EASL Clinical Practice Guidelines: Autoimmune hepatitis

Infliximab-induced autoimmune-like hepatitis in a patient with Crohn's disease: a case report

As medical treatments advance, drug-induced liver injury (DILI) becomes more prevalent, occurring at a rate of 14 to 19 cases per 100,000 individuals. We present a unique case of a female patient with Crohn's disease developing autoimmune-like hepatitis during infliximab treatment. Autoimmune-like hepatitis can pose diagnostic challenges when distinguishing it from idiopathic autoimmune hepatitis. The diagnostic journey, including the absence of distinct pathognomonic criteria, is discussed. The only discriminative factor observed was the absence of relapse in autoimmune-like hepatitis patients after discontinuation of immuno-suppressive therapy. The case highlights the importance of recognizing this adverse event in clinical practice and underscores the challenges in balancing the benefits and risks of powerful immunomodulatory agents.

Predictors of Mortality in Patients Diagnosed With Autoimmune Hepatitis - Insights from a Prospective, 90-day Follow--up Study

Background and aims

The response to corticosteroids and optimal timing for liver transplantation (LT) in patients with autoimmune hepatitis (AIH) remain significant clinical challenges. This study aimed to assess short-term (90-day) mortality in patients with acute AIH (with or without underlying cirrhosis and chronic liver disease) treated with corticosteroids, and to identify factors that predict mortality in this population.

Methods

We conducted a prospective, single-center study between 2022 and 2024, involving patients with histologically confirmed AIH. All patients received corticosteroid treatment and were monitored for various clinical and laboratory parameters on days 3, 7, and 90 after initiating therapy.

Results

A total of 104 patients were included in the study, with a mean age of 46.1 ± 14.3 years; 77% of the patients were female. The 90-day mortality rate following the initiation of corticosteroids was 13.47%. Univariate analysis identified several significant predictors of mortality, including older age, diabetes mellitus, cirrhosis, esophageal varices, hepatic encephalopathy, low serum albumin on day 3, model of end-stage liver disease (MELD) scores on days 3 and 7, and the survival and prognostic factors for acute severe autoimmune hepatitis (SURFASA) score (P < 0.05). Multivariate analysis revealed that MELD score on day 7 (odds ratio [OR] 1.25; 95% confidence interval [CI] {1.09-1.48}; P = 0.00) and SURFASA score (OR 7.46; 95% CI {1.05-53.06}; P = 0.04) were significant. Specifically, a MELD score ≥27.5 on day 7 (area under the receiver operating characteristic curve [AUC] = 0.998) with 100% sensitivity and 97.8% specificity, and a SURFASA score ≥ -2.95 (AUC = 0.969) with 100% sensitivity and 95.6% specificity were highly predictive of mortality.

Conclusion

Despite corticosteroid treatment, mortality rates remain high in the decompensated AIH and acute on chronic liver failure-AIH groups. The SURFASA score, along with MELD scores on days 3 and 7, are strong predictors of mortality and can assist clinicians in making timely decisions regarding referral for early liver transplantation.

Efficacy and safety of infliximab in patients with autoimmune hepatitis

BACKGROUND AND AIMS

A limited number of drugs are used as standard or alternative therapies in autoimmune hepatitis (AIH). No specific recommendations are available for patients failing to respond to these therapies. We analyzed the efficacy and safety of infliximab in patients with AIH.

APPROACH AND RESULTS

We performed a retrospective study of 42 patients with AIH who received infliximab at 21 liver centers in 12 countries. Patients were categorized according to the reason for infliximab therapy. Patients in group 1 (n=20) had failed standard, second-line (mycophenolate mofetil and 6-mercaptopurine) or third-line (tacrolimus or cyclosporine) therapy. In group 2 (n=22), infliximab was given for treatment of concomitant extrahepatic autoimmune diseases. Patients received a median of 17 (range: 3-104) infliximab infusions. Complete biochemical response (CR) was achieved or maintained in 33 (78%) patients during infliximab therapy. In group 1, infliximab induced CR in 11 of 20 (55%) patients. In group 2, 16 patients with CR prior to infliximab maintained remission, and the remaining 6 patients with active AIH (5 on standard and 1 on both second-line and third-line therapy) showed CR following infliximab therapy. Infliximab led to CR in 75% (6/8) of nonresponders to second-line and in 46% (6/13) of failing third-line therapy. Overall, 65% (17/26) of the patients with active AIH achieved CR on infliximab. Infliximab was discontinued in 3 patients of group 1. One patient had a severe allergic reaction and 2 developed anti-infliximab autoantibodies.

CONCLUSIONS

Our study suggests that infliximab may be an effective and safe rescue therapy in AIH.

Role of regulatory T cells in inflammatory liver diseases

The liver is the human body's largest digestive gland, which can participate in digestion, metabolism, excretion, detoxification and immunity. Chronic liver diseases such as metabolic dysfunction-associated fatty liver disease (MAFLD) or viral hepatitis involve ongoing inflammation and resulting liver fibrosis may ultimately lead to the development of hepatobiliary cancers (HCC). Inflammation is the coordinated reaction of different liver cell types to cell signals and death of inflammation, which are linked to injury pathways within the liver or external agents from the gut-liver axis and the circulation. Regulatory T (Treg) cells play a crucial role in controlling inflammation and are essential for maintaining immune tolerance and balance. In this review, we highlight the recent discoveries related to the function of immune systems in liver inflammation and discuss the role of Treg cells in the different liver diseases (including MAFLD, autoimmune hepatitis and others).

Is high IgG level associated with disease activity and organ damage in patients with Sjögren's syndrome? A 3-year follow-up cohort study

Hypergammaglobulinemia is prevalent in primary Sjögren's syndrome (pSS) and is considered a marker of disease activity. However, limited data exist regarding its association with disease activity and organ damage. We enrolled patients with pSS from the Chinese Rheumatism Data Centre and categorized them into four groups based on the IgG levels over a 3-year follow-up: consistently high, consistently intermediate, consistently normal, and intermittent. Disease activity and organ damage at the end of the third year were compared across these groups. A total of 351 patients were included in this study, all females with a median age of 45 (IQR 35-53) years. The median baseline IgG was 17.2 (IQR 13.4-21.4) g/L. About 40% of the patients with elevated baseline IgG levels remained in the consistently high or intermediate IgG group. Compared to patients with consistently normal IgG levels, those with consistently high IgG levels had higher median SSDDI scores (2 vs. 1, p = 0.014), higher median ESSPRI scores (2.5 vs. 1.7, p = 0.005), more extra-glandular organ manifestations (IRR 2.34, 95%CI 1.48-3.7, p = < 0.001), and more extra-glandular organ damage (IRR 2.06, 95%CI 1.03-4.12, p = 0.040) at the third-year follow-up. No significant differences in extra-glandular involvement were found between the consistently intermediate IgG group and the consistently normal IgG group. The consistently high IgG level, but not the consistently intermediate level, was associated with a greater number of extra-glandular manifestations and increased extra-glandular organ damage.

MMF Is an Effective and Safer Treatment Options for Treatment-Naïve Patients With Autoimmune Hepatitis Compared to Azathioprine: A Systematic Review and Meta-Analysis

OBJECTIVES

Autoimmune Hepatitis (AIH) is a chronic inflammatory liver disease with significant morbidity and mortality if untreated. Current first-line treatment involves corticosteroids and azathioprine (AZA), which are effective but are associated with significant adverse effects and treatment intolerance. Mycophenolate mofetil (MMF), an immunosuppressive agent with a potentially better safety profile, has emerged as an alternative. This meta-analysis evaluated the efficacy and safety of MMF compared to AZA in treatment-naïve AIH patients.

METHODS

We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Databases were searched for articles published up to May 2024. Statistical analysis was performed using RevMan, employing a random-effects model.

RESULTS

Five studies involving 621 patients were included. MMF showed significantly higher rates of complete biochemical response compared to AZA (odds ratio [OR] 3.64, 95% confidence interval [CI] 2.07-6.40, p < 0.00001) and lower non-response rates (OR 0.45, 95% CI 0.24-0.85, p = 0.01). Corticosteroid withdrawal rates were also higher in the MMF group (OR 2.89, 95% CI 1.69-4.94, p = 0.0001). Relapse rate and cumulative prednisolone dose were comparable between the two groups. MMF demonstrated a better safety profile, with significantly lower rates of gastrointestinal symptoms (OR 0.46, 95% CI 0.27-0.79, p = 0.005).

CONCLUSIONS

MMF shows superior efficacy and tolerability compared to AZA in treatment-naïve AIH patients and may serve as a preferred first-line therapy, offering improved patient adherence and clinical outcomes. Further randomized controlled trials are warranted to confirm these findings.

Effect of Mediterranean and Western diets on fatigue in patients with autoimmune hepatitis: Protocol for a randomized crossover diet intervention trial

BACKGROUND

Fatigue is a debilitating symptom in patients with autoimmune hepatitis (AIH), and no effective treatment interventions are currently available. The anti-inflammatory properties of a Mediterranean diet (MD) may offer a potential non-pharmacological approach to reducing fatigue. This paper outlines the rationale, design, and protocol for a randomized crossover diet intervention trial to assess the effects of Mediterranean diet (MD) compared to a Western diet (WD) on fatigue levels in patients with AIH.

METHODS

In this crossover study, 48 subjects will be randomized to start either a MD or WD arm. After completing the initial arm, participants will switch to the opposite diet. The study team (including the PI and coordinator) and patients will remain blinded to the dietary intervention. The primary outcome will be the change in the fatigue component score of the PROMIS®-29 Profile v.2.0 survey during each dietary intervention. Secondary outcomes include changes in individual PROMIS-29 domain scores, mental and physical summary scores, circulating markers of inflammation (C-reactive protein and others), key liver serum biomarker levels (alanine aminotransferase, immunoglobulin G, total protein), stool microbiome (16S) and short-chain fatty acids, liver stiffness and steatosis, serum iron studies (ferritin, total iron binding capacity, transferrin saturation, hemoglobin), and nutritional markers such as serum vitamin D and magnesium levels.

CONCLUSION

If the Mediterranean diet (MD) is associated with a statistically significant decrease in the fatigue component score of the PROMIS®-29 survey, it could serve as a promising non-pharmacological intervention to reduce fatigue in AIH patients, offering a novel approach to improve quality of life in this population.

CLINICALTRIALS

gov ID: NCT06250309.

EASL Clinical Practice Guidelines on the management of autoimmune hepatitis

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.

IgG4-Related Cholangitis

IgG4-related cholangitis (IRC) is a rare fibroinflammatory disease of the biliary tree and liver and presents the major hepatobiliary manifestation of IgG4-related systemic disease (IgG4-RD). IRC also includes the IgG4-related inflammatory pseudotumor of the liver and IgG4-related cholecystitis. IRC mimics other cholangiopathies such as primary sclerosing cholangitis or cholangiocarcinoma. IRC may be found in 30 to 60% of cases with type 1 autoimmune pancreatitis, the most frequent manifestation of IgG4-RD. The pathogenesis of IRC (and IgG4-RD) is incompletely understood. Genetic predisposition, environmental factors, oligoclonal glucocorticosteroid-sensitive expansion of IgG4+ B cells/plasmablasts in blood and affected tissue and blocking autoantibody formation against protective IgG4-specific autoantigens such as annexin A11 and laminin 511-E8 with impaired protection of biliary epithelia against toxic bile acids have been described in IRC. Specific T cell subtypes are involved in the inflammatory process. The diagnosis of IRC is made according to HISORt criteria comprising histopathology, imaging, serology, other organ manifestations, and response to therapy. Treatment of IRC aiming to prevent organ failure and improve symptoms includes remission induction with highly effective glucocorticosteroids and long-term maintenance of remission with immunomodulators such as glucocorticosteroid sparing additives or B cell depleting approaches.

Low-background Near-infrared Fluorescent Probe for Real-time Monitoring of β-Glucuronidase Activity in Inflammation and Therapy

β-Glucuronidase (GUS) is an acidic hydrolase enzyme overexpressed in various inflammatory diseases, making it a promising biomarker for inflammation. However, current tools for real-time, in situ imaging of GUS activity are hindered by background interference, which reduces their effectiveness in dynamic biological environments. To address this challenge, we developed Ox-GUS, a GUS-specific fluorescent probe with a unique molecular design featuring a disrupted conjugated structure. This design provided Ox-GUS with near-zero background optical properties, a significantly enhanced signal-to-noise ratio, and a highly sensitive detection ability. The probe demonstrated a fluorescence enhancement of up to 400 folds in response to GUS activity, with a detection limit as low as 0.0035 U/mL. We successfully employed Ox-GUS to visualize GUS activity in real-time in mouse models of rheumatoid arthritis, autoimmune hepatitis, and inflammatory bowel disease, and effectively monitored therapeutic responses. This study highlights the potential of Ox-GUS as a robust tool for advancing research on GUS-related inflammatory mechanisms and for early diagnosis and treatment monitoring of inflammatory diseases.

The safety and efficacy of rituximab in autoimmune hepatitis: a systematic review and quality assessment

Up now, several medications were proposed for the treatment of autoimmune hepatitis (AIH); however, because of the unclear pathophysiology of AIH, the most optimal treatment option needs to be elucidated. This systematic review sought to investigate the safety and efficacy of rituxiamb (RTX) in patients with AIH. A total of 27 studies were included in the present study. A total of 80 patients had the eligibility criteria, of which the majority of them were female (63 female and 17 male). Of the 80 patients, nine patients were pediatrics. The induction of remission and maintenance therapy were the most common indications for RTX in AIH. Of the 80 patients, we found complete remission in 55% of patients (n = 44) and partial remission in 11% of patients (n = 11). Of the nine pediatric patients, we found complete remission in 77% of patients (n = 7) and partial remission in 22% of patients (n = 2). Unclear response was also reported in 31% of patients (n = 25), which included four studies. 375 mg/m2 × 4 followed by 1000 mg × 2 was the most commonly applied RTX dosage used for treatment of AIH. RTX therapy was associated with infectious complications in six patients; however, one episode of cancer, death, mild conjunctivitis, and large bowel perforation were also reported. RTX is an anti-CD20 mAb and was shown to be effective for the treatment of AIH, but there is no consensus regarding the therapeutic role of RTX in AIH.

Characteristics and Outcomes of Hepatocellular Carcinoma in Patients with Autoimmune Hepatitis

BACKGROUND

The incidence of HCC in patients with autoimmune hepatitis (AIH) is low and, due to the paucity of data in the literature, a thorough characterization of these patients is missing.

AIM

To describe the main characteristics and outcome of patients with AIH and HCC.

METHODS

Among patients with HCC included in the Italian Liver Cancer (ITA.LI.CA) database during the period 2009-2022, we selected those with AIH, and we described their liver disease characteristics, modality of HCC diagnosis, tumor stage, treatment, and outcome.

RESULTS

Among 10,026 patients with HCC, we identified 23 patients (0.2%) with AIH (43.5% males, 69.6% aged > 65 years, 91.0% with cirrhosis). Fifteen patients (65.2%) had co-factors of liver disease [8 patients (34.8%) metabolic dysfunction-associated steatotic liver disease, 4 patients (17.4%) alcohol abuse, 3 patients (13.0%) AIH/Primary Biliary Cholangitis overlap syndrome]. Tumors diagnosed under surveillance (60.9%) were more frequently uninodular (85.7% vs 66.6%, p = 0.146) and Milan-in (85.7% vs 44.4%, p = 0.066) than those diagnosed outside surveillance. Treatment with curative intent was more frequent among patients under surveillance (78.6% vs 33.3%, p = 0.077). Median overall survival was 41.7 months and was remarkably longer in patients under surveillance than in those diagnosed outside surveillance (68.2 vs 27.4 months, p = 0.032).

CONCLUSION

AIH accounts for a minimal fraction of patients with HCC, and in most patients, risk co-factors for HCC are present. In patients with AIH, too, surveillance is associated with better tumor stage, higher access rate to potentially curative treatments, and improved survival.

Clinical trajectories in liver cirrhosis: An evidence-based reappraisal for the internist

Over the last few years, the approach to clinical recognition and risk stratification of advanced liver disease has changed substantially, and liver cirrhosis has been increasingly conceptualized as a clinical rather than a histopathologic condition. In this Clinical Insight, we summarize the latest developments on recognition and management of 'clinically' advanced chronic liver disease.

Update in clinical science: Autoimmune hepatitis

Autoimmune hepatitis (AIH) is an enigmatic, relatively rare disease with a variable spectrum of presentation whose pathogenesis, diagnosis and management remain a major challenge. We have performed a review of recent developments in basic science, epidemiology, clinical science, therapeutics, and regulatory science, evaluating the challenges associated with the application of translational research and clinical trial design to a condition that is a chameleon in nature, where outcomes range from relatively benign disease through cirrhosis and acute liver failure. This review is focused on developments from 2020 onwards so we can present a forward-looking view on the challenges and remaining questions that must be addressed to improve patient care and outcomes in AIH. We also outline areas of debate and offer insights into these areas.

Estimation of liver fibrosis using elastography in cholestatic diseases: systematic review and meta-analysis

INTRODUCTION

staging fibrosis extent in liver disease is highly relevant for appropriate management. Liver biopsy remains the reference standard for assessment, but noninvasive methods such as elastography are becoming increasingly accurate and relevant. However, evidence regarding elastography in cholestatic diseases is lower than in other etiologies.

METHODS

we searched MEDLINE, EMBASE and Web of Science for publications on the diagnostic accuracy of transient elastography and sonoelastography in cholestatic diseases (PBC and PSC) using biopsy as the reference standard. A systematic review and meta-analysis of the results was then carried out.

RESULTS

a total of 13 studies were included. Using transient elastography in PBC sensitivity and specificity were estimated to be 0.76 and 0.93; 0.88 and 0.9; and 0.91 and 0.95 for ≥ F2, ≥ F3 and = F4, respectively. For sonoelastography in PBC sensitivity and specificity estimates were 0.79 and 0.82; 0.95 and 0.86; and 0.94 and 0.85 for ≥ F2, ≥ F3 y = F4, respectively. In PSC, transient elastography had a sensivity and specificity of 0.76 and 0.88; 0.91 and 0.86; and 0.71 and 0.93 for ≥ F2, ≥ F3 and = F4, respectively.

CONCLUSION

elastography has adequate diagnostic accuracy in the assessment of fibrosis stages in cholestatic liver diseases.

Recurrence of autoimmune hepatitis cholestatic variant syndromes after liver transplantation affects graft and patient survival

Background & Aims

A significant proportion of patients with variant syndromes (VSs), namely autoimmune hepatitis/primary biliary cholangitis or autoimmune hepatitis/primary sclerosing cholangitis, require liver transplantation (LT) despite treatment. The frequency of disease recurrence and the effect on graft survival are yet to be clarified. The aim of this international, multicentric, retrospective study is to evaluate the risk factors associated with recurrence and the impact of the disease recurrence after LT on graft and patient survival.

Methods

We evaluated 166 patients undergoing LT for VS in 33 centers in North America, South America, Europe, and Asia. Clinical data before and after LT, biochemical data within the first 12 months after LT, and immunosuppression after LT were analyzed to identify patients with a higher risk of recurrence of autoimmune disease based on a histological and radiological diagnosis. Cumulative probabilities of graft and overall survival after LT were calculated using a semi-Markov model.

Results

The autoimmune pattern of recurrence resembled the original VS in 19 cases (61%). Recurrence of autoimmune liver disease (rALD) after LT was observed in 23% and 33% of patients after 5 and 10 years, respectively. Increased alkaline phosphatase (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.13-2.25, p <0.01) and alanine aminotransferase (HR 1.25, 95% CI 1.01-1.53, p = 0.03) at 12 months after LT and acute rejection (HR 3.58, 95% CI 1.60-7.73, p <0.01) were associated with a higher risk of VS recurrence, whereas the use of predniso(lo)ne was associated with a reduced risk (HR 0.30, 95% CI 0.14-0.64, p <0.01). After adjusting for alanine aminotransferase and alkaline phosphatase at 12 months, the use of predniso(lo)ne was found to be independently and negatively associated with recurrent disease. The rALD was found to be significantly associated with graft loss and patient survival in the multivariate Cox regression analysis with a time-dependent covariate. The 5- and 10-year probabilities of graft survival were 68% and 41% in patients with recurrent VS compared with 83% and 60% in patients without recurrent disease, respectively (p = 0.01). The overall survival was significantly reduced in patients with recurrent disease (p = 0.01), with event probability at 5 and 10 years of 75% and 49% vs. 84% and 60% in patients without recurrence, respectively.

Conclusions

rALD after LT is frequent and is associated with elevation in liver enzymes within the first year after LT and rejection episodes. According to our data, VS recurrence appears to be associated with poorer graft and patient survival. Further studies are needed to explore strategies that can prevent VS recurrence or mitigate its potential impact.

Impact and implications

This study investigated the recurrence of autoimmune liver diseases (rALD) in patients transplanted for variant syndromes (VSs) and its effect on graft and patient survival. The findings reveal a significant association between rALD and poorer graft and overall survival, highlighting the need for preventive strategies. This research is crucial for transplant physicians and healthcare providers, as it underscores the impact of early liver enzyme monitoring and tailored immunosuppressive therapy on long-term outcomes. These insights can inform more effective post-LT management protocols, potentially improving patient prognosis.

Ultrasound Shear Wave Elastography and Shear Wave Dispersion: Correlation with Histopathological Changes in Autoimmune Hepatitis Patients

OBJECTIVE

To evaluate the correlation between liver viscosity, as measured by shear wave dispersion (SWD), and fibrosis and inflammation in patients with autoimmune hepatitis (AIH). Additionally, to assess its potential as a non-invasive biomarker for hepatic fibrosis compared to shear wave elastography (SWE).

METHODS

This prospective study included 25 AIH patients who underwent pre-biopsy SWD and SWE measurements using the SuperSonic Mach30 system. Liver biopsy samples were assessed for fibrosis using the Scheuer grading system and for inflammation using the modified Hepatic Activity Index (mHAI). Correlations between viscosity, elastography, fibrosis, and inflammation were analysed using Spearman's correlation coefficients.

RESULTS

Viscosity demonstrated a significant correlation with fibrosis stages (Spearman's coefficient: 0.58, p = 0.002), while SWE showed a weaker correlation (Spearman's coefficient: 0.50, p = 0.01). Viscosity measurements also correlated moderately with the mHAI score (Spearman's coefficient: 0.62, p = 0.001). Subgroup analyses revealed weak to moderate correlations between viscosity and mHAI components across fibrosis stages.

CONCLUSION

Our study suggests that viscosity may be better than SWE as a non-invasive marker for assessing hepatic fibrosis in AIH, particularly in the pre-treatment period when inflammation levels are elevated. However, we could not conclusively determine the relationship between viscosity and hepatic inflammation, as a small sample size limited our findings. Further research with a larger cohort of AIH patients is necessary to better understand the correlation between viscosity and inflammation in this rare condition.

Identification of abdominal MRI features associated with histopathological severity and treatment response in autoimmune hepatitis

To identify abdominal contrast magnetic resonance imaging (MRI) features associated with histopathological severity, and treatment response in autoimmune hepatitis (AIH).

PATIENTS AND METHODS

AIH patients who had abdominal contrast MRI within 3 months of liver biopsy were retrospectively enrolled. Histopathological severity, liver volume, MRI features, laboratory tests, and treatment response were collected. MRI and serum models were constructed through stepwise univariate and multivariate logistic regression for diagnosing severe histopathology and predicting insufficient response (IR).

RESULTS

One hundred AIH patients were included (median age: 57.0 years, 79.0% female). For diagnosing severe portal inflammation, reticular fibrosis and volume ratio of segment V-VIII to total liver (SV-SVIII/TLV) achieved an area under the receiver operating characteristic curve (AUROC) of 0.765 (95% CI 0.670-0.860). Severe confluent necrosis was modeled using hepatic fissure widening, reticular fibrosis, and volume ratio of segment I-III to segments IV-VIII, achieving an AUROC of 0.796 (95% CI 0.708-0.885). Severe histological activity was modeled using ascites, and SV-SVIII/TLV achieved an AUROC of 0.748 (95% CI 0.649-0.847). To diagnose cirrhosis, ascites, reticular fibrosis, and the volume ratio of segment I to the total liver were employed, yielding an AUROC of 0.833 (95% CI 0.716-0.949); IR (transaminases and/or immunoglobulin G remaining unnormal after 6 months of immunosuppressive treatment) was modeled using ascites, gallbladder wall edema, and transient hepatic attenuation difference, achieving an AUROC of 0.796 (95% CI 0.691-0.902).

CONCLUSION

The MRI models demonstrated relatively good performance in evaluating histopathological severity and treatment response. Combining MRI and serum models could enhance diagnostic and prognostic efficacy.

KEY POINTS

Question Abdominal contrast MRI may help clinicians better evaluate the histopathological severity and treatment response of autoimmune hepatitis (AIH), but there is currently limited research. Findings Models based on MRI features perform well in diagnosing severe portal inflammation, confluent necrosis, histological activity, and cirrhosis, as well as predicting insufficient response. Clinical relevance Abdominal contrast MRI, combined with serological parameters, provides a new and stronger noninvasive method for clinically assessing AIH progression and treatment.

PD-L1 and ICAM1 over expression empowers immunoregulation of mesenchymal stromal cells to improve the autoimmune hepatitis treatment efficacy

BACKGROUND

Autoimmune hepatitis (AIH) is an immune-mediated disease for which there is no effective treatment. Mesenchymal stromal cells (MSCs) have become a promising treatment, but low AIH treatment efficacy has hampered the clinical application of MSCs.

METHODS

By using Good Manufacturing Practices, we generated mesenchymal stromal cells with enhanced immunomodulation by over-expressing PD-L1 and ICAM1 (PI-MSCs). PI-MSCs biological characteristics were established, a tertiary cell bank created, and safety of PI-MSCs determined. Finally, the efficacy of PI-MSCs for treatment of AIH was evaluated.

RESULTS

PI-MSCs preserved MSCs identity, with a normal karyotype, stable genome, and no tumorigenicity. The long-term safe dose was up to 5.0 × 107 cells/kg. PI-MSCs showed better therapeutic effect than conventional MSCs for treating AIH in a mouse model. Notably, PI-MSCs showed better homing to injured liver tissue than conventional MSCs. Furthermore, PI-MSCs treatment significantly increased Treg cells in the blood and spleen of AIH model mice compared to conventional MSCs.

CONCLUSION

PD-L1 and ICAM1 empower MSCs immuno-regulation, these empowered MSCs are more effective treatment for AIH. These findings provide support for the translation of PI-MSCs to the clinic for treatment of AIH patients.

Testosterone affects female CD4+ T cells in healthy individuals and autoimmune liver diseases

Autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) are autoimmune liver diseases with strong female predominance. They are caused by T cell-mediated injury of hepatic parenchymal cells, but the mechanisms underlying this sex bias are unknown. Here, we investigated whether testosterone contributes to T cell activation in women with PBC. Compared with sex- and age-matched healthy controls (n = 23), cisgender (cis) women with PBC (n = 24) demonstrated decreased testosterone serum levels and proinflammatory CD4+ T cell profile in peripheral blood. Testosterone suppressed the expression of TNF and IFN-γ by human CD4+ T cells in vitro. In trans men receiving gender-affirming hormone therapy (GAHT) (n = 25), testosterone affected CD4+ T cell function by inhibiting Th1 and Th17 differentiation and by supporting the differentiation into regulatory Treg. Mechanistically, we provide evidence for a direct effect of testosterone on T cells using mice with T cell-specific deletion of the cytosolic androgen receptor. Supporting a role for testosterone in autoimmune liver disease, we observed an improved disease course and profound changes in T cell states in a trans man with AIH/primary sclerosing cholangitis (PSC) variant syndrome receiving GAHT. We here report a direct effect of testosterone on CD4+ T cells that may contribute to future personalized treatment strategies.

Risk of hepatocellular carcinoma and cirrhosis decompensation in a large retrospective cohort of cirrhotic patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease that can lead to cirrhosis in up to 30% of patients. Cirrhotic patients are at risk of high morbidity and mortality due to cirrhosis decompensation and hepatocellular carcinoma (HCC). This retrospective study assessed the rates of decompensated cirrhosis and HCC in patients with AIH-related cirrhosis. A total of 774 AIH patients were included, with 40% developing cirrhosis. Over a median follow-up of 8.2 years (IQR 2.9-12.3), the annual incidence of decompensated cirrhosis was 4.25%, with a mean time of 8.2 years from cirrhosis diagnosis to decompensation. Nineteen cirrhotic patients (6.2%) developed HCC, with a yearly incidence rate of 0.63%. Most HCC cases occurred within the first years of cirrhosis diagnosis. The rate of decompensated cirrhosis in AIH patients was lower than in other cirrhotic liver diseases, suggesting AIH may follow a different clinical course. The annual incidence of HCC was also significantly lower than the threshold for HCC surveillance. This indicates the need to reassess current surveillance guidelines, particularly in the late years following a cirrhosis diagnosis.

Spleen Stiffness Predicts the Risk of Liver-related Complications in Patients With Compensated Advanced Chronic Liver Disease

BACKGROUND & AIMS

The development of portal hypertension (PH) is a key prognostic factor in patients with compensated advanced chronic liver disease (cACLD). The gold standard for assessing PH is the hepatic venous pressure gradient measurement. However, noninvasive tools have gained significant importance in recent years, mainly liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE). Spleen stiffness measurement (SSM) by VCTE using a dedicated 100-Hz module has emerged as a promising non-invasive diagnostic tool, although data on its prognostic value remain limited. This study aimed to evaluate the accuracy of SSM, as measured by transient elastography, in predicting the risk of liver decompensation.

METHODS

A prospective study was conducted including patients with cACLD followed at a tertiary center from January 2020 to April 2024. All patients underwent liver and spleen VCTE (utilizing the 100-Hz module) performed by the same blinded operator. Patients were subsequently monitored at the same institution for the development of PH complications.

RESULTS

The study included 242 patients with cACLD, with a mean age of 63.0 ± 10.5 years and who were 78.5% male. The most common etiology was alcoholic liver disease (62.0%). The median LSM value was 21.9 kPa (interquartile range [IQR], 15.0-34.0 kPa), and the median SSM value was 38.9 kPa (IQR, 28.0-58.0 kPa). The median follow-up period was 501.5 days (IQR, 343.0-725.3 days). During this time, 28 patients (11.6%) developed liver decompensations, with 20 requiring hospital admission. SSM demonstrated good predictive capacity for the risk of liver decompensation (area under the curve, 0.823; 95% confidence interval, 0.742-0.904). Alongside LSM, SSM was an effective predictor of liver decompensation, with a cutoff of 50.0 kPa indicating a significantly increased risk of hepatic decompensation.

CONCLUSION

Noninvasive assessment using SSM may serve as an excellent tool for predicting the risk of liver-related complications and risk-stratifying patients with cACLD, thereby improving their management.

The entrenchment of NLRP3 inflammasomes in autoimmune disease-related inflammation

Autoinflammation and autoimmunity are almost "opposite" phenomena characterized by chronic activation of the immune system, 'innate' in the first and 'adaptive' in the second, leading to inflammation of several tissues with specific protean effectors of tissue damage. The mechanism of involvement of multiprotein complexes called 'inflammasomes' within autoimmune pictures, differently from autoinflammatory conditions, is yet undeciphered. In this review we provide a comprehensive overview on NLRP3 inflammasome contribution into the pathogenesis of some autoimmune diseases. In response to autoantibodies against nucleic acids or tissue-specific antigens the NLRP3 inflammasome is activated within dendritic cells and macrophages of patients with systemic lupus erythematosus. Crucial is NLRP3 inflammasome to amplify tissue inflammation with interleukin-1 overexpression and matrix metalloproteinase production at the joint level in rheumatoid arthritis. A deregulated NLRP3 inflammasome activation occurs in the serous acini of salivary and lacrimal glands prone to Sjogren's syndrome, but also in the inflammatory process involving endothelial cells, leucocyte recruitment, and platelet plugging of vasculitides. Furthermore, organ-specific autoimmune diseases such as thyroiditis and hepatitis may display hyperactive NLRP3 inflammasomes at the level of resident immune cells within thyroid or liver, respectively. Therefore, it is not unexpected that preclinical studies have shown how specific inflammasome inhibitors may significantly overthrow the severity of different autoimmune diseases and slow down their trend towards an ominous progression. Specific markers of inflammasome activation could also reveal subclinical inflammatory components escaping conventional diagnostic approaches or improve monitoring of autoimmune diseases and personalizing their treatment.

Hepatic Encephalopathy and MELD-Na Predict Treatment Benefit in Autoimmune Hepatitis-related Decompensated Cirrhosis

BACKGROUND & AIMS

Management of patients with autoimmune hepatitis (AIH)-related decompensated cirrhosis is challenging because of the risk of treatment-related complications and lack of clinical recommendations. We investigated the predictive factors for treatment benefit in AIH-related decompensated cirrhosis at diagnosis and developed an algorithm to guide treatment decisions in clinical practice.

METHODS

This retrospective, international, multicenter study included 232 patients with histologically confirmed AIH-related decompensated cirrhosis at diagnosis. The sub-hazard ratio (SHR) of mortality was determined by competing risk analysis, considering liver transplantation (LT) as competing event. A decision tree analysis was used to develop a treatment algorithm.

RESULTS

At diagnosis, 89% of patients had ascites, and 41% had overt hepatic encephalopathy (OHE). Treated patients (n = 214; 92%) had higher aminotransferases, bilirubin, and modified hepatic activity index. The SHR of mortality was lower in treated patients (0.438; 95% confidence interval [CI], 0.196-0.981; P = .045). Patients without OHE grade 3/4 and Model for End-Stage Liver Disease-Sodium (MELD-Na) ≤28 at diagnosis were more likely to benefit from treatment. In these patients, a decline in MELD-Na ≥11 after 4 weeks of treatment had a 100% negative predictive value for death/LT. Forty-nine percent of treated patients recompensated during follow-up. Twenty percent of patients had to discontinue treatment, 65% during the first 4 weeks, and only 4% due to infectious complications. OHE ≥grade 2 and MELD-Na at diagnosis predicted the need for treatment discontinuation.

CONCLUSIONS

Immunosuppression is beneficial in patients with AIH-related decompensated cirrhosis and active disease. OHE and MELD-Na at diagnosis, along with a decline in MELD-Na at 4 weeks of treatment, are the most important determinants of outcome and can guide treatment decisions.

Clinical management of autoimmune liver diseases: juncture, opportunities, and challenges ahead

The three major autoimmune liver diseases are autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC).These conditions are assumed to result from a breakdown in immunological tolerance, which leads to an inflammatory process that causes liver damage.The self-attack is started by T-helper cell-mediated identification of liver autoantigens and B-cell production of autoantibodies,and it is maintained by a reduction in the number and activity of regulatory T-cells.Infections and environmental factors have been explored as triggering factors for these conditions, in addition to a genetic predisposition.Allelic mutations in the HLA locus have been linked to vulnerability, as have relationships with single nucleotide polymorphisms in non-HLA genes.Despite the advances in the management of these diseases, there is no curative treatment for these disorders, and a significant number of patients eventually progress to an end-stage liver disease requiring liver transplantation.In this line, tailored immune-therapeutics have emerged as possible treatments to control the disease.In addition, early diagnosis and treatment are pivotal for reducing the long-lasting effects of these conditions and their burden on quality of life.Herein we present a review of the etiology, clinical presentation, diagnosis, and challenges on ALDs and the feasible solutions for these complex diseases.

Clinicopathological characteristics of autoimmune‑like hepatitis after drug‑induced liver injury

Autoimmune hepatitis (AIH) can be induced by drugs, but the underlying mechanisms remain unclear. The present study attempted to elucidate the clinicopathological characteristics of autoimmune-like hepatitis following drug-induced liver injury (DILI-ALH). The medical records of 57 patients diagnosed with AIH at Mie General Medical Center (Yokkaichi, Japan) were retrospectively reviewed, paying particular attention to the history of drug administration. Patients were classified into three groups: De novo AIH, drug-induced ALH (DI-ALH) and DILI-ALH. DILI-ALH was newly defined as cases in which the patient had a history of DILI and where the liver injury initially improved after drug discontinuation, but later worsened and was diagnosed as AIH. Of the 57 patients diagnosed with AIH, 42 patients were included in this study. De novo AIH was diagnosed in 29 patients, DI-ALH in 10 patients and DILI-ALH in 3 patients. Suspected causative drugs for drug-related pathologies were variable, including statins, health foods and supplements. No significant differences in sex or mean age were observed for DI-ALH and DILI-ALH compared with those for AIH. Distinguishing DI-ALH or DILI-ALH from AIH serologically and pathologically is difficult. No significant differences in the number of steroids used or the recurrence rate were observed between any groups. These findings suggest that drugs may present a more diverse cause of ALH than generally predicted. In particular, some AIH cases clearly present with DILI-ALH. Clarifying the involvement of drugs in the pathogenesis of AIH and establishing guidelines for diagnosis and treatment represent important issues for the future.

Increased IgG Levels at Diagnosis Are Associated With Worse Prognosis of Patients With Primary Biliary Cholangitis

BACKGROUND AND AIM

A proportion of patients with primary biliary cholangitis (PBC) have increased IgG (I-IgG) levels at baseline, though not fulfilling the criteria of autoimmune hepatitis/PBC variant. Our aim was to evaluate whether I-IgG has prognostic significance in non-cirrhotic PBC patients.

METHODS

Retrospective analysis of prospectively collected data from 675 PBC patients (592 non-cirrhotic) with available IgG levels at first evaluation was performed.

RESULTS

Among non-cirrhotic patients, 97 with I-IgG were more frequently females (p < 0.05), having a higher frequency of concurrent autoimmune diseases (p = 0.01) and a higher frequency of PBC-specific ANA (p < 0.001), sp100 (p < 0.001) and gp210 (p = 0.029) compared to 495 with normal IgG (N-IgG). Patients with I-IgG were older (p < 0.001) and had lower albumin (p < 0.001) and higher AST (p < 0.001), ALT (p = 0.005), ALP (p = 0.006), γGT (p = 0.038) and IgM (p < 0.001) compared to those with N-IgG. I-IgG patients had a higher probability of cirrhosis development (Breslow p < 0.001; log-rank p = 0.05) and liver-related death (Breslow p = 0.034; log-rank p < 0.05) compared to N-IgG patients. IgG > 1.5xULN was the highest risk factor for cirrhosis development (HR = 9.507, 95% CI: 1.221-74.038, p = 0.032) and liver-related death (HR = 27.140, 95% CI: 3.111-236.783; p = 0.003); IgG normalisation after 1 year of UDCA treatment had a favourable effect on disease outcome. Ν-IgG was associated with a higher probability of liver stiffness regression (p = 0.025).

CONCLUSIONS

This long-term study demonstrates that I-IgG levels characterise a subgroup of non-cirrhotic PBC patients with faster disease progression and increased probability of liver-related death. Normalisation of IgG levels during UDCA treatment seems to improve prognosis and therefore, these patients could benefit from stricter follow-up and earlier add-on second-line treatments.

Is ChatGPT-4 a Reliable Tool in Autoimmune Hepatitis?

INTRODUCTION

Artificial intelligence-based chatbots offer a potential avenue for delivering personalized counseling to patients with autoimmune hepatitis. We assessed accuracy, completeness, comprehensiveness, and safety of Chat Generative Pretrained Transformer-4 responses to 12 inquiries out of a pool of 40 questions posed by 4 patients with autoimmune hepatitis.

METHODS

Questions were categorized into 3 areas: diagnosis (1-3), quality of life (4-8), and medical treatment (9-12). 11 key opinion leaders evaluated responses using a Likert scale with 6 points for accuracy, 5 points for safety, and 3 points for completeness and comprehensiveness.

RESULTS

Median scores for accuracy, completeness, comprehensiveness, and safety were 5 (4-6), 2 (2-2), and 3 (2-3), respectively; no domain exhibited superior evaluation. Postdiagnosis follow-up question was the trickiest with low accuracy and completeness, but safe and comprehensive features. Agreement among key opinion leaders (Fleiss Kappa statistics) was slight for the accuracy (0.05) but poor for the remaining features (-0.05, -0.06, and -0.02, respectively).

DISCUSSION

Chatbots show good comprehensibility, but lack reliability. Further studies are needed to integrate Chat Generative Pretrained Transformer within clinical practice.

Response to azathioprine treatment in autoimmune hepatitis is dependent on glutathione transferase genotypes

BACKGROUND

Azathioprine (AZA) is part of the standard treatment for autoimmune hepatitis (AIH). The first step in the complex bioconversion of AZA to active metabolites is mediated by glutathione transferases (GSTs).

AIMS

Elucidate the association between GSTM1 and GSTT1 copy number variation (CNV), genetic variation in GSTA2, GSTP1, and inosine-triphosphate-pyrophosphatase, and the response to AZA in AIH.

METHODS

Genotyping was performed in AIH patients (n = 131) on AZA, and in a Swedish background population (n = 283). Thiopurine metabolites in blood erythrocytes were determined by high performance liquid chromatography.

RESULTS

GSTM1 and GSTT1 CNV were associated with treatment response to AZA. Gene deletion of GSTM1-but not of GSTT1-was associated with the liver transaminase levels. None of the studied genetic variants were associated with the thiopurine metabolite concentrations, suggesting non-enzymatic mechanisms of GSTM1 and GSTT1 in the context of AZA efficacy in AIH. The prevalence of GSTM1 and GSTT1 CNV genotypes was similar in AIH and in the background population.

CONCLUSION

This study shows the effects of GSTM1 and GSTT1 CNV on AZA efficacy in AIH, not previously described. It also elaborates on the impact of the definition of treatment response, on the importance of the various GSTs studied. Furthermore, the GSTM1 and GSTT1 CNV frequencies previously reported in European populations were confirmed.

Natural history and long-term management of autoimmune hepatitis

INTRODUCTION

Autoimmune hepatitis (AIH) is a relatively infrequent and complex liver disease characterized by acute or chronic inflammation, interface hepatitis in histology examination, elevation of immunoglobulin G (IgG), production of autoantibodies, and is often responsive to immunosuppression. The incidence of AIH has been increasing worldwide, affecting people of all ages and sexes. AIH represents a diagnostic challenge because of its heterogeneous presentation and the lack of pathognomonic findings. Even when treated, AIH can remain a progressive disease. In this review, we present recent data on the natural history of AIH and the developing evidence on the management of patients with AIH.

AREAS COVERED

This review outlines the clinical presentation, risk factors linked to poorer clinical outcomes, the diagnostic algorithm, and the current management strategies for individuals living with AIH.

EXPERT OPINION

AIH remains a clinical challenge, and new tools for better diagnosis and stratification of risk are needed. In addition, better treatments are needed as a complete response is achieved in less than 60% of cases, and intolerance to first-line treatment is frequent. The use of biological treatment in AIH seems to improve the response rate and minimize the risk of side effects of current medication in this increasingly prevalent disease.

Advancements in autoimmune hepatitis epidemiology, treatment and complication - a 15-year retrospective study

INTRODUCTION AND OBJECTIVES

Autoimmune hepatitis (AIH) is a rare, heterogeneous liver disease marked by autoantibodies, hypergammaglobulinemia, and distinct histological features. Predominantly affecting women, its incidence and prevalence show significant regional variability globally. Therefore, our aim is to examine the trends of AIH and to assess its demographics, management, and disease progression using an extensive population-based database.

MATERIALS AND METHODS

This retrospective, population-based study analyzed data from 2.7 million adults in Clalit Health Services, focusing on autoimmune hepatitis (AIH) diagnoses between 2009 and 2023. Data reordered included demographics, clinical details, and treatment regimens. Key outcomes tracked were the development of cirrhosis and its complications.

RESULTS

This study included 992 AIH patients with a median age of 51.5 years, 80.4 % female, and a median follow-up of 6.1 years. Obesity was present in 23.2 %, and 10.9 % had thyroid disease. At diagnosis, 22.9 % had cirrhosis, and an additional 137 patients developed cirrhosis during follow-up, leading to a total prevalence of 36.5 %. Among cirrhotic patients, 29.9 % experienced decompensation, 25.3 % developed ascites, 9.3 % had variceal bleeding, and 10.4 % developed hepatic encephalopathy. Hepatocellular carcinoma (HCC) occurred in 5.24 % of cirrhotic patients, with an incidence rate of 6.32 cases per 1000 patient-years. Overall, 11.2 % of cirrhotic patients underwent liver transplantation. The proportion of AIH patients diagnosed with cirrhosis at the time of diagnosis significantly decreased over the study period (p = 0.0028).

CONCLUSIONS

This study demonstrates a decreasing trend in AIH patients diagnosed with cirrhosis, suggesting earlier detection and improved management, alongside a lower documented incidence of HCC.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

What is the optimal first-line treatment of autoimmune hepatitis? A systematic review with meta-analysis of randomised trials and comparative cohort studies

OBJECTIVES

Uncertainty remains about many aspects of first-line treatment of autoimmune hepatitis (AIH).

DESIGN

Systemic review with meta-analysis (MA).

DATA SOURCES

Bespoke AIH Endnote Library, updated to 30 June 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and comparative cohort studies including adult patients with AIH, reporting death/transplantation, biochemical response (BR) and/or adverse effects (AEs).

DATA EXTRACTION AND SYNTHESIS

Data pooled in MA as relative risk (RR) under random effects. Risk of bias (ROB) assessed using Cochrane ROB-2 and ROBINS-1 tools.

RESULTS

From seven RCTs (five with low and two with some ROB) and 18 cohort studies (12 moderate ROB, six high for death/transplant), we found lower death/transplantation rates in (a) patients receiving pred+/-aza (vs no pred): overall (RR 0.38 (95% CI 0.20 to 0.74)), in patients without symptoms (0.38 (0.19-0.75)), without cirrhosis (0.30 (0.14-0.65)), and with decompensated cirrhosis (RR 0.38 (0.23-0.61)), and (b) patients receiving pred+aza (vs pred alone) (0.38 (0.22-0.65)). Patients receiving higher (vs lower) initial pred doses had similar BR rates (RR 1.07 (0.92-1.24)) and mortality (0.71 (0.25-2.05)) but more AEs (1.73 (1.17-2.55)). Patients receiving bud (vs pred) had similar BR rates (RR 0.99 (0.71-1.39)), with fewer cosmetic AEs (0.46 (0.34-0.62)). Patients receiving mycophenolate mofetil (MMF) (vs aza) had similar BR rates (RR 1.32 (0.73-2.38)) and fewer AEs requiring drug cessation (0.20 (0.09-0.43)).

CONCLUSIONS

Mortality is lower in pred-treated (vs untreated) patients, overall and in several subgroups, and in those receiving pred+aza (vs pred). Higher initial pred doses confer no clear benefit and cause more AEs. Bud (vs pred) achieves similar BR rates, with fewer cosmetic AEs. MMF (vs aza) achieves similar BR rates, with fewer serious AEs.

Diagnostic performance of FibroTest-ActiTest, transient elastography, and the fibrosis-4 index in patients with autoimmune hepatitis using histological reference

BACKGROUND

Noninvasive tests are crucial for the management and follow-up of patients with autoimmune hepatitis, but their validation is limited because of insufficient data.

AIM

To investigate the diagnostic performance of three fibrosis noninvasive tests [FibroTest, vibration-controlled transient elastography (VCTE), and the fibrosis-4 index (FIB-4) and two activity biomarkers (alanine aminotransferase (ALT) and ActiTest].

METHODS

This study enrolled 103 patients for whom liver biopsy, hepatic elastography results, and laboratory markers were available. Diagnostic performance was assessed with receiver operating characteristic (ROC) curves, the Obuchowski measure (OM), and the Bayesian latent class model.

RESULTS

FibroTest and VCTE outperformed FIB-4 in cases of significant fibrosis (≥ F2), with areas under the ROC curve of 0.83 [95% confidence interval (CI): 0.73-0.90], 0.86 (95%CI: 0.77-0.92), and 0.71 (95%CI: 0.60-0.80), respectively. The mean (standard error) OM values were 0.92 (0.01), 0.93 (0.01), and 0.88 (0.02) for FibroTest, VCTE, and FIB-4, respectively; FibroTest and VCTE performed comparably, and both were superior to FIB-4 (P = 0.03 and P = 0.005). The areas under the ROC curve values for activity biomarkers were 0.86 (95%CI: 0.76-0.92) for ActiTest and 0.84 (95%CI: 0.73-0.90) for ALT (P = 0.06). The OM values for ActiTest and ALT were 0.92 (0.02) and 0.90 (0.02), respectively (P = 0.005).

CONCLUSION

FibroTest and VCTE outperformed FIB-4 according to the OM. FibroTest-ActiTest facilitated the evaluation of both fibrosis and activity.

Evaluation of biological therapies in autoimmune hepatitis: A case-based systematic review

BACKGROUND

Autoimmune hepatitis (AIH) is typically treated with immunomodulators and steroids. However, some patients are refractory to these treatments, necessitating alternative approaches. Biological therapies have recently been explored for these difficult cases.

AIM

To assess the efficacy and safety of biologics in AIH, focusing on patients unresponsive to standard treatments and evaluating outcomes such as serological markers and histological remission.

METHODS

A case-based systematic review was performed following the PRISMA protocol to evaluate the efficacy and safety of biological therapies in AIH. The primary focus was on serological improvement and histological remission. The secondary focus was on assessing therapy safety and additional outcomes. A standardized search command was applied to MEDLINE, EMBASE, and Cochrane Library databases to identify relevant studies. Inclusion criteria encompassed adult AIH patients treated with biologics. Data were analyzed based on demographics, prior treatments, and therapy-related outcomes. A narrative synthesis was employed to address biases and provide a comprehensive overview of the evidence.

RESULTS

A total of 352 studies were reviewed, with 30 selected for detailed analysis. Key findings revealed that Belimumab led to a favourable response in five out of eight AIH patients across two studies. Rituximab demonstrated high efficacy, with 41 out of 45 patients showing significant improvement across six studies. Basiliximab was assessed in a single study, where the sole patient treated experienced a beneficial outcome. Additionally, a notable number of AIH cases were induced by anti-tumor necrosis factor (TNF) medications, including 16 cases associated with infliximab and four cases with adalimumab. All these cases showed improvement upon withdrawal of the biologic agent.

CONCLUSION

Belimumab and Rituximab show promise as effective alternatives for managing refractory AIH, demonstrating significant improvements in clinical outcomes and liver function. However, the variability in patient responses to different therapies highlights the need for personalized treatment strategies. The risk of AIH induced by anti-TNF therapies underscores the need for vigilant monitoring and prompt symptom recognition. These findings support the incorporation of biologic agents into AIH treatment protocols, particularly for patients who do not respond to conventional therapies.

Acute Liver Failure During Early Pregnancy-Case Report and Review of Literature

Background/Objectives: This article presents the case of a 31-year-old primigravida who experienced acute liver failure in the 23rd week of pregnancy, along with a review of the literature on this rare condition during pregnancy. The purpose of this publication is to highlight the diagnostic and therapeutic challenges associated with acute liver failure in pregnant women. Methods: The patient presented with jaundice, pruritus, and dark-colored urine. Laboratory tests revealed a significant increase in aminotransferase, bilirubin, and bile acid levels, suggesting liver problems; however, due to the patient's rapidly deteriorating condition and test results, autoimmune hepatitis was considered. Viral infections and other causes of liver damage were excluded. No clear diagnosis was established. The patient was administered ursodeoxycholic acid and due to her worsening condition, a cesarean section was performed at 23 weeks of gestation. After delivery, the patient's condition improved, although she did experience cardiac arrest during hospitalization. The patient was discharged with a diagnosis of acute liver failure in the course of an overlap syndrome of autoimmune hepatitis and primary cholangitis or intrahepatic cholestasis of pregnancy. No abnormalities were noted during a follow-up visit 6 weeks after delivery. Despite a detailed case analysis, a final diagnosis was not established, which complicates planning for future pregnancies. Discussion: Several liver conditions can occur during pregnancy, including intrahepatic cholestasis of pregnancy, primary biliary cholangitis, and autoimmune hepatitis. Diagnosing these conditions can be challenging due to overlapping symptoms and metabolic and immunological adaptations during pregnancy that can affect the course of liver diseases. Rapid intervention is crucial to protect the health of both the mother and the fetus. Conclusions: In summary, this article aims to increase awareness of the complexities surrounding acute liver failure during pregnancy, highlighting the diagnostic challenges and importance of prompt medical intervention for the well-being of both the mother and the child. This paper aims to provide a comprehensive overview of the complexities surrounding acute liver failure during pregnancy, aiming to improve the understanding, diagnosis, and management of this condition.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Role of B-Cell Inhibition in Autoimmune Hepatitis: Lessons Learnt From Systemic Lupus Erythematosus

Autoimmune hepatitis (AIH) is a chronic liver disease characterized by histological, clinical, and laboratory findings, including elevated liver enzymes, immunoglobulin G (IgG), and autoantibodies. Belimumab, a monoclonal antibody targeting B-lymphocyte stimulator (BLyS), is primarily approved for systemic lupus erythematosus (SLE) but shows promise in improving liver function tests (LFTs) in patients with concurrent AIH and SLE. We present the case of a 24-year-old female diagnosed with AIH and SLE, whose elevated LFTs initially resisted standard azathioprine therapy. Upon switching to mycophenolate and belimumab, a notable reduction in LFTs was observed. This case highlights belimumab's potential as an adjunct therapy in AIH, especially in patients with overlapping autoimmune conditions, supporting its role in reducing systemic inflammation and autoimmune activity.

Decline of Persistent Jaundice in a Patient With Autoimmune Hepatitis and Vanishing Bile Duct Syndrome Treated With Elobixibat for Constipation

We present the case of a 49-year-old woman with autoimmune hepatitis and persistent jaundice. On admission, pathology and laboratory results supported the diagnosis of autoimmune hepatitis-primary biliary cholangitis (AIH-PBC) overlap syndrome with vanishing bile duct syndrome (VBDS). Standard treatment, including methylprednisolone pulse therapy, prednisolone, azathioprine, bezafibrate, and ursodeoxycholic acid, failed to resolve jaundice. In addition to jaundice, the patient also had constipation and regularly used magnesium oxide and sennoside. Notably, the addition of elobixibat, initially prescribed for constipation, resulted in a marked improvement in jaundice. This case highlights the diagnostic and therapeutic challenges of AIH-PBC overlap syndrome with VBDS, particularly in cases of refractory jaundice. The observed efficacy of elobixibat suggests that it may be a valuable adjunctive therapy for severe cholestasis. Further research is warranted to clarify its therapeutic potential and underlying mechanisms in similar cases.

Hepatitis Associated with Catha edulis Consumption-A Single-Center Study

Background/Objectives:Catha edulis, also known as Khat, is a stimulant with hepatotoxic properties. Studies reporting laboratory patterns are scarce. The aim was to assess the patterns associated with hepatic dysfunction due to Khat usage. Methods: Patients with liver injury and self-reported Khat consumption presenting to the gastroenterology department at the King Fahad Central Hospital in Jazan between January 2017-May 2024 were retrospectively included in the study. Patients with any signs of cirrhosis or viral hepatitis were excluded to have a more homogenous inclusion. Normal distribution was not assumed; data were presented as the median (IQR or %). Results: Sixty-three patients (of which 62 (98.4%) were male) aged 35 (29-41) years were included in the study. An IgG > 20 g/L was present in 41 (61.5%) patients, and the majority (n = 48, 76.2%) had a hepatocellular injury pattern based on an R-factor > 5. Over half of the patients had at least one positive autoantibody(ANA 47.6%; SMA 55.6% and AMA 4.8%), while 57 (90.5%) patients received immunosuppressive therapy. Conclusions: Khat-induced liver injury seems to be predominantly AIH-like in nature, given the IgG elevation, hepatocellular injury pattern, and relatively high rate of autoantibody positivity.

Real-world pharmacovigilance study of drug-induced autoimmune hepatitis from the FAERS database

This study aims to identify and evaluate the most common drugs associated with the risks of autoimmune hepatitis (AIH) using the FDA Adverse Event Reporting System (FAERS) database. Adverse drug events (ADEs) associated with drug-induced AIH (DI-AIH) were retrieved from the FAERS database (January 2004-June 2024). Disproportionality analysis was performed to identify drugs significantly linked to DI-AIH, and time-to-onset (TTO) analyses were conducted to evaluate the timing and risk profiles of DI-AIH adverse reactions. Our study identified 2,511 ADEs linked to autoimmune hepatitis. Disproportionality analysis identified 22 drugs significantly associated with AIH risk, including 4 antibiotics, 3 antivirals, 4 cardiovascular drugs, 5 antitumor agents, 2 immunomodulators, 2 nonsteroidal anti-inflammatory drugs, and 1 drug each from the respiratory and nervous system categories. The highest DI-AIH risks were observed with minocycline (ROR = 53.97), nitrofurantoin (ROR = 57.02), and doxycycline (ROR = 16.12). Antitumor drugs had the shortest median TTO (77.00 days), whereas cardiovascular drugs exhibited the longest (668.30 days). Through a comprehensive analysis of the FAERS database, our study identified drugs strongly associated with AIH. Preventing DI-AIH requires careful drug selection and monitoring. This study provides evidence-based insights into implicated drugs, aiming to optimize clinical management and mitigate risks.

Immunosuppressive treatment in autoimmune decompensated cirrhosis, when to say enough: A retrospective analysis

Immunosuppressive therapy in decompensated cirrhotic patients with an indication for liver transplantation (LT) is controversial. This study aims to evaluate transplant-free survival rates in patients diagnosed with decompensated autoimmune hepatitis (AIH) with and without immunosuppressants (IS) treatment, and to identify predictors of mortality or LT. We retrospectively analyzed LT-evaluated consecutive patients with decompensated AIH at a single center, between 2013 and 2021. Patients were categorized into IS (IS Group) and non-IS (No IS Group). Survival curves for the 2 groups were evaluated using the Kaplan-Meier method, and differences were compared using the Log-rank test. Multiple regression analysis was conducted using Cox test. A total of 125 consecutive patients (mean age: 36.4 years; 81.6% female) were evaluated. The median transplant-free survival in the IS Group (72/125) were 22.6 months vs 6.57 months in the No IS Group (53/125) (P = .002). Cox-regression analysis revealed associations between moderate/severe ascites (hazard ratio [HR] = 2.37, 95% CI = 1.48-3.80, P = <.001) and MELD-Na (HR = 1.12, 95% CI = 1.08-1.16, P = <.001) with transplantation or death, while immunosuppression treatment acted protectively (HR = 0.55, 95% CI = 0.86-0.85, P = .008). Analyzing patients with MELD >22 (27/125) showed a loss of IS protective effect (OR = 0.45, 95% CI = 0.17-1.20, P = .11), and the presence of moderate/severe ascites increased the risk of death/LT (HR = 5.86, 95% CI = 1.26-27.2, P = .02). Autoimmune decompensated cirrhosis is associated with high overall mortality, and IS improves the transplant-free survival rate. In patients with MELD-Na >22, treatment ceases to be beneficial, especially if they have moderate/severe ascites. These patients, if receiving immunosuppression, may be disadvantaged in the possibility of accessing LT.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Deep learning helps discriminate between autoimmune hepatitis and primary biliary cholangitis

BACKGROUND & AIMS

Biliary abnormalities in autoimmune hepatitis (AIH) and interface hepatitis in primary biliary cholangitis (PBC) occur frequently, and misinterpretation may lead to therapeutic mistakes with a negative impact on patients. This study investigates the use of a deep learning (DL)-based pipeline for the diagnosis of AIH and PBC to aid differential diagnosis.

METHODS

We conducted a multicenter study across six European referral centers, and built a library of digitized liver biopsy slides dating from 1997 to 2023. A training set of 354 cases (266 AIH and 102 PBC) and an external validation set of 92 cases (62 AIH and 30 PBC) were available for analysis. A novel DL model, the autoimmune liver neural estimator (ALNE), was trained on whole-slide images (WSIs) with H&E staining, without human annotations. The ALNE model was evaluated against clinico-pathological diagnoses and tested for interobserver variability among general pathologists.

RESULTS

The ALNE model demonstrated high accuracy in differentiating AIH from PBC, achieving an area under the receiver operating characteristic curve of 0.81 in external validation. Attention heatmaps showed that ALNE tends to focus more on areas with increased inflammation, associating such patterns predominantly with AIH. A multivariate explainable ML model revealed that PBC cases misclassified as AIH more often had ALP values between 1 × upper limit of normal (ULN) and 2 × ULN, coupled with AST values above 1 × ULN. Inconsistency among general pathologists was noticed when evaluating a random sample of the same cases (Fleiss's kappa value 0.09).

CONCLUSIONS

The ALNE model is the first system generating a quantitative and accurate differential diagnosis between cases with AIH or PBC.

IMPACT AND IMPLICATIONS

This study demonstrates the significant potential of the autoimmune liver neural estimator model, a transformer-based deep learning system, in accurately distinguishing between autoimmune hepatitis and primary biliary cholangitis using digitized liver biopsy slides without human annotation. The scientific justification for this work lies in addressing the challenge of differentiating these conditions, which often present with overlapping features and can lead to therapeutic mistakes. In addition, there is need for quantitative assessment of information embedded in liver biopsies, which are currently evaluated on qualitative or semi-quantitative methods. The results of this study are crucial for pathologists, researchers, and clinicians, providing a reliable diagnostic tool that reduces interobserver variability and improves diagnostic accuracy of these conditions. Potential methodological limitations, such as the diversity in scanning techniques and slide colorations, were considered, ensuring the robustness and generalizability of the findings.

Current practice in the management of paediatric autoimmune liver disease in Europe

OBJECTIVE

Paediatric autoimmune liver disease (pAILD) is a rare condition with serious health implications. Notwithstanding treatment advancements, areas of uncertainty and knowledge gaps still exist. We here investigated the real-life approach to pAILD management in Europe.

METHODS

A survey was distributed to members of the European Rare Liver Disease Reference Network (ERN RARE-LIVER) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Hepatology Interest Group. Information was gathered regarding clinical activity, medications used, and access to paediatric drug formulations at each site.

RESULTS

Thirty-six centres from 22 European countries responded to the survey. The majority are exclusively paediatric units (86%). Among participants, 80% follow <50 children with pAILD, of which 25%-50% are <10 years old in 44% of centres. All centres use predniso(lo)ne as first-line therapy, alone (15/36) or with azathioprine (21/36). Azathioprine and mycophenolate are the preferred second-line options in centres using first-line steroid monotherapy (11/15) or combined steroid-azathioprine (19/21), respectively. Tacrolimus is used as third-line agent in 15/36 centres. Proactive measurement of drug metabolites and target levels vary widely among centres. Paediatric predniso(lo)ne formulations are commercially available in 7/22 European countries, azathioprine in 3, mycophenolate in 14, tacrolimus in 15 and ursodeoxycholic acid in 14. When paediatric formulations are unavailable, children are treated with magisterial preparations or 'solid' formulations (crushed or intact).

CONCLUSIONS

Treatment of pAILD in Europe varies widely in terms of medications used and treatment monitoring. Availability of paediatric drug formulations across Europe is limited. Collaborative initiatives are needed to define evidence-based strategies for management of pAILD and to promote an equal, age-appropriate treatment for affected children.

Quo vadis autoimmune hepatitis? - Summary of the 5th international autoimmune hepatitis group research workshop 2024

Autoimmune hepatitis (AIH) is a rare chronic liver disease with an increasing incidence in many countries. Chronic autoimmune responses against the liver can cause hepatic and extrahepatic symptoms, decreased quality of life and reduced liver transplant-free survival if inadequately treated. Although standard treatment with corticosteroids and thiopurines improves the life expectancy of patients with AIH, remission rates and tolerability are generally overestimated and the development of alternative first-line and salvage therapies has been disappointingly slow compared to in rheumatological diseases or inflammatory bowel disease. Other gaps include the lack of disease-specific diagnostic markers for AIH. Similarly, the new entity of drug-induced autoimmune-like hepatitis underscores the need to re-evaluate previous diagnostic criteria. The International AIH Group (IAIHG) has initiated a series of research workshops over the last decade to promote the identification of research gaps and subsequently improve the pace of scientific progress by stimulating collaboration between expert centres. This review reports on the results of the 5th Research Workshop, held in Hannover, Germany in June 2024, and summarises the progress made since the 4th Workshop in 2022. Patient representatives from the European Reference Network (ERN) Rare Liver Youth Panel participated in the workshop. The specific objectives of this year's 5th Workshop were: (1) To further improve diagnostics. (2) Initiate clinical trials including knowledge transfer on drugs from extrahepatic immune-mediated diseases, including B cell-depleting CAR T cells. (3) Utilisation of multi-omics approaches to improve the understanding of disease pathogenesis. (4) Application of machine learning-based approaches established in oncology or transplantation medicine to improve diagnosis and outcome prediction in AIH.

Mortality in Autoimmune Liver Disease in Sweden: A Population-Based Cohort Study of 9,654 Patients

BACKGROUND/AIMS

Epidemiological data on mortality in autoimmune liver diseases (AILDs) are scarce. We examined all-cause and cancer-related mortality in individuals with AILD from Sweden.

METHODS

We identified 9654 individuals with AILD (3342 with autoimmune hepatitis (AIH), 3751 with primary biliary cholangitis (PBC), and 2561 with primary sclerosing cholangitis (PSC)) using national Swedish registries between 2001 and 2020. These were matched with 80 685 comparators from the general population at a ratio of 1:10 on age, sex, year of diagnosis and municipality. Rates of outcomes were estimated using Cox regression models, adjusted for matching factors and cardiovascular disease, diabetes, inflammatory bowel disease, chronic obstructive pulmonary disease, and education.

RESULTS

Individuals with AILD had higher mortality than comparators (adjusted hazard ratio (aHR) = 2.3, 95% CI = 2.2-2.4) and higher rates of cancer-related death (aHR = 2.1, 95% CI = 1.9-2.3). The presence of liver cirrhosis in AILD was related to even higher mortality, with aHR 5.8 (95% CI = 5.1-6.6). Both males and females with AILD had increased mortality (males aHR = 2.6, 95% CI = 2.4-3.0, and females aHR = 2.2, 95% CI = 2.1-2.3). The mortality was higher in individuals aged 18-50 years (aHR = 4.6, 95% CI = 3.6-5.8), than in individuals above 50 years (aHR = 2.2, 95% CI = 2.1-2.3). Overall mortality rates and cancer-related death were particularly high in individuals with PSC compared to their matched comparators, with aHR = 4.1 (95% CI = 3.2-5.2) and aHR = 6.4 (95% CI = 4.0-10.3), respectively.

CONCLUSIONS

Patients with AILDs have increased rates of overall and cancer-related mortality compared to matched comparators, and relative risks are highest in cirrhosis, younger age and PSC.

Real-world evidence for factors associated with maintenance treatment practices among US adults with autoimmune hepatitis

BACKGROUND AND AIMS

While avoidance of long-term corticosteroids is a common objective in the management of autoimmune hepatitis (AIH), prolonged immunosuppression is usually required to prevent disease progression. This study investigates the patient and provider factors associated with treatment patterns in US patients with AIH.

APPROACH AND RESULTS

A retrospective cohort of adults with the incident and prevalent AIH was identified from Optum's deidentified Clinformatics Data Mart Database. All patients were followed for at least 2 years, with exposures assessed during the first year and treatment patterns during the second. Patient and provider factors associated with corticosteroid-sparing monotherapy and cumulative prednisone use were identified using multivariable logistic and linear regression, respectively.The cohort was 81.2% female, 66.3% White, 11.3% Black, 11.2% Hispanic, and with a median age of 61 years. Among 2203 patients with ≥1 AIH prescription fill, 83.1% received a single regimen for >6 months of the observation year, which included 52.2% azathioprine monotherapy, 16.9% azathioprine/prednisone, and 13.3% prednisone monotherapy. Budesonide use was uncommon (2.1% combination and 1.9% monotherapy). Hispanic ethnicity (aOR: 0.56; p = 0.006), cirrhosis (aOR: 0.73; p = 0.019), osteoporosis (aOR: 0.54; p =0.001), and top quintile of provider AIH experience (aOR: 0.66; p = 0.005) were independently associated with lower use of corticosteroid-sparing monotherapy. Cumulative prednisone use was greater with diabetes (+441 mg/y; p = 0.004), osteoporosis (+749 mg/y; p < 0.001), and highly experienced providers (+556 mg/y; p < 0.001).

CONCLUSIONS

Long-term prednisone therapy remains common and unexpectedly higher among patients with comorbidities potentially aggravated by corticosteroids. The greater use of corticosteroid-based therapy with highly experienced providers may reflect more treatment-refractory disease.