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Dalekos G, Gatselis N, Drenth JP, Heneghan M, Jørgensen M, Lohse AW, Londoño M, Muratori L, Papp M, Samyn M, Tiniakos D, Lleo A. EASL Clinical Practice Guidelines on the management of autoimmune hepatitis. J Hepatol 2025:S0168-8278(25)00173-4. [PMID: 40348684 DOI: 10.1016/j.jhep.2025.03.017] [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: 03/20/2025] [Accepted: 03/20/2025] [Indexed: 05/14/2025]
Abstract
Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology which may affect any patient irrespective of age, sex, and ethnicity. At baseline, the clinical spectrum of the disease varies largely from asymptomatic cases to acute liver failure with massive hepatocyte necrosis. The aim of these EASL guidelines is to provide updated guidance on the diagnosis and management of AIH both in adults and children. Updated guidance on the management of patients with variants and specific forms of AIH is also provided, as is detailed guidance on the management of AIH-associated cirrhosis, including surveillance for portal hypertension and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis.
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Warner S, Rajanayagam J, Russell E, Lloyd C, Ferguson J, Kelly DA, Hirschfield GM. Biliary disease progression in childhood onset autoimmune liver disease: A 30-year follow-up into adulthood. JHEP Rep 2024; 6:100901. [PMID: 38235169 PMCID: PMC10790098 DOI: 10.1016/j.jhepr.2023.100901] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/03/2023] [Accepted: 08/24/2023] [Indexed: 01/19/2024] Open
Abstract
Background & Aims Long-term follow-up studies of paediatric onset autoimmune liver disease (AILD) are invaluable in helping better understand the clinical course of disease. In day-to-day practice clinicians struggle with disease definitions whilst patients and parents lack clear prognostic information. Methods The clinical progression of 159 patients with childhood onset AILD between June 1990 and December 2013 was reviewed, capturing data up to adulthood (ending May 2021). Results Presentation with autoimmune hepatitis (AIH) was dominant (n = 119); biliary presentations accounted for 25%. During follow up, biliary disease progression confirmed by cholangiography and/or liver histology was observed frequently: 19.8% (20/101) patients with childhood onset AIH type 1 (AIH-1) developed biliary features by adulthood and of these 50% phenotypically transitioned to primary sclerosing cholangitis (PSC); the remaining transitioned to an overlap disease phenotype. No patients with AIH type 2 developed biliary progression. Two-thirds of patients with overlap features (14/21) in childhood had phenotypically progressed to PSC by adulthood. Approximately 43% (6/14) of AIH-1 patients requiring a liver transplant in adulthood had explant evidence of biliary disease compared with 11% (1/9) in childhood, whereas 35.7% (5/14) of patients had histology diagnostic of PSC in their explant liver and 7.1% (1/14) had overlap features. All patients with biliary phenotypes (PSC, autoimmune sclerosing cholangitis, overlap) who required a transplant (n = 18) were found to have explant histology consistent with PSC. Twelve of 14 patients with biliary progression developed ulcerative colitis during follow-up with 92% progressing to PSC. Conclusions Three decades of follow-up demonstrated how children presenting with AILD had a significant risk of clinical transformation to PSC. Biliary progression was significantly associated with the development of inflammatory bowel disease. Impact and implications Childhood onset autoimmune liver disease remains very impactful for patients and families. Disease nomenclature can however be confusing. Long-term follow up studies as children become adults is important to help understand how and why disease behaves over time. Understanding more about the long-term course of childhood autoimmune liver disease will help patients, families and doctors striving to improve care and reduce poor clinical outcomes. We followed over 150 patients with childhood onset autoimmune liver diseases into adulthood. We found that amongst patients with classical autoimmune hepatitis, 1 in 5 developed biliary disease over time, mostly consisting of primary sclerosing cholangitis. This was associated with developing inflammatory bowel disease. Our study design was retrospective and has relevant limitations. Defining phenotypes of autoimmune liver diseases is difficult and there is insufficient consensus, especially between adult and childhood physicians. Our data confirms the critical importance of careful long-term follow-up of patients, including safe transition to adult care, as well as robustly demonstrates, using real-world data, how disease nature can change over time. Our study affirms the need for investment in prospective cohort studies.
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Affiliation(s)
- Suz Warner
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Jeremy Rajanayagam
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Emily Russell
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Carla Lloyd
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - James Ferguson
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Deirdre A. Kelly
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - Gideon M. Hirschfield
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
- Toronto Centre for Liver Disease, Department of Medicine, University of Toronto, Toronto, Canada
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Vasant R, Haigh A, O Hooley D. COVID-19 self-isolation patterns in UK dental care professionals from February to April 2020. Br Dent J 2023; 234:519-525. [PMID: 37059782 PMCID: PMC10103668 DOI: 10.1038/s41415-023-5694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 04/16/2023]
Abstract
Aim Dentistry is routinely associated with aerosol generating procedures. It has been suggested that aerosol generating procedures may place the dental professionals at increased risk of infection from respiratory pathogens. In the absence of widespread testing of the dental workforce to ascertain the incidence of COVID-19, a web-based self-reporting survey captured self-isolation patterns in dental professionals.Method A web-based closed questionnaire via the Survey Monkey platform captured reported COVID-19 self-isolation patterns in the dental team.Results A total of 3,309 responses were collected: 2,888 (87.3%) responses contained valid data and 26.8% of respondents reported self-isolating. Of these, 31.2% did so because they were suffering from COVID-like symptoms, 21.3% did so in order to protect a vulnerable member of their household, 25.7% did because a member of their household was suffering from COVID-like symptoms, and 21.8% self-isolated to protect themselves.Conclusion Despite the inherent limitations of self-reporting surveys, a web-based self-reporting questionnaire rapidly captured self-isolating patterns in DCPs. The initial findings from this survey would suggest that between February and April 2020, dental professionals did not experience disproportionately higher levels of COVID-like symptoms than the general population.
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Affiliation(s)
- Ronuk Vasant
- Specialist in Prosthodontics, MK Vasant and Associates, London, UK.
| | - Andre Haigh
- General Dental Practitioner, The Clearly Different Dental Practice, Derby, UK
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Wunsch E, Krause L, Gevers TJG, Schramm C, Janik MK, Krawczyk M, Willemse J, Uhlenbusch N, Löwe B, Lohse AW, Milkiewicz P. Confidence in treatment is contributing to quality of life in autoimmune liver diseases. The results of ERN RARE-LIVER online survey. Liver Int 2023; 43:381-392. [PMID: 36177700 PMCID: PMC10091761 DOI: 10.1111/liv.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Autoimmune liver diseases (AILDs) are associated with impaired health-related quality of life (HrQoL). The aim of this project was to identify potentially modifiable factors related to HrQoL in a large transnational cohort of patients with AILDs. METHODS A cross-sectional online survey was conducted on patients with autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) or primary sclerosing cholangitis from 15 European countries. HrQoL was measured with EQ-5D-5L and EQ visual analogue scale (EQ-VAS) and analysed in relation to demographic, psychosocial, disease- and treatment-related factors. A Patient Health Questionnaire-2 score >3 indicated relevant depression. Multivariable linear regression analyses were used to identify potentially modifiable factors associated with HrQoL and confidence in treatment whilst adjusting for known confounders. RESULTS A group of 1178 European patients (79% female, mean age 48 ± 14 years) participated in the study. HrQoL was impaired in all three diseases (mean EQ-5D-5L = 0.75, mean EQ VAS = 68.9), most markedly in PBC (mean EQ-5D-5L = 0.73, mean EQ-VAS = 66.2). Relevant depression, which was detected in 17% of patients, was prominently associated with impaired HrQoL. In the regression analysis, treatment confidence was identified as an important modifiable factor positively contributing to HrQoL. This influence was observable even after adjusting for other covariates including depression. Management in a transplant centre, treatment with azathioprine in AIH, and with ursodeoxycholic acid in PBC, was associated with increased treatment confidence. Finally, improved patient-physician relationships contributed to treatment confidence. CONCLUSION Treatment confidence is a relevant modifiable determinant of HrQoL and should be further investigated to improve the standards of care for patients with AILDs.
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Affiliation(s)
- Ewa Wunsch
- Translational Medicine GroupPomeranian Medical University in SzczecinSzczecinPoland
- RARE‐LIVER European Reference Network
| | - Linda Krause
- Institute of Medical Biometry and EpidemiologyUniversity Medical Centre Hamburg‐EppendorfHamburgGermany
| | - Tom JG Gevers
- RARE‐LIVER European Reference Network
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Christoph Schramm
- RARE‐LIVER European Reference Network
- Department of Medicine and Martin Zeitz Centre for Rare DiseasesUniversity Medical Centre Hamburg‐EppendorfHamburgGermany
- Hamburg Center for Translational Immunology (HCTI)HamburgGermany
| | - Maciej K. Janik
- RARE‐LIVER European Reference Network
- Liver and Internal Medicine UnitMedical University of WarsawWarsawPoland
| | - Marcin Krawczyk
- RARE‐LIVER European Reference Network
- Department of Medicine IISaarland University Medical CenterHomburgGermany
- Laboratory of Metabolic Liver Diseases, Department of General, Transplant and Liver SurgeryMedical University of WarsawWarsawPoland
| | - José Willemse
- RARE‐LIVER European Reference Network
- Dutch Liver Patients AssociationHooglandThe Netherlands
| | - Natalie Uhlenbusch
- RARE‐LIVER European Reference Network
- Department of Psychosomatic Medicine and PsychotherapyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Bernd Löwe
- RARE‐LIVER European Reference Network
- Department of Psychosomatic Medicine and PsychotherapyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Ansgar Wilhelm Lohse
- RARE‐LIVER European Reference Network
- Department of MedicineUniversity Medical Centre Hamburg‐EppendorfHamburgGermany
| | - Piotr Milkiewicz
- Translational Medicine GroupPomeranian Medical University in SzczecinSzczecinPoland
- RARE‐LIVER European Reference Network
- Liver and Internal Medicine UnitMedical University of WarsawWarsawPoland
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Chazouilleres O, Beuers U, Bergquist A, Karlsen TH, Levy C, Samyn M, Schramm C, Trauner M. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761-806. [PMID: 35738507 DOI: 10.1016/j.jhep.2022.05.011] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023]
Abstract
Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.
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McCrary J, Trout AT, Mahalingam N, Singh R, Rojas CC, Miethke AG, Dillman JR. Associations Between Quantitative MRI Metrics and Clinical Risk Scores in Children and Young Adults With Autoimmune Liver Disease. AJR Am J Roentgenol 2022; 219:142-150. [PMID: 35080454 DOI: 10.2214/ajr.21.27204] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. The Mayo risk score and SCOPE (Sclerosing Cholangitis Outcomes in Pediatrics) index are clinical risk scores for monitoring the progression of primary sclerosing cholangitis (PSC) and predicting clinically important endpoints. OBJECTIVE. The purpose of this study was to evaluate relationships between quantitative MRI measures of liver disease and clinical risk scores in children and young adults with autoimmune liver disease (AILD). METHODS. This prospective study included 58 patients (35 male and 23 female patients; mean age, 15.1 ± 1.1 [SD] years [range, 6-24 years]) with AILD (16 with PSC, 30 with autoimmune hepatitis, and 12 with autoimmune sclerosing cholangitis) who underwent research liver MRI examinations including MR elastography, T2*-corrected T1 (cT1), and quantitative MRCP measurements. Associations between quantitative MRI metrics and clinical risk scores were evaluated using Spearman rank-order correlation coefficients and multivariable regression analyses. RESULTS. The mean Mayo risk score was -1.1 ± 0.9 (SD) (range, -2.9 to 1.1); the mean SCOPE index was 2.7 ± 2.2 (range, 0-9). Mean liver stiffness was 2.8 ± 1.1 kPa, whole-liver mean cT1 was 874.7 ± 77.7 ms, and whole-liver cT1 interquartile range (IQR) was 150.8 ± 55.6 ms. The Mayo risk score was significantly correlated with liver stiffness (ρ = 0.56; p < .001), whole-liver mean cT1 (ρ = 0.31; p = .02), whole-liver cT1 IQR (ρ = 0.58; p < .001), and multiple quantitative MRCP measures (ρ = 0.36-0.45, p < .001). SCOPE index was significantly correlated with liver stiffness (ρ = 0.68; p < .001), whole-liver cT1 IQR (ρ = 0.51; p < .001), and multiple quantitative MRCP measures (ρ = 0.47-0.49; p < .001). Multivariable linear regression analyses identified liver stiffness, whole-liver cT1 IQR, and left hepatic duct maximum diameter as significant independent predictors of the Mayo risk score (adjusted R2 = 0.45), and liver stiffness, whole-liver cT1 IQR, maximum common bile duct (CBD) diameter, and median CBD diameter as significant independent predictors of the SCOPE index (adjusted R2 = 0.69). On logistic regression analysis, greater than low risk by SCOPE index was best predicted by liver stiffness [odds ratio [OR] = 49.6; 95% CI, 3.1-793.6) and maximum CBD diameter (OR = 2.5; 95% CI, 1.3-4.7). CONCLUSION. Increased liver stiffness, increased cT1 IQR, and larger bile duct diameters are independently associated with higher (worse) Mayo risk score and SCOPE index among children and young adults with AILD and may be surrogate markers of clinically meaningful endpoints. CLINICAL IMPACT. Multiparametric MRI of the liver incorporating quantitative metrics may serve as a noninvasive diagnostic and prognostic tool in pediatric AILD. TRIAL REGISTRATION. ClinicalTrials.gov: NCT03175471.
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Affiliation(s)
- Joseph McCrary
- Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Neeraja Mahalingam
- Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Ave, Cincinnati, OH 45229
| | - Ruchi Singh
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Cyd Castro Rojas
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Alexander G Miethke
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
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Janik MK, Smyk W, Kruk B, Szczepankiewicz B, Górnicka B, Lebiedzińska-Arciszewska M, Potes Y, Simões ICM, Weber SN, Lammert F, Więckowski MR, Milkiewicz P, Krawczyk M. MARC1 p.A165T variant is associated with decreased markers of liver injury and enhanced antioxidant capacity in autoimmune hepatitis. Sci Rep 2021; 11:24407. [PMID: 34949757 PMCID: PMC8702547 DOI: 10.1038/s41598-021-03521-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022] Open
Abstract
The clinical picture of autoimmune hepatitis (AIH) varies markedly between patients, potentially due to genetic modifiers. The aim of this study was to evaluate genetic variants previously associated with fatty liver as potential modulators of the AIH phenotype. The study cohort comprised 313 non-transplanted adults with AIH. In all patients, the MARC1 (rs2642438), HSD17B13 (rs72613567), PNPLA3 (rs738409), TM6SF2 (rs58542926), and MBOAT7 (rs641738) variants were genotyped using TaqMan assays. Mitochondrial damage markers in serum were analyzed in relation to the MARC1 variant. Carriers of the protective MARC1 allele had lower ALT and AST (both P < 0.05). In patients treated for AIH for ≥ 6 months, MARC1 correlated with reduced AST, ALP, GGT (all P ≤ 0.01), and lower APRI (P = 0.02). Patients carrying the protective MARC1 genotype had higher total antioxidant activity (P < 0.01) and catalase levels (P = 0.02) in serum. The PNPLA3 risk variant was associated with higher MELD (P = 0.02) in treated patients, whereas MBOAT7 increased the odds for liver cancer (OR = 3.71). None of the variants modulated the risk of death or transplantation. In conclusion, the MARC1 polymorphism has protective effects in AIH. Genotyping of MARC1, PNPLA3, and MBOAT7 polymorphisms might help to stratify patients with AIH.
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