiovascular collapse, cerebral edema, acute kidney injury, respiratory failure, sepsis) which ultimately determine the likelihood of death.Acute liver failure (ALF) continues to carry a high risk of mortality or the need for transplantation despite recent improvements in overall outcomes over the past two decades. Optimal management begins with identifying that liver failure is indeed present and its etiology, since outcomes and the need for transplantation vary widely across the different etiologies. Most causes of ALF can be divided into hyperacute (ischemia and acetaminophen) and subacute types (other etiologies), based on time of evolution of signs and symptoms of liver failure; the former evolve in 3 to 4 days and the latter typically in 2 to 4 weeks. Both involve intense release of cytokines and hepatocellular contents into the circulation with multiorgan effects/consequences.Management involves optimizing fluid balance and cardiovascular support, including the use of continuous renal replacement therapy, vasopressors, and pulmonary ventilation. Early evaluation for liver transplantation is advised particularly for acetaminophen toxicity, which evolves so rapidly that delay is likely to lead to death.Vasopressor support, high-grade hepatic encephalopathy, and unfavorable (subacute) etiologies heighten the need for urgent listing for liver transplantation. Prognostic scores such as Kings Criteria, Model for End-Stage Liver Disease, and the Acute Liver Failure Group prognostic index take these features into account and provide reasonable but imperfect predictive accuracy. Future treatments may include liver support devices and/or agents that improve hepatocyte regeneration.
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Affiliation(s)
- Shannan Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R. Todd Stravitz
- Section of Hepatology, Department of Internal Medicine, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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Hasegawa N, Matsuoka R, Ishikawa N, Endo M, Terasaki M, Seo E, Tsuchiya K. Autoimmune hepatitis with history of HCV treatment triggered by COVID-19 vaccination: case report and literature review. Clin J Gastroenterol 2022; 15:791-795. [PMID: 35716255 PMCID: PMC9206395 DOI: 10.1007/s12328-022-01654-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/30/2022] [Indexed: 01/06/2023]
Abstract
Although vaccines have been effective against the worldwide pandemic of Coronavirus Disease 19 (COVID-19), some case reports have described autoimmune hepatitis triggered by COVID-19 vaccination. Meanwhile, hepatitis C virus (HCV) is known to be related to autoimmune diseases. Here, we report a case of autoimmune hepatitis with history of HCV treatment triggered by COVID-19 vaccination. An 82-year-old woman was referred to our hospital for severe liver injury. She had received a COVID-19 vaccination 7 days prior. She had a history of HCV treatment with direct-acting antivirals 7 years previously. In her blood data, despite HCV antibody positivity, she was negative for HCV RNA by real-time RT-PCR. Anti-nuclear antibody was positive and IgG was elevated. Interface hepatitis and plasma cell infiltration were confirmed pathologically. She was diagnosed as autoimmune hepatitis and her liver injury quickly improved after initiation of steroid administration. This is a first case report of autoimmune hepatitis with history of HCV treatment triggered by COVID-19 vaccination.
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Affiliation(s)
- Naoyuki Hasegawa
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Ryota Matsuoka
- Department of Pathology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Ishikawa
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Masato Endo
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Masahiko Terasaki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Emiko Seo
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
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Lenti MV, Rossi CM, Melazzini F, Gastaldi M, Bugatti S, Rotondi M, Bianchi PI, Gentile A, Chiovato L, Montecucco C, Corazza GR, Di Sabatino A. Seronegative autoimmune diseases: A challenging diagnosis. Autoimmun Rev 2022; 21:103143. [PMID: 35840037 DOI: 10.1016/j.autrev.2022.103143] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/10/2022] [Indexed: 12/19/2022]
Abstract
Autoimmune diseases (AID) are increasingly prevalent conditions which comprise more than 100 distinct clinical entities that are responsible for a great disease burden worldwide. The early recognition of these diseases is key for preventing their complications and for tailoring proper management. In most cases, autoantibodies, regardless of their potential pathogenetic role, can be detected in the serum of patients with AID, helping clinicians in making a definitive diagnosis and allowing screening strategies for early -and sometimes pre-clinical- diagnosis. Despite their undoubted crucial role, in a minority of cases, patients with AID may not show any autoantibody, a condition that is referred to as seronegative AID. Suboptimal accuracy of the available laboratory tests, antibody absorption, immunosuppressive therapy, immunodeficiencies, antigen exhaustion, and immunosenescence are the main possible determinants of seronegative AID. Indeed, in seronegative AID, the diagnosis is more challenging and must rely on clinical features and on other available tests, often including histopathological evaluation and radiological diagnostic tests. In this review, we critically dissect, in a narrative fashion, the possible causes of seronegativity, as well as the diagnostic and management implications, in several AID including autoimmune gastritis, celiac disease, autoimmune liver disease, rheumatoid arthritis, autoimmune encephalitis, myasthenia gravis, Sjögren's syndrome, antiphospholipid syndrome, and autoimmune thyroid diseases.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Carlo Maria Rossi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Federica Melazzini
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Serena Bugatti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Unit of Rheumatology, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Mario Rotondi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
| | - Paola Ilaria Bianchi
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Antonella Gentile
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Luca Chiovato
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Unit of Rheumatology, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy.
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Liao TJ, Pan B, Hong H, Hayashi P, Rule JA, Ganger D, Lee WM, Rakela J, Chen M. Whole Exome Sequencing Reveals Genetic Variants in HLA Class II Genes Associated With Transplant-free Survival of Indeterminate Acute Liver Failure. Clin Transl Gastroenterol 2022; 13:e00502. [PMID: 35905417 PMCID: PMC10476814 DOI: 10.14309/ctg.0000000000000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/17/2022] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Indeterminate acute liver failure (IND-ALF) is a rare clinical syndrome with a high mortality rate. Lacking a known etiology makes rapid evaluation and treatment difficult, with liver transplantation often considered as the only therapeutic option. Our aim was to identify genetic variants from whole exome sequencing data that might be associated with IND-ALF clinical outcomes. METHODS Bioinformatics analysis was performed on whole exome sequencing data for 22 patients with IND-ALF. A 2-tier approach was used to identify significant single-nucleotide polymorphisms (SNPs) associated with IND-ALF clinical outcomes. Tier 1 identified the SNPs with a higher relative risk in the IND-ALF population compared with those identified in control populations. Tier 2 determined the SNPs connected to transplant-free survival and associated with model for end-stage liver disease serum sodium and Acute Liver Failure Study Group prognostic scores. RESULTS Thirty-one SNPs were found associated with a higher relative risk in the IND-ALF population compared with those in controls, of which 11 belong to the human leukocyte antigen (HLA) class II genes but none for the class I. Further analysis showed that 5 SNPs: rs796202376, rs139189937, and rs113473719 of HLA-DRB5; rs9272712 of HLA-DQA1; and rs747397929 of IDO1 were associated with a higher probability of IND-ALF transplant-free survival. Using 3 selected SNPs, a model for the polygenic risk score was developed to predict IND-ALF prognoses, which are comparable with those by model for end-stage liver disease serum sodium and Acute Liver Failure Study Group prognostic scores. DISCUSSION Certain gene variants in HLA-DRB5, HLA-DQA1, and IDO1 were found associated with IND-ALF transplant-free survival. Once validated, these identified SNPs may help elucidate the mechanism of IND-ALF and assist in its diagnosis and management.
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Affiliation(s)
- Tsung-Jen Liao
- Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration (FDA) National Center for Toxicological Research, Jefferson, Arkansas, USA;
| | - Bohu Pan
- Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration (FDA) National Center for Toxicological Research, Jefferson, Arkansas, USA;
| | - Huixiao Hong
- Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration (FDA) National Center for Toxicological Research, Jefferson, Arkansas, USA;
| | - Paul Hayashi
- Division of Hepatology and Nutrition, Office of New Drugs, FDA Center for Drug Evaluation and Research, Silver Spring, Maryland, USA;
| | - Jody A. Rule
- Division of Gastroenterology and Hepatology, University of Texas Southwestern, Dallas, Texas, USA;
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA;
| | - William M. Lee
- Division of Gastroenterology and Hepatology, University of Texas Southwestern, Dallas, Texas, USA;
| | - Jorge Rakela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA.
| | - Minjun Chen
- Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration (FDA) National Center for Toxicological Research, Jefferson, Arkansas, USA;
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Ohira H, Takahashi A, Zeniya M, Abe M, Arinaga-Hino T, Joshita S, Takaki A, Nakamoto N, Kang JH, Suzuki Y, Sogo T, Inui A, Koike K, Harada K, Nakamoto Y, Kondo Y, Genda T, Tsuneyama K, Matsui T, Tanaka A. Clinical practice guidelines for autoimmune hepatitis. Hepatol Res 2022; 52:571-585. [PMID: 35533021 DOI: 10.1111/hepr.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Takahashi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mikio Zeniya
- Akasaka Sanno Medical Center, International University of Health and Welfare, Tokyo, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | | | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuhiro Nakamoto
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jong-Hon Kang
- Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | | | - Tsuyosi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology and Hepatology, The Third Hospital of Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yasuteru Kondo
- Department of Hepatology, Sendai Kousei Hospital, Sendai, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Koichi Tsuneyama
- Department of Pathology and Laboratory Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Takushima, Japan
| | - Tsuyoshi Matsui
- Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Téllez L, Sánchez Rodríguez E, Rodríguez de Santiago E, Llovet L, Gómez‐Outomuro A, Díaz‐Fontenla F, Álvarez López P, García‐Eliz M, Amaral C, Sánchez‐Torrijos Y, Fortea JI, Ferre‐Aracil C, Rodríguez‐Perálvarez M, Abadía M, Gómez‐Camarero J, Olveira A, Calleja JL, Crespo J, Romero M, Hernández‐Guerra M, Berenguer M, Riveiro‐Barciela M, Salcedo M, Rodríguez M, Londoño MC, Albillos A. Early predictors of corticosteroid response in acute severe autoimmune hepatitis: a nationwide multicenter study. Aliment Pharmacol Ther 2022; 56:131-143. [PMID: 35470447 PMCID: PMC9324977 DOI: 10.1111/apt.16926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/28/2021] [Accepted: 04/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS To assess whether corticosteroids improve prognosis in patients with AS-AIH, and to identify factors at therapy initiation and during therapy predictive of the response to corticosteroids. METHODS This was a retrospective cohort study including all patients with AS-AIH admitted to 13 tertiary centres from January 2002 to January 2019. The composite primary outcome was death or liver transplantation within 90 days of admission. Kaplan-Meier and Cox regression methods were used for data analysis. RESULTS Of 242 consecutive patients enrolled (mean age [SD] 49.7 [16.8] years), 203 received corticosteroids. Overall 90-day transplant-free survival was 61.6% (95% confidence interval [CI] 55.4-67.7). Corticosteroids reduced the risk of a poor outcome (adjusted hazard ratio [HR] 0.25; 95% CI 0.2-0.4), but this treatment failed in 30.5%. An internally validated nomogram composed of older age, MELD, encephalopathy and ascites at the initiation of corticosteroids accurately predicted the response (C-index 0.82; [95% CI 0.8-0.9]). In responders, MELD significantly improved from days 3 to 14 but remained unchanged in non-responders. MELD on day 7 with a cut-off of 25 (sensitivity 62.5%[95% CI: 47.0-75.8]; specificity 95.2% [95% CI: 89.9-97.8]) was the best univariate predictor of the response. Prolonging corticosteroids did not increase the overall infection risk (adjusted HR 0.75; 95% CI 0.3-2.1). CONCLUSION Older patients with high MELD, encephalopathy or ascites at steroid therapy initiation and during treatment are unlikely to show a favourable response and so prolonged therapy in these patients, especially if they are transplantation candidates, should be avoided.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de AlcaláMadridSpain
| | - Eugenia Sánchez Rodríguez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de AlcaláMadridSpain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de AlcaláMadridSpain
| | - Laura Llovet
- Liver Unit, Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de BarcelonaBarcelonaSpain
| | - Ana Gómez‐Outomuro
- Liver Unit, Division of Gastroenterology and Hepatology, Hospital Universitario Central de AsturiasISPA, Universidad de OviedoOviedoSpain
| | - Fernando Díaz‐Fontenla
- Liver Unit, Hospital General Universitario Gregorio Marañón, IISGM. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad Complutense de MadridMadridSpain
| | - Patricia Álvarez López
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d´Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de BarcelonaBarcelonaSpain
| | - María García‐Eliz
- Department of Gastroenterology and Hepatology, Hospital Universitario La Fe, IISLaFe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de ValenciaValenciaSpain
| | - Carla Amaral
- Liver Unit, Hospital Universitario de Canarias, CIBICAN, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de La LagunaTenerifeSpain
| | - Yolanda Sánchez‐Torrijos
- Department of Gastroenterology and Hepatology, Hospital Universitario Virgen del Rocío, IBiS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de SevillaSevillaSpain
| | - José Ignacio Fortea
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de CantabriaSantanderSpain
| | - Carlos Ferre‐Aracil
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, IISPH, Universidad Autónoma de MadridCentro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Manuel Rodríguez‐Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina SofíaIMIBIC, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)CórdobaSpain
| | - Marta Abadía
- Department of Gastroenterology and Hepatology, Hospital Universitario La Paz, IDIPAZUniversidad Autónoma de MadridMadridSpain
| | - Judith Gómez‐Camarero
- Department of Gastroenterology and HepatologyComplejo Asistencial Universitario de BurgosBurgosSpain
| | - Antonio Olveira
- Department of Gastroenterology and Hepatology, Hospital Universitario La Paz, IDIPAZUniversidad Autónoma de MadridMadridSpain
| | - José Luis Calleja
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, IISPH, Universidad Autónoma de MadridCentro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Javier Crespo
- Department of Gastroenterology and Hepatology, Hospital Universitario Virgen del Rocío, IBiS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de SevillaSevillaSpain
| | | | - Manuel Hernández‐Guerra
- Liver Unit, Hospital Universitario de Canarias, CIBICAN, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de La LagunaTenerifeSpain
| | - Marina Berenguer
- Department of Gastroenterology and Hepatology, Hospital Universitario La Fe, IISLaFe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de ValenciaValenciaSpain
| | - Mar Riveiro‐Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d´Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de BarcelonaBarcelonaSpain
| | - Magdalena Salcedo
- Liver Unit, Hospital General Universitario Gregorio Marañón, IISGM. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad Complutense de MadridMadridSpain
| | - Manuel Rodríguez
- Liver Unit, Division of Gastroenterology and Hepatology, Hospital Universitario Central de AsturiasISPA, Universidad de OviedoOviedoSpain
| | - María Carlota Londoño
- Liver Unit, Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)Universidad de BarcelonaBarcelonaSpain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de AlcaláMadridSpain
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Flatley S, Dube AK, Gleeson D. Histopathologist and clinician interface in diagnosis and management of autoimmune hepatitis. Frontline Gastroenterol 2022; 13:e94-e101. [PMID: 35812025 PMCID: PMC9234737 DOI: 10.1136/flgastro-2022-102192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/22/2022] [Indexed: 02/04/2023] Open
Abstract
Diagnosis of AIH is based on a combination of clinical, laboratory and histological information. It has been formalised by diagnostic scoring systems, to which liver biopsy contributes substantially. Diagnostic biopsy is thus, desirable in nearly all patients. An adequate biopsy size, provision by clinicians of adequate information to histopathologists and active discussion at regular meetings are all important for accurate histological diagnosis. Recently, the specificity of some features previously thought to suggest AIH has been questioned, and new recommendations for histological diagnosis have been proposed, although not yet validated. The histology of acutely presenting AIH and that of severe or fulminant AIH include some characteristic features. Primary biliary cholangitis, primary sclerosing cholangitis and non-alcoholic fatty liver disease may co-exist with AIH on biopsy. Liver biopsy also enables grading of severity of inflammation and staging of fibrosis. Presence of cirrhosis is a poor prognostic marker. Repeat liver biopsy after achieving biochemical remission, although not performed routinely, enables assessment of (a) histological remission, a favourable prognostic indicator and (b) fibrosis progression. It can thus help determine further management.
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Affiliation(s)
- Sarah Flatley
- Liver Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Asha K Dube
- Department of Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dermot Gleeson
- Liver Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Olivas I, Rodríguez-Tajes S, Londoño MC. Hepatitis autoinmune: retos y novedades. Med Clin (Barc) 2022; 159:289-298. [DOI: 10.1016/j.medcli.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
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Lin S, Araujo C, Hall A, Kumar R, Phillips A, Hassan M, Engelmann C, Quaglia A, Jalan R. Prognostic Role of Liver Biopsy in Patients With Severe Indeterminate Acute Hepatitis. Clin Gastroenterol Hepatol 2022; 20:1130-1141.e7. [PMID: 34389485 DOI: 10.1016/j.cgh.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/15/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Severe indeterminate acute hepatitis (sIAH) is a poorly understood rare disease with no specific therapy. This study aims to define the clinicopathological characteristics of sIAH and the role of liver biopsy in determining prognosis. METHODS Patients with sIAH admitted to a single center between 2010 and 2019 were included. Histopathological patterns of liver biopsies were reviewed by 2 histopathologists, and key findings further were specified by multiplex immunofluorescence. Patients that died or underwent liver transplantation were analyzed as nonsurvivors. RESULTS Of 294 patients with acute hepatitis, 43 with sIAH were included. Seventeen (39.5%) underwent liver transplantation and 7 (16.2%) died within 3 months. Multilobular necrosis was the predominant histopathological feature, being significantly more frequent in nonsurvivors (62.5% vs 21.1%; P = .016). Necrotic areas showed low HNF4α and Ki67 expression but high expression of CK19 and cell death markers identifying areas of severe tissue injury and inadequate regenerative response. Patients with multilobular necrosis had higher international normalized ratio, Model for End-Stage Liver Disease, and Model for End-Stage Liver Disease-Sodium scores compared with those without (P values for all markers <.05). Multivariate Cox analysis revealed that multilobular necrosis (hazard ratio, 3.675; 95% confidence interval, 1.322-10.211) and lower body mass index (hazard ratio, 0.916; 95% confidence interval, 0.848-0.991) independently predicted death or transplantation. CONCLUSIONS The results of this study provide novel insights into the important role of liver biopsy in sIAH patients, suggesting that the presence of multilobular necrosis is an early indicator of poor prognosis.
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Affiliation(s)
- Su Lin
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom; Hepatology Research Institute, Department of Hepatology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Catarina Araujo
- Department of Cellular Pathology, Royal Free Hospital, London, United Kingdom; Anatomical-Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Andrew Hall
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom; Department of Cellular Pathology, Royal Free Hospital, London, United Kingdom; Sheila Sherlock Liver Center, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Rahul Kumar
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom; Department of Gastroenterology and Hepatology, Duke-NUS Academic Medical Centre, Changi General Hospital, Singapore
| | - Alexandra Phillips
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom
| | - Mohsin Hassan
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom; Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany; Section of Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany; Berlin Institute of Health, Berlin, Germany
| | - Alberto Quaglia
- Department of Cellular Pathology, UCL Cancer Institute, Royal Free Hospital, London, United Kingdom
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, Royal Free Hospital, University College London Medical School, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
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Mieli-Vergani G, Zen Y, Vergani D. Reassessement of the histological features of autoimmune hepatitis. Liver Int 2022; 42:954-956. [PMID: 35447009 DOI: 10.1111/liv.15219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Giorgina Mieli-Vergani
- Paediatric Liver, GI and Nutrition Centre, MowatLabs, King's College London Faculty of Life Sciences & Medicine at King's College Hospital, London, United Kingdom
| | - Yoh Zen
- Institute of Liver Studies, MowatLabs, King's College London Faculty of Life Sciences & Medicine at King's College Hospital, London, United Kingdom
| | - Diego Vergani
- Institute of Liver Studies, MowatLabs, King's College London Faculty of Life Sciences & Medicine at King's College Hospital, London, United Kingdom
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36
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Jagadisan B, Dhawan A. Emergencies in paediatric hepatology. J Hepatol 2022; 76:1199-1214. [PMID: 34990749 DOI: 10.1016/j.jhep.2021.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022]
Abstract
The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.
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Affiliation(s)
- Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK.
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Rao A, Rule JA, Hameed B, Ganger D, Fontana RJ, Lee WM. Secular Trends in Severe Idiosyncratic Drug-Induced Liver Injury in North America: An Update From the Acute Liver Failure Study Group Registry. Am J Gastroenterol 2022; 117:617-626. [PMID: 35081550 PMCID: PMC10668505 DOI: 10.14309/ajg.0000000000001655] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced liver injury (DILI) is the second leading cause of acute liver failure (ALF) in the United States. Our study aims were to characterize secular trends in the implicated agents, clinical features, and outcomes of adults with DILI ALF over a 20-year period. METHODS Among 2,332 patients with ALF enrolled in the ALF Study Group registry, 277 (11.9%) were adjudicated as idiosyncratic DILI ALF (INR ≥ 1.5 and hepatic encephalopathy) through expert opinion. The 155 cases in era 1 (January 20, 1998-January 20, 2008) were compared with the 122 cases in era 2 (January 21, 2008-January 20, 2018). RESULTS Among 277 cases of DILI ALF, 97 different agents, alone or in combination, were implicated: antimicrobials, n = 118 (43%); herbal/dietary supplements (HDS), n = 42 (15%); central nervous system agents/illicit substances, n = 37 (13%); oncologic/biologic agents, n = 29 (10%); and other, n = 51 (18%). Significant trends over time included (i) an increase in HDS DILI ALF (9.7% vs 22%, P < 0.01) and decrease in antimicrobial-induced DILI ALF (45.8% vs. 38.5%, P = 0.03) and (ii) improved overall transplant-free survival (23.5%-38.7%, P < 0.01) while the number of patients transplanted declined (46.4% vs 33.6%, P < 0.03). DISCUSSION DILI ALF in North America is evolving, with HDS cases rising and other categories of suspect drugs declining. The reasons for a significant increase in transplant-free survival and reduced need for liver transplantation over time remain unclear but may be due to improvements in critical care, increased NAC utilization, and improved patient prognostication.
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Affiliation(s)
- Ashwin Rao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jody A. Rule
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Robert J. Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Lin S, Araujo C, Hall A, Kumar R, Phillips A, Hassan M, Engelmann C, Quaglia A, Jalan R. Presence of multilobular necrosis on liver biopsy identifies corticosteroid responsiveness in acute indeterminate hepatitis. Liver Int 2022; 42:853-863. [PMID: 34936189 DOI: 10.1111/liv.15144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/29/2021] [Accepted: 12/15/2021] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Treatment of patients with severe indeterminate hepatitis (IAH) is an unmet need. Corticosteroids are often used in the management of these patients but criteria for the selection of patients for this intervention are arbitrary. The aims of this study were to analyse the clinical and pathological features of patients with IAH to define predictors of corticosteroid responsiveness. METHODS This study included consecutive patients with acute indeterminate hepatitis admitted to a single hospital and underwent a liver biopsy. The clinical manifestation and histopathological features of steroid and non-steroid groups were compared and their relationship with corticosteroids response was evaluated. RESULTS Forty-eight patients were included, 24 (50%) recovered and the other half underwent liver transplantation or died within 3-months. Of the 48 cases, 24 received corticosteroids (initial dose of 45 ± 12 mg prednisolone). Corticosteroids were initiated 2.7 ± 3.8 days after admission. Liver biopsy was performed 2-days (median, IQR 1-3) after admission. Fifteen (62.5%) patients receiving corticosteroids survived without transplantation compared with 9 (37.5%) that did not receive steroids (P = .149). In those with multilobular necrosis, 50% reduction in the death/transplantation rate was observed after steroid treatment (P = .018). In patients without multilobular necrosis and with or without perivenulitis, corticosteroids did not impact the outcome. Response to corticosteroids was independent of the MELD score. CONCLUSIONS The presence of multilobular necrosis on liver biopsy helps identify a subgroup of IAH cases who may benefit from the administration of corticosteroids.
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Affiliation(s)
- Su Lin
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK.,Department of Hepatology, Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Catarina Araujo
- Department of Cellular Pathology, Royal Free Hospital, London, UK.,Anatomical-Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Andrew Hall
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK.,Department of Cellular Pathology, Royal Free Hospital, London, UK.,Sheila Sherlock Liver Center, Royal Free London NHS Foundation Trust, London, UK
| | - Rahul Kumar
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK.,Department of Gastroenterology and Hepatology, Duke-NUS academic Medical Centre, Changi General Hospital, Singapore, Singapore
| | - Alexandra Phillips
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
| | - Mohsin Hassan
- Department of Hepatology and Gastroenterology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK.,Department of Hepatology and Gastroenterology, Charité-Universitaetsmedizin Berlin, Berlin, Germany.,Section Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Alberto Quaglia
- Department of Cellular Pathology and UCL cancer Institute, Royal Free Hospital, London, UK
| | - Rajiv Jalan
- Liver failure Group, Institute for Liver and Digestive Health, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK.,European Foundation for the Study of Chronic Liver Failure (EFCLIF), Barcelona, Spain
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Björnsson ES, Vucic V, Stirnimann G, Robles-Díaz M. Role of Corticosteroids in Drug-Induced Liver Injury. A Systematic Review. Front Pharmacol 2022; 13:820724. [PMID: 35222034 PMCID: PMC8867035 DOI: 10.3389/fphar.2022.820724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction: Apart from cessation of the implicated agent leading to drug-induced liver injury (DILI), there is no standard therapy for DILI. Corticosteroids have been used in DILI, although their efficacy is unclear. Published data showed either beneficial effects or no improvement associated with steroid therapy. The aim of the current study was to perform a systematic review of the role of corticosteroids in the treatment of DILI. Methods: A search was performed in PubMed, searching for the terms: “corticosteroids” and “drug-induced liver injury”. Observation studies were included, but case reports excluded. Results: A total of 24 papers were retrieved. Most of these were observational studies on the effects of corticosteroids in moderate/severe DILI (n = 8), reports on the corticosteroid treatment in patients with drug-induced autoimmune hepatitis (DI-AIH) (n = 5), and effects of corticosteroids in drug-induced fulminant acute liver failure (ALF, n = 2). Furthermore, treatment of corticosteroids in patients with liver injury due to check point inhibitors (CPIs) was addressed in nine studies. In moderate/severe DILI, six out of eight studies suggested steroid treatment to be beneficial, whereas two studies showed negative results. All five observational studies on the effects of corticosteroids in DI-AIH showed good therapeutic response with rapid and long lasting effects after discontinuation of corticosteroids and without evidence of relapse. Steroid therapy was not associated with improved overall survival in patients with drug-induced fulminant ALF. CPIs-induced liver injury was found to improve spontaneously in 33–50% without corticosteroids, and the rate of patients who were treated responded to steroids in 33–100% (mean 72%). Conclusions: The majority of studies analyzing the effects of corticosteroids in moderate/severe DILI have demonstrated beneficial effects. However, this was not the case in drug-induced fulminant ALF. Patients with DI-AIH had an excellent response to corticosteroids. The majority of those with CPIs-induced liver injury responded to corticosteroids; however, patients without treatment usually recovered spontaneously. The observational design and comparison with historical controls in these studies makes it very difficult to draw conclusions on the efficacy of corticosteroids in DILI. Therefore, there is a strong need for a randomized controlled trial to properly assess the role of corticosteroids in DILI.
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Affiliation(s)
- Einar S. Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology, Landspitali University Hospital Reykjavik, Reykjavik, Iceland
- *Correspondence: Einar S. Björnsson,
| | - Vesna Vucic
- Department of Nutritional Biochemistry and Dietology, Centre of Research Excellence in Nutrition and Metabolism, National Institute for Medical Research, University of Belgrade, Belgrade, Serbia
| | - Guido Stirnimann
- Hepatology, Departement for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Mercedes Robles-Díaz
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Facultad de Medicina, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Málaga, Spain
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40
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Yang Y, Choi J, Chen Y, Invernizzi P, Yang G, Zhang W, Shao TH, Jordan F, Nemeria NS, Coppel RL, Ridgway WM, Kurth M, Ansari AA, Leung PSC, Gershwin ME. E. coli and the etiology of human PBC: Antimitochondrial antibodies and spreading determinants. Hepatology 2022; 75:266-279. [PMID: 34608663 DOI: 10.1002/hep.32172] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/31/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS The increased frequency of urinary tract infections in patients with primary biliary cholangitis (PBC) and the cross-reactivity between the lipoyl domains (LD) of human pyruvate dehydrogenase complex (hPDC-E2) and Escherichia coli PDC-E2 (ePDC-E2) have long suggested a role of E. coli in causality of PBC. This issue, however, has remained speculative. We hypothesized that by generating specific constructs of human and E. coli PDC-E2, we would be able to assess the specificity of autoantibody responses and define whether exposure to E. coli in susceptible hosts is the basis for the antimitochondrial antibody (AMA) response. APPROACH AND RESULTS Importantly, the reactivity of hPDC-E2 LD (hPDC-E2LD) affinity-purified antibodies against hPDC-E2LD could only be removed by prior absorption with hPDC-E2LD and not ePDC-E2, suggesting the presence of unique human PDC-E2 epitopes distinct from E. coli PDC-E2. To identify the autoepitope(s) present in hPDC-E2LD, a more detailed study using a variety of PDC-E2 constructs was tested, including the effect of lipoic acid (LA) on ePDC-E2 conformation and AMA recognition. Individual recombinant ePDCE2 LD domains LD1, LD2 and LD3 did not react with either AMA or antibodies to LA (anti-LA), but in contrast, anti-LA was readily reactive against purified recombinant LD1, LD2, and LD3 expressed in tandem (LP); such reactivity increased when LP was precultured with LA. Moreover, when the three LD (LD1, LD2, LD3) domains were expressed in tandem in pET28a or when LD1 was expressed in another plasmid pGEX, they were lipoylated and reactive to PBC sera. CONCLUSIONS In conclusion, our data are consistent with an exposure to E. coli that elicits specific antibody to ePDC-E2 resulting in determinant spreading and the classic autoantibody to hPDC-E2LD. We argue this is the first step to development of human PBC.
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Affiliation(s)
- Yao Yang
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA.,School of Food Science and Pharmaceutical EngineeringNanjing Normal UniversityNanjingChina
| | - Jinjung Choi
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA.,Division of RheumatologyCHA University Medical CenterBundangKorea
| | - Ying Chen
- School of Food Science and Pharmaceutical EngineeringNanjing Normal UniversityNanjingChina
| | - Pietro Invernizzi
- International Center for Digestive HealthDepartment of Medicine and SurgeryUniversity of Milan-BicoccaMilanItaly
| | - Guoxiang Yang
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
| | - Weici Zhang
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
| | - Ti-Hong Shao
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
| | - Frank Jordan
- Department of ChemistryRutgers UniversityNewarkNew JerseyUSA
| | | | - Ross L Coppel
- Department of Microbiology, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - William M Ridgway
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
| | - Mark Kurth
- Department of ChemisrtyUniversity of California DavisDavisCaliforniaUSA
| | - Aftab A Ansari
- Department of PathologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Patrick S C Leung
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical ImmunologyUniversity of California DavisDavisCaliforniaUSA
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41
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Lin T, Wang S, Munker S, Jung K, Macías-Rodríguez RU, Ruiz-Margáin A, Schierwagen R, Liu H, Shao C, Fan C, Feng R, Yuan X, Wang S, Wandrer F, Meyer C, Wimmer R, Liebe R, Kroll J, Zhang L, Schiergens T, Ten Dijke P, Teufel A, Marx A, Mertens PR, Wang H, Ebert MPA, Bantel H, N De Toni E, Trebicka J, Dooley S, Shin D, Ding H, Weng HL. Follistatin-controlled activin-HNF4α-coagulation factor axis in liver progenitor cells determines outcome of acute liver failure. Hepatology 2022; 75:322-337. [PMID: 34435364 DOI: 10.1002/hep.32119] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/01/2021] [Accepted: 08/15/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS In patients with acute liver failure (ALF) who suffer from massive hepatocyte loss, liver progenitor cells (LPCs) take over key hepatocyte functions, which ultimately determines survival. This study investigated how the expression of hepatocyte nuclear factor 4α (HNF4α), its regulators, and targets in LPCs determines clinical outcome of patients with ALF. APPROACH AND RESULTS Clinicopathological associations were scrutinized in 19 patients with ALF (9 recovered and 10 receiving liver transplantation). Regulatory mechanisms between follistatin, activin, HNF4α, and coagulation factor expression in LPC were investigated in vitro and in metronidazole-treated zebrafish. A prospective clinical study followed up 186 patients with cirrhosis for 80 months to observe the relevance of follistatin levels in prevalence and mortality of acute-on-chronic liver failure. Recovered patients with ALF robustly express HNF4α in either LPCs or remaining hepatocytes. As in hepatocytes, HNF4α controls the expression of coagulation factors by binding to their promoters in LPC. HNF4α expression in LPCs requires the forkhead box protein H1-Sma and Mad homolog 2/3/4 transcription factor complex, which is promoted by the TGF-β superfamily member activin. Activin signaling in LPCs is negatively regulated by follistatin, a hepatocyte-derived hormone controlled by insulin and glucagon. In contrast to patients requiring liver transplantation, recovered patients demonstrate a normal activin/follistatin ratio, robust abundance of the activin effectors phosphorylated Sma and Mad homolog 2 and HNF4α in LPCs, leading to significantly improved coagulation function. A follow-up study indicated that serum follistatin levels could predict the incidence and mortality of acute-on-chronic liver failure. CONCLUSIONS These results highlight a crucial role of the follistatin-controlled activin-HNF4α-coagulation axis in determining the clinical outcome of massive hepatocyte loss-induced ALF. The effects of insulin and glucagon on follistatin suggest a key role of the systemic metabolic state in ALF.
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Affiliation(s)
- Tao Lin
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Shanshan Wang
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany.,Beijing Institute of HepatologyBeijing You'an HospitalCapital Medical UniversityBeijingChina
| | - Stefan Munker
- Department of Medicine IIUniversity Hospital, Campus Großhadern, LMU MunichMunichGermany
| | - Kyounghwa Jung
- Department of Developmental BiologyMcGowan Institute for Regenerative MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Ricardo U Macías-Rodríguez
- Department of GastroenterologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico cityMexico
| | - Astrid Ruiz-Margáin
- Department of GastroenterologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico cityMexico
| | - Robert Schierwagen
- Translational Hepatology, Medical Department IFrankfurt University HospitalFrankfurtGermany
| | - Hui Liu
- Department of PathologyBeijing You'an HospitalAffiliated with Capital Medical UniversityBeijingChina
| | - Chen Shao
- Department of PathologyBeijing You'an HospitalAffiliated with Capital Medical UniversityBeijingChina
| | - Chunlei Fan
- Department of Gastroenterology and HepatologyBeijing You'an HospitalAffiliated with Capital Medical UniversityBeijingChina
| | - Rilu Feng
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Xiaodong Yuan
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Sai Wang
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Franziska Wandrer
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Christoph Meyer
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Ralf Wimmer
- Department of Medicine IIUniversity Hospital, Campus Großhadern, LMU MunichMunichGermany
| | - Roman Liebe
- Clinic of Gastroenterology, Hepatology and Infectious DiseasesHeinrich Heine UniversityDüsseldorfGermany.,Department of Medicine IISaarland University Medical CenterSaarland UniversityHomburgGermany
| | - Jens Kroll
- Vascular Biology and Tumor AngiogenesisEuropean Center for AngioscienceMedical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Long Zhang
- Life Sciences Institute and Innovation Center for Cell Signaling NetworkHangzhouChina
| | - Tobias Schiergens
- Department of General, Visceral, Transplantation, Vascular and Thoracic SurgeryUniversity HospitalLMU MunichMunichGermany
| | - Peter Ten Dijke
- Oncode Institute and Department of Cell and Chemical BiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Andreas Teufel
- Division of Hepatology, Division of Clinical Bioinformatics, Department of Medicine II, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany.,Clinical Cooperation Unit Healthy MetabolismCenter for Preventive Medicine and Digital Health Baden-WürttembergMedical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Alexander Marx
- Institute of PathologyUniversity Medical Center MannheimHeidelberg UniversityMannheimGermany
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetes and EndocrinologyOtto-von-Guericke-UniversityMagdeburgGermany
| | - Hua Wang
- Department of Oncologythe First Affiliated Hospital of Anhui Medical UniversityHefeiChina.,Inflammation and Immune Mediated Disease Laboratory of Anhui ProvinceHefeiChina
| | - Matthias P A Ebert
- Mannheim Institute for Innate ImmunoscienceMannheimGermany.,Clinical Cooperation Unit Healthy MetabolismCenter of Preventive Medicine and Digital HealthMedical Faculty MannheimHeidelberg UniversityMannheimGermany.,Department of Medicine II, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Heike Bantel
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Enrico N De Toni
- Department of Medicine IIUniversity Hospital, Campus Großhadern, LMU MunichMunichGermany
| | - Jonel Trebicka
- Translational Hepatology, Medical Department IFrankfurt University HospitalFrankfurtGermany.,European Foundation for Study of Chronic Liver FailureBarcelonaSpain
| | - Steven Dooley
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
| | - Donghun Shin
- Department of Developmental BiologyMcGowan Institute for Regenerative MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Huiguo Ding
- Department of Gastroenterology and HepatologyBeijing You'an HospitalAffiliated with Capital Medical UniversityBeijingChina
| | - Hong-Lei Weng
- Department of Medicine II, Section Molecular Hepatology, University Medical Center Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
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42
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Miño Bernal JF, López Morales E, Sandino NJ, Molano Franco D. Cirrosis hepática o falla hepática crónica agudizada: definición y clasificación. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La cirrosis se considera el estadio crónico e irreversible de la lesión hepática. Su etiología es diversa y abarca causas como las infecciones víricas, tóxicos como el alcohol, medicamentos, patologías autoinmunes y otras. La descompensación de la cirrosis hepática es consecuencia de cambios fisiopatológicos que se dan con el tiempo como ascitis, peritonitis bacteriana espontánea, hemorragia del tubo digestivo, síndrome hepatorrenal, encefalopatía hepática o hipertensión portopulmonar, mientras que la falla hepática crónica agudizada debe considerarse como una entidad que debe diferenciarse de la anterior, ya que es una falla multiorgánica de curso rápido, por lo regular en pacientes hospitalizados en unidad de cuidado intensivo, a menudo secundaria a desencadenantes como estados de choque. El clínico debe identificarlas para su abordaje y evaluación. El método actual adecuado para estadificar esta entidad es el puntaje CLIFF SOFA, que evalúa la mortalidad a 28 y 90 días, permitiendo intervenciones adecuadas en cada caso.
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43
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Zhou YJ, Gu HY, Tang QQ, Li F, Zhu J, Ai T, Zhu K, Xu BY, Wang Q, Huang AL, Chen J, Zhang ZZ. Case report: A case of severe acute hepatitis of unknown origin. Front Pediatr 2022; 10:975628. [PMID: 36275068 PMCID: PMC9579323 DOI: 10.3389/fped.2022.975628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
According to analyses of etiology, clinical features, diagnostic methods, and treatment strategies by summarizing a case of unexplained acute hepatitis recently experienced, we are aiming to provide some information to enrich the clinical experience in diagnosis and treatment of severe acute hepatitis of unknown etiology in young children. A boy, aged 10 years and 6 months old, was admitted to the hospital due to acute abdominal pain, jaundice, and exceptionally high levels of ALT and AST. A range of measures, including patient history, physical examination, and routine laboratory testing, were performed. Furthermore, strategies such as trio-based next-generation sequencing (Trio-NGS) and liver biopsy, as well as metagenomic NGS (mNGS) of blood and liver samples were also performed. In summary, this case was an acute severe non-A-E hepatitis that is a probable case with hepatitis of unknown origin. Immunohistochemical analysis showed an immune injury in liver tissues. Torque teno virus (TTV) sequences were detected by mNGS assay. As for treatment strategies, in addition to general treatment, this patient also underwent plasmapheresis and methylprednisolone treatment due to disease deterioration. The patient's liver function was improved afterward and discharged after one month of treatment. Taken together, this work reported the clinical feature and treatment of severe acute hepatitis with non-A-E hepatitis in detail. The potential mechanism of liver damage might be due to an immune attack in which TTV might play a role as a co-factor.
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Affiliation(s)
- Yu-Jiao Zhou
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Hui-Ying Gu
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Qi-Qin Tang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Li
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Zhu
- Department of Pathology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ting Ai
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Zhu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Bin-Yue Xu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Qing Wang
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Ai-Long Huang
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Juan Chen
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China.,Key Laboratory of Laboratory Medical Diagnostics, Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Zhen-Zhen Zhang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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44
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Khedr MA, Adawy NM, Salim TA, Salem ME, Ghazy RM, Elharoun AS, Sultan MM, Ehsan NA. Kupffer Cell Hyaline Globules in Children With Autoimmune Hepatitis. J Clin Exp Hepatol 2022; 12:20-28. [PMID: 35068781 PMCID: PMC8766698 DOI: 10.1016/j.jceh.2021.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/26/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hyaline globules (HGs) in the cytoplasm of Kupffer cells (KCs) have been appraised for being a typical feature of autoimmune hepatitis (AIH). This study aimed to determine how useful Kupffer cell hyaline globules (KCHGs) are in diagnosing AIH vs. other causes of pediatric chronic liver diseases (PCLDs). MATERIALS AND METHODS This retrospective study recruited 124 children; 58 with AIH, 50 with chronic hepatitis C virus (HCV) infection, and 16 with Wilson's disease (WD). Two pathologists retrieved paraffin blocks of liver biopsies and prepared new cut sections for Periodic acid-Schiff-Diastase (PAS-D) stain. They independently examined liver biopsies before starting treatment. Two pediatricians reviewed medical records for demographic, clinical, laboratory, and serological findings. RESULTS Females represented 48.6% of the studied children with a median age of 5.8 (4.9) years. Pathologists identified KCHGs in 67.24%, 12.5%, and 6.0% of AIH, WD, and HCV affected children respectively, P < 0.001. A significantly higher proportion of seropositive than seronegative AIH patients had KCHGs (77.5% vs. 50.0%), (P < 0.05). In multivariate analysis, KCHGs and prolonged prothrombin time were the only significant predictors that differentiate between AIH and the other studied PCLDs. The odds ratio of having AIH increased 68 times if KCHGs were seen. Among children with AIH, the presence of KCHGs was associated with higher median levels of direct bilirubin 2.2 (1.3) vs. 1.2 (2.2), and immunoglobulin G 3.2 (1.9) vs. 2.0 (1.7), (P < 0.05), but not to histopathological findings or hepatic fibrosis and activity. CONCLUSIONS KCHGs are key indicators that can differentiate between AIH and other PCLDs, and between seropositive and seronegative AIH.
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Key Words
- AIH, Autoimmune hepatitis
- ALP, Alkaline phosphatase
- ALT, Alanine aminotransferase
- AMA, Antimitochondrial antibody
- ANA, Antinuclear antibody
- AST, Aspartate aminotransferase
- GGT, Gamma-glutamyl transpeptidase
- H&E, Hematoxylin and eosin
- HCV, Hepatitis C virus
- IAIHG, International Autoimmune Hepatitis Group
- KCHGs, Kupffer cell hyaline globules
- KCs, Kupffer cells
- Kupffer cells
- LKMA, Liver-kidney microsome 1 antibody
- PAS, Periodic Acid Schiff
- PAS-D, Periodic acid–Schiff–Diastase
- PCLD, Pediatric chronic liver disease
- SMA, Smooth muscle antibody
- WBCs, White blood cell count
- WD, Wilson’s disease
- Wilson’s disease
- antiLC1, Antiliver cytosol type 1 antibody
- autoimmune hepatitis
- hepatitis C virus infection
- hyaline globules
- liver histopathology
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Affiliation(s)
- Mohammed A. Khedr
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, Egypt
| | - Nermin M. Adawy
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, Egypt
| | - Tahany A. Salim
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, Egypt
| | - Menan E. Salem
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, Egypt
| | - Ramy M. Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Egypt
| | - Ahmed S. Elharoun
- Microbiology and Immunology Department, Faculty of Medicine, Menoufia University, Egypt
| | - Mervat M. Sultan
- Department of Pathology, National Liver Institute, Menoufia University, Egypt
| | - Nermine A. Ehsan
- Department of Pathology, National Liver Institute, Menoufia University, Egypt
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45
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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46
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Lal BB, Sood V, Rastogi A, Mukund A, Khanna R, Sharma MK, Alam S. Safety, Feasibility, Yield, Diagnostic and Prognostic Implications of Transjugular Liver Biopsy in Children and Adolescents. J Pediatr Gastroenterol Nutr 2021; 73:e109-e114. [PMID: 34310440 DOI: 10.1097/mpg.0000000000003249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objectives of the study were to evaluate the indications, feasibility, complications and clinical implications of transjugular liver biopsy (TJLB) in children. METHODS Data of all TJLB performed in children <18 years old was retrieved from the computerized hospital information system. TJLB was done using a 19 G quick-core needle biopsy system with 20 mm throw length. Hepatic venous pressure gradient was additionally measured in children with portal hypertension. A single pathologist reviewed all the biopsies again and provided structured information. RESULTS A total of 102 children, including 5 with acute liver failure underwent TJLB with technical success in 101 (99%). A mean of 2.3 ± 0.9 passes (range: 1-5) was taken for the biopsy. The most common indications for TJLB in our cohort were elevated international normalized ratio >1.5 (66, 64.7%), ascites (46, 45.1%) and thrombocytopenia (platelet count < 60,000/mm3) (42, 41.2%). Mean size of the tissue received was 14.5 ± 5.6 mm with an average of 10.2 ± 4.7 portal tracts. Only one child developed major (category D) complication (hemobilia) and 12 (11.8%) developed minor complications post-procedure. Etiological diagnosis could be made in a total of 64 (63.9%) children undergoing TJLB, the most common diagnosis being autoimmune hepatitis (n = 31), non-cirrhotic portal fibrosis (n = 16) and drug-induced liver injury (n = 4). CONCLUSION TJLB is well tolerated, feasible and helps make a diagnosis in close to 64% children allowing timely medical and/or surgical intervention. It is especially useful for diagnosis of autoimmune liver diseases, drug-induced liver injury and non-cirrhotic portal fibrosis.
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Affiliation(s)
| | | | | | | | | | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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47
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Yamaguchi A, Teratani T, Chu PS, Suzuki T, Taniki N, Mikami Y, Shiba S, Morikawa R, Amiya T, Aoki R, Kanai T, Nakamoto N. Hepatic Adenosine Triphosphate Reduction Through the Short-Chain Fatty Acids-Peroxisome Proliferator-Activated Receptor γ-Uncoupling Protein 2 Axis Alleviates Immune-Mediated Acute Hepatitis in Inulin-Supplemented Mice. Hepatol Commun 2021; 5:1555-1570. [PMID: 34510840 PMCID: PMC8435281 DOI: 10.1002/hep4.1742] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/08/2021] [Accepted: 04/24/2021] [Indexed: 02/04/2023] Open
Abstract
How liver tolerance is disrupted in immune-mediated liver injury is currently unclear. There is also insufficient information available regarding susceptibility, precipitation, escalation, and perpetuation of autoimmune hepatitis. To explore how dietary fiber influences hepatic damage, we applied the concanavalin A (ConA)-induced acute immune-mediated liver injury model in mice fed a diet supplemented with 6.8% inulin, a water-soluble fermentable fiber. Twelve hours after ConA administration, inulin-supplemented diet-fed mice demonstrated significantly alleviated hepatic damage histologically and serologically, with down-regulation of hepatic interferon-γ and tumor necrosis factor and reduced myeloperoxidase (MPO)-producing neutrophil infiltration. Preconditioning with an inulin-supplemented diet for 2 weeks significantly reduced hepatic adenosine triphosphate (ATP) content; suramin, a purinergic P2 receptor antagonist, abolished the protective effect. Of note, the portal plasma derived from mice fed the inulin-supplemented diet significantly alleviated ConA-induced immune-mediated liver injury. Mechanistically, increased portal short-chain fatty acid (SCFA) levels, such as those of acetate and butyrate, by inulin supplementation leads to up-regulation of hepatic γ-type peroxisome proliferator-activated receptor (Pparg) and uncoupling protein 2 (Ucp2), which uncouples mitochondrial ATP synthesis downstream of PPARγ. Pparg down-regulating small interfering RNA cancelled the protective effect of inulin supplementation against MPO-producing neutrophil infiltration and the subsequent immune-mediated liver injury, suggesting that the SCFA-PPARγ-UCP2 axis plays a key role in the protective effect by inulin supplementation. Moreover, significant changes in the gut microbiota, including increased operational taxonomic units in genera Akkermansia and Allobaculum, also characterized the protective effect of the inulin-supplemented diet. Conclusion: There is a possible unraveled etiopathophysiological link between the maintenance of liver tolerance and dietary fiber. The SCFA-PPARγ-UCP2 axis may provide therapeutic targets for immune-mediated liver injury in the future.
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Affiliation(s)
- Akihiro Yamaguchi
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan.,Department of Gastroenterology and HepatologyNational Hospital Organization Saitama HospitalSaitamaJapan
| | - Toshiaki Teratani
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Po-Sung Chu
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Takahiro Suzuki
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan.,Miyarisan Pharmaceutical Co., Ltd.TokyoJapan
| | - Nobuhito Taniki
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Yohei Mikami
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Shunsuke Shiba
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Rei Morikawa
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Takeru Amiya
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan.,Research Unit/Immunology and InflammationSohyaku Innovative Research DivisionMitsubishi Tanabe Pharma CoKanagawaJapan
| | - Ryo Aoki
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan.,Institute of Health ScienceEzaki Glico Co., Ltd.OsakaJapan
| | - Takanori Kanai
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Nobuhiro Nakamoto
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
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48
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De Martin E, Duclos-Vallée JC. Reply to: "Acute severe autoimmune hepatitis - timing for steroids and role of other immunosuppressive agents". J Hepatol 2021; 75:495-496. [PMID: 34051331 DOI: 10.1016/j.jhep.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Eleonora De Martin
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, France.
| | - Jean-Charles Duclos-Vallée
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, France
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49
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Rodgers SK, Horrow MM. Acute (fulminant) liver failure: a clinical and imaging review. Abdom Radiol (NY) 2021; 46:3117-3127. [PMID: 33635361 DOI: 10.1007/s00261-021-02973-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/22/2021] [Accepted: 02/09/2021] [Indexed: 12/13/2022]
Abstract
Acute liver failure (ALF) is a rare clinical entity with high morbidity and mortality frequently requiring liver transplantation for survival. Imaging, particularly with ultrasound, plays an important role, especially to distinguish patients with underlying chronic liver disease who have lower transplant priority. We discuss the clinical and imaging findings in the three subtypes of ALF using a multi-modality approach with an emphasis on ultrasound.
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50
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De Martin E, Coilly A, Chazouillères O, Roux O, Peron JM, Houssel-Debry P, Artru F, Silvain C, Ollivier-Hourmand I, Duvoux C, Heurgue A, Barge S, Ganne-Carrié N, Pageaux GP, Besch C, Bourlière M, Fontaine H, de Ledinghen V, Dumortier J, Conti F, Radenne S, Debette-Gratien M, Goria O, Durand F, Potier P, Di Martino V, Reboux N, Ichai P, Sebagh M, Mathurin P, Agostini H, Samuel D, Duclos-Vallée JC. Early liver transplantation for corticosteroid non-responders with acute severe autoimmune hepatitis: The SURFASA score. J Hepatol 2021; 74:1325-1334. [PMID: 33503489 DOI: 10.1016/j.jhep.2020.12.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/08/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS In acute severe autoimmune hepatitis (AS-AIH), the optimal timing for liver transplantation (LT) remains controversial. The objectives of this study were to determine early predictive factors for a non-response to corticosteroids and to propose a score to identify patients in whom LT is urgently indicated. METHODS This was a retrospective, multicenter study (2009-2016). A diagnosis of AS-AIH was based on: i) Definite or probable AIH based on the simplified IAIHG score; ii) international normalized ratio (INR) ≥1.5 and/or bilirubin >200 μmol/L; iii) No previous history of AIH; iv) Histologically proven AIH. A treatment response was defined as LT-free survival at 90 days. The evolution of variables from corticosteroid initiation (day-D0) to D3 was estimated from: Δ%3 = (D3-D0)/D0. RESULTS A total of 128 patients were included, with a median age of 52 (39-62) years; 72% were female. Overall survival reached 88%. One hundred and fifteen (90%) patients received corticosteroids, with a LT-free survival rate of 66% at 90 days. Under multivariate analysis, D0-INR (odds ratio [OR] 6.85; 95% CI 2.23-21.06; p <0.001), Δ%3-INR ≥0.1% (OR 6.97; 95% CI 1.59-30.46; p <0.01) and Δ%3-bilirubin ≥-8% (OR 5.14; 95% CI 1.09-24.28; p <0.04) were predictive of a non-response. The SURFASA score: -6.80+1.92∗(D0-INR)+1.94∗(Δ%3-INR)+1.64∗(Δ%3-bilirubin), created by combining these variables, was highly predictive of LT or death (AUC = 0.93) (88% specificity; 84% sensitivity) with a cut-off point of <-0.9. Below this cut-off, the chance of responding was 75%. With a score higher than 1.75, the risk of dying or being transplanted was between 85% and 100%. CONCLUSION In patients with AS-AIH, INR at the introduction of corticosteroids and the evolution of INR and bilirubin are predictive of LT or death. Within 3 days of initiating corticosteroids, the SURFASA score can identify non-responders who require a referral for LT. This score needs to be validated in a prospective cohort. LAY SUMMARY The management of patients with acute severe autoimmune hepatitis is highly challenging, particularly regarding their early referral for liver transplantation. We found that international normalized ratio at the initiation of corticosteroid therapy and the evolution of international normalized ratio and bilirubin values after 3 days of therapy were highly predictive of liver transplantation or death. We are thus proposing a score that combines these variables and identifies patients in whom liver transplantation is urgently required.
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Affiliation(s)
- Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Inserm Unité 1193, Université Paris-Saclay, FHU Hépatinov, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Villejuif, France.
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Inserm Unité 1193, Université Paris-Saclay, FHU Hépatinov, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Villejuif, France
| | - Olivier Chazouillères
- AP-HP Hôpital St Antoine, Université Pierre et Marie Curie Paris 6, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Service d'Hépato-Gastroentérologie, Paris, France
| | - Olivier Roux
- AP-HP Hôpital Beaujon, Centre de Références des Maladies Vasculaires du Foie, Service d'Hépatologie, Clichy, France
| | - Jean-Marie Peron
- Service d'Hépatologie, Hôpital Rangueil CHU Toulouse, Université Paul Sabatier III, Toulouse, France
| | - Pauline Houssel-Debry
- CHU de Rennes, Hôpital Pontchaillou, Service d'Hépatologie et Transplantation Hépatique, Rennes, France
| | - Florent Artru
- CHRU Lille, Hôpital Claude Huriez, Service des Maladies de l'Appareil Digestif, Lille, France
| | | | | | - Christophe Duvoux
- AP-HP Hôpital Henri-Mondor, Service d'Hépato-Gastroentérologie, Créteil, France
| | - Alexandra Heurgue
- CHU Reims Service Hépato-Gastro-Entérologie et Cancérologie Digestive, Reims, France
| | - Sandrine Barge
- Hôpital Saint Camille, Service Hépato-Gastro-entérologie, Bry-sur-Marne, France
| | | | - Georges-Philippe Pageaux
- CHU Saint-Eloi, Département d'Hépato-Gastroentérologie et de Transplantation Hépatique, Montpellier, France
| | - Camille Besch
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service de Chirurgie Générale, Hépatique, Endocrinienne et Transplantation, Strasbourg, France
| | - Marc Bourlière
- Hôpital St Joseph, Service d'Hépato-Gastroentérologie, Marseille, France
| | - Hélène Fontaine
- AP-HP CHU Cochin, Service d'Hépatologie, Université Paris Descartes, INSERM U-818 et USM20, Institut Pasteur, Paris, France
| | | | - Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital édouard Herriot, Fédération des Spécialités Digestives, et Université de Lyon, Lyon, France
| | - Filomena Conti
- AP-HP Hôpital de la Pitié Salpêtrière, Service de Transplantation Hépatique, Paris, France
| | - Sylvie Radenne
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | | | - Odile Goria
- CHU Rouen, Service d'Hépato-gastroentérologie, Rouen, France
| | - François Durand
- AP-HP Hôpital Beaujon, Centre de Références des Maladies Vasculaires du Foie, Service d'Hépatologie, Clichy, France
| | - Pascal Potier
- CHR d'Orléans, Service d'Hépato-Gastro-entérologie et Oncologie Digestive, Orléans, France
| | | | - Noemi Reboux
- Hôpital La Cavale Blanche, Service d'Hépato-Gastroentérologie, Brest, France
| | - Philippe Ichai
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Inserm Unité 1193, Université Paris-Saclay, FHU Hépatinov, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Villejuif, France
| | - Mylène Sebagh
- AP-HP Hôpital du Kremlin-Bicêtre, Service Anatomie et Cytologie Pathologiques, Le Kremlin-Bicêtre, France
| | - Philippe Mathurin
- CHRU Lille, Hôpital Claude Huriez, Service des Maladies de l'Appareil Digestif, Lille, France
| | - Hélène Agostini
- AP-HP Paris Saclay, Unité de Recherche Clinique des Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Inserm Unité 1193, Université Paris-Saclay, FHU Hépatinov, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Villejuif, France
| | - Jean-Charles Duclos-Vallée
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Inserm Unité 1193, Université Paris-Saclay, FHU Hépatinov, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Villejuif, France.
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