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Takahashi K, Horio R, Ohyama H, Kan M, Ouchi M, Nagashima H, Okitsu K, Ohno I, Kato N. Prognostic significance of clinical scoring systems for large-duct primary sclerosing cholangitis in Japanese patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2025; 32:385-392. [PMID: 40013440 DOI: 10.1002/jhbp.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2025]
Abstract
PURPOSE This study aimed to identify the significant factors associated with liver transplant-free survival time in Japanese patients with large-duct primary sclerosing cholangitis (PSC) by evaluating the association between various parameters and clinical scores at PSC diagnosis. METHODS This single-center retrospective study investigated factors influencing liver transplant-free survival in Japanese large-duct PSC patients. Univariate analysis using log-rank tests identified significant clinical parameters and scoring systems, which were further analyzed with multivariate Cox proportional hazards models to determine independent predictors of liver transplant-free survival. RESULTS A total of 77 patients with large-duct PSC were included. The univariate analysis identified that age (p < .001), serum albumin level (p = .024), Child-Pugh score (p = .0012), albumin-bilirubin score (p = .0083), Amsterdam-Oxford PSC score (p < .001), and revised Mayo risk score (p < .001) were significant predictors of liver transplant-free survival time. However, the multivariate analysis revealed that only the Amsterdam-Oxford PSC score remained as an independent factor significantly associated with liver transplant-free survival time (hazard ratio: 12.90, 95% confidence interval: 2.78-59.81, p = .0011). CONCLUSIONS This study underscored the importance of utilizing the Amsterdam-Oxford PSC score in clinical practice to assess disease prognosis and guide patient management in Japanese patients with large-duct PSC.
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Affiliation(s)
- Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ryosuke Horio
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kohichiroh Okitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Manns MP, Bergquist A, Karlsen TH, Levy C, Muir AJ, Ponsioen C, Trauner M, Wong G, Younossi ZM. Primary sclerosing cholangitis. Nat Rev Dis Primers 2025; 11:17. [PMID: 40082445 DOI: 10.1038/s41572-025-00600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2025] [Indexed: 03/16/2025]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic biliary inflammation associated with periductular fibrosis of the intrahepatic and extrahepatic bile ducts leading to strictures, bacterial cholangitis, decompensated liver disease and need for liver transplantation. This rare focal liver disease affects all races and ages, with a predominance of young males. There is an up to 88% association with inflammatory bowel disease. Although the aetiology is unknown and the pathophysiology is poorly understood, PSC is regarded as an autoimmune liver disease based on a strong immunogenetic background. Further, the associated risk for various malignancies, particularly cholangiocellular carcinoma, is also poorly understood. No medical therapy has been approved so far nor has been shown to improve transplant-free survival. However, ursodeoxycholic acid is widely used since it improves the biochemical parameters of cholestasis and is safe at low doses. MRI of the biliary tract is the primary imaging technology for diagnosis. Endoscopic interventions of the bile ducts should be limited to clinically relevant strictures for balloon dilatation, biopsy and brush cytology. End-stage liver disease with decompensation is an indication for liver transplantation with recurrent PSC in up to 38% of patients. Several novel therapeutic strategies are in various stages of development, including apical sodium-dependent bile acid transporter and ileal bile acid transporter inhibitors, integrin inhibitors, peroxisome proliferator-activated receptor agonists, CCL24 blockers, recombinant FGF19, CCR2/CCR5 inhibitors, farnesoid X receptor bile acid receptor agonists, and nor-ursodeoxycholic acid. Manipulation of the gut microbiome includes faecal microbiota transplantation. This article summarizes present knowledge and defines unmet medical needs to improve quality of life and survival.
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Affiliation(s)
- Michael P Manns
- Hannover Medical School (MHH) and Centre for Individualised Infection Medicine (CiiM), Hannover, Germany.
| | - Annika Bergquist
- Division of Hepatology, Department of Upper Gastrointestinal Disease, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tom H Karlsen
- Norwegian PSC Research Center, Department of Transplantation Medicine, Clinic of Surgery and Specialized medicine, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine, Miami, FL, USA
| | - Andrew J Muir
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Cyriel Ponsioen
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Grace Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Union Hospital, Hong Kong SAR, China
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Lytvyak E, Wang D, Shreekumar D, Ebadi M, Alrifae Y, Mason A, Montano-Loza AJ. PSC-specific prognostic scores associated with graft loss and overall mortality in recurrent PSC after liver transplantation. Dig Liver Dis 2025:S1590-8658(25)00223-3. [PMID: 40011121 DOI: 10.1016/j.dld.2025.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 02/05/2025] [Accepted: 02/07/2025] [Indexed: 02/28/2025]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a progressive liver disease with no treatment apart from liver transplantation (LT). After LT, patients can develop recurrent PSC (rPSC). The United-Kingdom (UK-PSC) and Amsterdam-Oxford (AOPSC) scores are used as prognostic models for PSC outcomes. AIM We aimed to assess these scores as predictive tools for graft loss and overall mortality in rPSC. METHODS We evaluated 67 people who developed rPSC. Using Cox regression models, we quantified associations between UK-PSC and AOPSC scores and graft loss and overall mortality. Cut-offs were established using receiver operator characteristic analysis and the highest Youden index. RESULTS Fifty-one individuals (76.1%) were males, with a mean age of 40±15 years. Both UK-PSC and AOPSC scores were independently associated with graft loss (hazard ratio [HR] 2.43 (p < 0.001) and HR 3.45 (p < 0.001), respectively), but only the UK-PSC score was independently associated with overall mortality (HR 2.63 (p = 0.009)). Individuals with UK-PSC ≥-4.2 (6.1 ± 0.8 vs. 14.7 ± 1.0 years; p = 0.001) and AOPSC ≥2.4 (5.4 ± 1.3 vs. 12.0 ± 1.1 years; p < 0.001) had shorter graft survival. CONCLUSION UK-PSC score at rPSC predicts both graft loss and overall mortality, while AOPSC scores using either age at rPSC or at diagnosis along with severe cholestasis predict graft loss in people with rPSC. These easy-to-administer tools can be utilized in clinical practice to identify high-risk rPSC patients and guide decisions about monitoring/interventions.
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Affiliation(s)
- Ellina Lytvyak
- Division of Preventive Medicine, Department of Medicine, University of Alberta, 5-30 University Terrace, 8303 112 Street, Edmonton, Alberta T6G 2T4, Canada.
| | - Dennis Wang
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
| | - Devika Shreekumar
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
| | - Maryam Ebadi
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
| | - Yousef Alrifae
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
| | - Andrew Mason
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
| | - Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit, Department of Medicine, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta T6G 2×8, Canada.
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Poetter-Lang S, Ba-Ssalamah A, Messner A, Bastati N, Ambros R, Kristic A, Kittinger J, Pochepnia S, Ba-Ssalamah SA, Hodge JC, Halilbasic E, Venkatesh SK, Kartalis N, Ringe K, Arrivé L, Trauner M. Disease severity prognostication in primary sclerosing cholangitis: a validation of the Anali scores and comparison with the potential functional stricture. Eur Radiol 2024; 34:7632-7644. [PMID: 38869640 PMCID: PMC11557717 DOI: 10.1007/s00330-024-10787-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVES Our aim was twofold. First, to validate Anali scores with and without gadolinium (ANALIGd and ANALINoGd) in primary sclerosing cholangitis (PSC) patients. Second, to compare the ANALIs prognostic ability with the recently-proposed potential functional stricture (PFS). MATERIALS AND METHODS This retrospective study included 123 patients with a mean age of 41.5 years, who underwent gadoxetic acid-enahnced MRI (GA-MRI). Five readers independently evaluated all images for calculation of ANALIGd and ANALINoGd scores based upon following criteria: intrahepatic bile duct change severity, hepatic dysmorphia, liver parenchymal heterogeneity, and portal hypertension. In addition, hepatobiliary contrast excretion into first-order bile ducts was evaluated on 20-minute hepatobiliary-phase (HBP) images to assess PFS. Inter- and intrareader agreement were calculated (Fleiss´and Cohen kappas). Kaplan-Meier curves were generated for survival analysis. ANALINoGd, ANALIGd, and PFS were correlated with clinical scores, labs and outcomes (Cox regression analysis). RESULTS Inter-reader agreement was almost perfect (ϰ = 0.81) for PFS, but only moderate-(ϰ = 0.55) for binary ANALINoGd. For binary ANALIGd, the agreement was slightly better on HBP (ϰ = 0.64) than on arterial-phase (AP) (ϰ = 0.53). Univariate Cox regression showed that outcomes for decompensated cirrhosis, orthotopic liver transplantation or death significantly correlated with PFS (HR (hazard ratio) = 3.15, p < 0.001), ANALINoGd (HR = 6.42, p < 0.001), ANALIGdHBP (HR = 3.66, p < 0.001) and ANALIGdAP (HR = 3.79, p < 0.001). Multivariate analysis identified the PFS, all three ANALI scores, and Revised Mayo Risk Score as independent risk factors for outcomes (HR 3.12, p < 0.001; 6.12, p < 0.001; 3.56, p < 0.001;3.59, p < 0.001; and 4.13, p < 0.001, respectively). CONCLUSION ANALINoGd and GA-MRI-derived ANALI scores and PFS could noninvasively predict outcomes in PSC patients. CLINICAL RELEVANCE STATEMENT The combined use of Anali scores and the potential functional stricture (PFS), both derived from unenhanced-, and gadoxetic acid enhanced-MRI, could be applied as a diagnostic and prognostic imaging surrogate for counselling and monitoring primary sclerosing cholangitis patients. KEY POINTS Primary sclerosing cholangitis patients require radiological monitoring to assess disease stability and for the presence and type of complications. A contrast-enhanced MRI algorithm based on potential functional stricture and ANALI scores risk-stratified these patients. Unenhanced ANALI score had a high negative predictive value, indicating some primary sclerosing cholangitis patients can undergo non-contrast MRI surveillance.
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Affiliation(s)
- Sarah Poetter-Lang
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Ahmed Ba-Ssalamah
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria.
| | - Alina Messner
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Nina Bastati
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Raphael Ambros
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Antonia Kristic
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Jakob Kittinger
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Svitlana Pochepnia
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Sami A Ba-Ssalamah
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Jacqueline C Hodge
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sudhakar K Venkatesh
- Department of Abdominal Imaging, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Nikolaos Kartalis
- Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Kristina Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Lionel Arrivé
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris (APHP) and Sorbonne University, Paris, France
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Färkkilä M, Åberg F, Alfthan H, Jokelainen K, Puustinen L, Kautiainen H, Tenca A. Surrogate markers of bile duct disease progression in primary sclerosing cholangitis - A prospective study with repeated ERCP examinations. JHEP Rep 2024; 6:101161. [PMID: 39290402 PMCID: PMC11405802 DOI: 10.1016/j.jhepr.2024.101161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/14/2024] [Accepted: 06/25/2024] [Indexed: 09/19/2024] Open
Abstract
Background & Aims Validated prognostic tools for estimating short-term bile duct disease progression in primary sclerosing cholangitis (PSC) are lacking. We evaluated the predictive value of serum and biliary biochemistry for the progression of bile duct disease in PSC using repeated endoscopic retrograde cholangiopancreatography (ERCP) examinations to identify surrogate markers for more personalized surveillance. Methods We conducted a prospective analysis including patients with PSC who underwent ERCP for confirmation of diagnosis, monitoring of disease progression, or dysplasia surveillance. ERCP findings were scored, and dilatation was performed if a dominant stricture was diagnosed or if a cytology brush could not be passed. Bile samples were aspirated for biliary IL8 and calprotectin. We analysed optimal cut-off values and AUCs for 20 laboratory markers and evaluated their association with the time to an ERCP score increase of ≥2 points or first dilatation, whichever came first. Of the 1,002 patients, 653 had ≥2 ERCP examinations and ≥3 years of follow-up. After excluding patients with PSC-overlap syndrome or initial dilatation, 398 patients were included. Results Of the patients included, 62% had mild or moderate and 38% had advanced bile duct disease. During follow-up, 41% of patients demonstrated progression of disease. Biliary calprotectin (AUC 0.76; 95% CI 0.69 to 0.82) and IL8 (AUC 0.76; 95% CI 0.69 to 0.84) were the only variables that demonstrated predictive value for disease progression and/or need for dilatation. Conclusions Biliary calprotectin and IL8 are promising surrogate markers for identifying patients with PSC at risk of progression and determining the timing for subsequent imaging. Conventional liver function tests may not be sensitive or specific enough to monitor PSC progression, particularly in the short term. Impact and implications Validated prognostic tools for estimating short-term bile duct disease progression in primary sclerosing cholangitis are lacking. In this prospective study, based on sequential endoscopic retrograde cholangiopancreatography examinations, biliary calprotectin and IL8 levels turned out to be more sensitive for predicting bile duct progression than traditional liver function tests, such as alkaline phosphatase, in the short term. These findings could lead to more personalized patient surveillance and improve clinical practice by providing a more accurate method for monitoring disease progression and treatment responses. Additionally, these markers have potential as surrogate endpoints in clinical drug trials. The limitation is that measurement of biliary IL8 and calprotectin requires endoscopic retrograde cholangiopancreatography with bile sampling.
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Affiliation(s)
- Martti Färkkilä
- Helsinki University, Finland
- Department of Gastroenterology, Helsinki University Hospital, Abdominal Center, Helsinki, Finland
| | - Fredrik Åberg
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Henrik Alfthan
- Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kalle Jokelainen
- Department of Gastroenterology, Helsinki University Hospital, Abdominal Center, Helsinki, Finland
| | - Lauri Puustinen
- Department of Gastroenterology, Helsinki University Hospital, Abdominal Center, Helsinki, Finland
| | - Hannu Kautiainen
- Folkhälsan Research Center, Helsinki, Finland and Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Andrea Tenca
- Department of Gastroenterology, Helsinki University Hospital, Abdominal Center, Helsinki, Finland
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Trivedi PJ, Arndtz K, Abbas N, Telford A, Young L, Banerjee R, Eddowes P, Jhaveri KS, Hirschfield GM. Quantitative MRCP and metrics of bile duct disease over time in patients with primary sclerosing cholangitis: A prospective study. Aliment Pharmacol Ther 2024; 59:1366-1375. [PMID: 38571284 DOI: 10.1111/apt.17944] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/13/2024] [Accepted: 02/28/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Imaging markers of biliary disease in primary sclerosing cholangitis (PSC) have potential for use in clinical and trial disease monitoring. Herein, we evaluate how quantitative magnetic resonance cholangiopancreatography (MRCP) metrics change over time, as per the natural history of disease. METHODS Individuals with PSC were prospectively scanned using non-contrast MRCP. Quantitative metrics were calculated using MRCP+ post-processing software to assess duct diameters and dilated and strictured regions. Additionally, a hepatopancreatobiliary radiologist (blinded to clinical details, biochemistry and quantitative biliary metrics) reported each scan, including ductal disease assessment according to the modified Amsterdam Cholangiographic Score (MAS). RESULTS At baseline, 14 quantitative MRCP+ metrics were found to be significantly different in patients with PSC (N = 55) compared to those with primary biliary cholangitis (N = 55), autoimmune hepatitis (N = 57) and healthy controls (N = 18). In PSC specifically, baseline metrics quantifying the number of strictures and the number and length of bile ducts correlated with the MAS, transient elastography and serum ALP values (p < 0.01 for all correlations). Over a median 371-day follow-up (range: 364-462), 29 patients with PSC underwent repeat MRCP, of whom 15 exhibited quantitative changes in MRCP+ metrics. Compared to baseline, quantitative MRCP+ identified an increasing number of strictures over time (p < 0.05). Comparatively, no significant differences in biochemistry, elastography or the MAS were observed between timepoints. Quantitative MRCP+ metrics remained stable in non-PSC liver disease. CONCLUSION Quantitative MRCP+ identifies changes in ductal disease over time in PSC, despite stability in biochemistry, liver stiffness and radiologist-derived cholangiographic assessment (trial registration: ISRCTN39463479).
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katherine Arndtz
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nadir Abbas
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
| | | | | | | | - Peter Eddowes
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research and Gastrointestinal Research, National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- NIHR Nottingham BRC, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kartik S Jhaveri
- Division of Radiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gideon M Hirschfield
- University Health Network and Department of Medicine, Toronto Centre for Liver Disease, University of Toronto, Toronto, Ontario, Canada
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Hussain N, Trivedi PJ. Risk Stratification in Primary Sclerosing Cholangitis: Does Size Matter? Dig Dis Sci 2024; 69:1083-1087. [PMID: 38347370 DOI: 10.1007/s10620-023-08262-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 04/19/2024]
Affiliation(s)
- Nasir Hussain
- National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
| | - Palak J Trivedi
- National Institute of Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK.
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK.
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Cornillet M, Villard C, Rorsman F, Molinaro A, Nilsson E, Kechagias S, von Seth E, Bergquist A. The Swedish initiative for the st udy of Primary sclerosing cholangitis (SUPRIM). EClinicalMedicine 2024; 70:102526. [PMID: 38500838 PMCID: PMC10945116 DOI: 10.1016/j.eclinm.2024.102526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024] Open
Abstract
Background Despite more than 50 years of research and parallel improvements in hepatology and oncology, there is still today neither a treatment to prevent disease progression in primary sclerosing cholangitis (PSC), nor reliable early diagnostic tools for the associated hepatobiliary cancers. Importantly, the limited understanding of the underlying biological mechanisms in PSC and its natural history not only affects the identification of new drug targets but implies a lack of surrogate markers that hampers the design of clinical trials and the evaluation of drug efficacy. The lack of easy access to large representative well-characterised prospective resources is an important contributing factor to the current situation. Methods We here present the SUPRIM cohort, a national multicentre prospective longitudinal study of unselected PSC patients capturing the representative diversity of PSC phenotypes. We describe the 10-year effort of inclusion and follow-up, an intermediate analysis report including original results, and the associated research resource. All included patients gave written informed consent (recruitment: November 2011-April 2016). Findings Out of 512 included patients, 452 patients completed the five-year follow-up without endpoint outcomes. Liver transplantation was performed in 54 patients (10%) and hepatobiliary malignancy was diagnosed in 15 patients (3%). We draw a comprehensive landscape of the multidimensional clinical and biological heterogeneity of PSC illustrating the diversity of PSC phenotypes. Performances of available predictive scores are compared and perspectives on the continuation of the SUPRIM cohort are provided. Interpretation We envision the SUPRIM cohort as an open-access collaborative resource to accelerate the generation of new knowledge and independent validations of promising ones with the aim to uncover reliable diagnostics, prognostic tools, surrogate markers, and new treatment targets by 2040. Funding This work was supported by the Swedish Cancer Society, Stockholm County Council, and the Cancer Research Funds of Radiumhemmet.
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Affiliation(s)
- Martin Cornillet
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Christina Villard
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Akademiska University Hospital, Uppsala, Sweden
| | - Antonio Molinaro
- Department of Hepatology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Emma Nilsson
- Gastroenterology Clinic, Skåne University Hospital, Sweden
| | - Stergios Kechagias
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik von Seth
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Bergquist
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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Trauner M, Halilbasic E, Tatscher E, Fickert P. [Primary sclerosing cholangitis-Diagnosis and treatment 2024]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:347-356. [PMID: 38498179 PMCID: PMC10959807 DOI: 10.1007/s00108-024-01697-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
The etiology of primary sclerosing cholangitis (PSC) remains unclear, which explains in part the lack of a causal treatment. The differential diagnostic distinction from the even rarer immunoglobulin 4 (IgG4)-associated cholangitis (IAC) is becoming increasingly more successful. Advances in the understanding of different clinical courses, improvements in noninvasive diagnostics through modern magnetic resonance imaging (MRI) and the introduction of liver elastography have led to the development of improved prognostic models. The evidence for recommendations on medicinal (e.g., ursodeoxycholic acid) or endoscopic treatment (e.g., balloon dilatation and/or stent insertion) for PSC is still low. In contrast, the long-term results of liver transplantation in PSC patients are constantly improving. Due to the lack of highly sensitive and specific screening methods the early recognition of cholangiocellular carcinoma (CCC) as the most important complication is rarely successful. The continuous improvement of endoscopic retrograde cholangiopancreatography (ERCP) and direct cholangioscopy in combination with molecular biological and fluorescence in situ hybridization (FISH) analyses of bile duct tissue samples are promising for refined diagnostics. Due to the significantly increased risk of colorectal cancer, an annual colonoscopy is recommended in the presence of inflammatory bowel disease. Improvement of the early diagnostics of PSC and successful testing of new treatment strategies raise hope for a continuous improvement in the medical support of these complex patients.
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Affiliation(s)
- Michael Trauner
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Emina Halilbasic
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Elisabeth Tatscher
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Peter Fickert
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
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10
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De Muynck K, Devisscher L. Targeting osteopontin to treat primary sclerosing cholangitis. Curr Opin Gastroenterol 2024; 40:77-84. [PMID: 38190383 DOI: 10.1097/mog.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW Primary sclerosing cholangitis is a chronic cholestatic liver disease for which no pharmacological treatment options are available. It is an immune-mediated disease and macrophages have been implicated in disease pathogenesis. However, which specific macrophage populations contribute to disease, and how we can apply this as therapeutic strategy is still unclear. RECENT FINDINGS Recent studies have shown that fibrous tissue is characterized by osteopontin-positive macrophages, including in patients with primary sclerosing cholangitis. Experimental models indicate that intracellular osteopontin in macrophages confers protection, while secreted osteopontin contributes to disease. Serum osteopontin is increased in different liver diseases, including primary sclerosing cholangitis, and might thus serve as therapeutic target. SUMMARY Although several studies report on the role of osteopontin in liver disease, only a minority of the studies have focused on isoform-specific functions, and the importance of the cellular source of secreted osteopontin. Future studies investigating these aspects, and how this can be translated to therapies for primary sclerosing cholangitis, and other chronic liver diseases, are required.
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Affiliation(s)
- Kevin De Muynck
- Gut-Liver ImmunoPharmacology unit, Basic and Applied Medical Sciences, Ghent University; Liver Research Center Ghent, Ghent University, University Hostpital Ghent, Belgium
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11
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Poetter-Lang S, Messner A, Bastati N, Ringe KI, Ronot M, Venkatesh SK, Ambros R, Kristic A, Korajac A, Dovjak G, Zalaudek M, Hodge JC, Schramm C, Halilbasic E, Trauner M, Ba-Ssalamah A. Diagnosis of functional strictures in patients with primary sclerosing cholangitis using hepatobiliary contrast-enhanced MRI: a proof-of-concept study. Eur Radiol 2023; 33:9022-9037. [PMID: 37470827 PMCID: PMC10667158 DOI: 10.1007/s00330-023-09915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 04/20/2023] [Accepted: 05/09/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES PSC strictures are routinely diagnosed on T2-MRCP as dominant- (DS) or high-grade stricture (HGS). However, high inter-observer variability limits their utility. We introduce the "potential functional stricture" (PFS) on T1-weighted hepatobiliary-phase images of gadoxetic acid-enhanced MR cholangiography (T1-MRC) to assess inter-reader agreement on diagnosis, location, and prognostic value of PFS on T1-MRC vs. DS or HGS on T2-MRCP in PSC patients, using ERCP as the gold standard. METHODS Six blinded readers independently reviewed 129 MRIs to diagnose and locate stricture, if present. DS/HGS was determined on T2-MRCP. On T1-MRC, PFS was diagnosed if no GA excretion was seen in the CBD, hilum or distal RHD, or LHD. If excretion was normal, "no functional stricture" (NFS) was diagnosed. T1-MRC diagnoses (NFS = 87; PFS = 42) were correlated with ERCP, clinical scores, labs, splenic volume, and clinical events. Statistical analyses included Kaplan-Meier curves and Cox regression. RESULTS Interobserver agreement was almost perfect for NFS vs. PFS diagnosis, but fair to moderate for DS and HGS. Forty-four ERCPs in 129 patients (34.1%) were performed, 39 in PFS (92.9%), and, due to clinical suspicion, five in NFS (5.7%) patients. PFS and NFS diagnoses had 100% PPV and 100% NPV, respectively. Labs and clinical scores were significantly worse for PFS vs. NFS. PFS patients underwent more diagnostic and therapeutic ERCPs, experienced more clinical events, and reached significantly more endpoints (p < 0.001) than those with NFS. Multivariate analysis identified PFS as an independent risk factor for liver-related events. CONCLUSION T1-MRC was superior to T2-MRCP for stricture diagnosis, stricture location, and prognostication. CLINICAL RELEVANCE STATEMENT Because half of PSC patients will develop clinically-relevant strictures over the course of the disease, earlier more confident diagnosis and correct localization of functional stricture on gadoxetic acid-enhanced MRI may optimize management and improve prognostication. KEY POINTS • There is no consensus regarding biliary stricture imaging features in PSC that have clinical relevance. • Twenty-minute T1-weighted MRC images correctly classified PSC patients with potential (PFS) vs with no functional stricture (NFS). • T1-MRC diagnoses may reduce the burden of diagnostic ERCPs.
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Affiliation(s)
- Sarah Poetter-Lang
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Alina Messner
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Nina Bastati
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Kristina I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Maxime Ronot
- Department of Medical Imaging at the Beaujon University Hospital in Clichy, University of Paris, Clichy, France
| | - Sudhakar K Venkatesh
- Division of Abdominal Imaging, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Raphael Ambros
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Antonia Kristic
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Aida Korajac
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Gregor Dovjak
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Martin Zalaudek
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Jacqueline C Hodge
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Christoph Schramm
- Department of Gastroenterology, Hepatology, University Medical Center Hamburg - Eppendorf, Hamburg, Germany
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, General Hospital of Vienna (AKH), Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, General Hospital of Vienna (AKH), Vienna, Austria
| | - Ahmed Ba-Ssalamah
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria.
- Department of Biomedical Imaging and Image-Guided Therapy, General Hospital of Vienna (AKH), Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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12
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Russo MW. Noninvasive prognostic models, imaging, and elastography to predict clinical events in primary sclerosing cholangitis: A review. World J Hepatol 2023; 15:1013-1020. [PMID: 37900215 PMCID: PMC10600698 DOI: 10.4254/wjh.v15.i9.1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/17/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023] Open
Abstract
Surrogate endpoints are needed to estimate clinical outcomes in primary sclerosing cholangitis (PSC). Serum alkaline phosphatase was among the first markers studied, but there is substantial variability in alkaline phosphatase levels during the natural history of PSC without intervention. The Mayo risk score incorporates noninvasive variables and has served as a surrogate endpoint for survival for more than two decades. Newer models have better test performance than the Mayo risk score, including the primary sclerosing risk estimate tool (PREsTo) model and UK-PSC score that estimate hepatic decompensation and transplant free survival, respectively. The c-statistics for transplant-free survival for the Mayo risk model and the long-term UK-PSC model are 0.68 and 0.85, respectively. The c-statistics for hepatic decompensation for the Mayo risk model and PREsTo model are 0.85 and 0.90, respectively. The Amsterdam-Oxford model included patients with large duct and small duct PSC and patients with PSC-autoimmune hepatitis overlap and had a c-statistic of 0.68 for transplant-free survival. Other noninvasive tests that warrant further validation include magnetic resonance imaging, elastography and the enhanced liver fibrosis score. Prognostic models, noninvasive tests or a combination of these surrogate endpoints may not only serve to be useful in clinical trials of investigational agents, but also serve to inform our patients about their prognosis.
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC 28204, United States.
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13
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Assis DN, Bowlus CL. Recent Advances in the Management of Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2023; 21:2065-2075. [PMID: 37084929 DOI: 10.1016/j.cgh.2023.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by fibroinflammatory damage to the biliary tree, typically in the setting of inflammatory bowel disease, with an increased risk of liver failure and cholangiocarcinoma. A complex pathophysiology, heterogeneity in clinical features, and the rare nature of the disease have contributed to the lack of effective therapy to date. However, recent innovations in the characterization and prognostication of patients with PSC, in addition to new tools for medical management and emerging pharmacologic agents, give rise to the potential for meaningful progress in the next several years. This review summarizes current concepts in PSC and highlights particular areas in need of further study.
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14
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Mulinacci G, Cristoferi L, Palermo A, Luca M, Gerussi A, Invernizzi P, Carbone M. Risk stratification in primary sclerosing cholangitis. Minerva Gastroenterol (Torino) 2023; 69:84-94. [PMID: 33300753 DOI: 10.23736/s2724-5985.20.02821-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic liver disorder commonly affecting young patients and associated with uncertain prognosis and elevated risk of end-stage liver disease and hepatobiliary cancer. Rate of progression in PSC is heterogeneous and accurately predicting the disease course is of paramount importance to clinical practice and interventional trial design. So far, efforts have brought to the development of models looking at short-to-middle-term outcome using composite models including clinical, laboratory, radiological and histological parameters with limited performance. In the era of whole genome sequencing and digital innovation, the time is ripe for the development of stratified medicine in PSC. Efforts should be directed toward developing well-phenotyped cohorts of patients with longitudinal follow-up across sustained periods of time, application of novel image-processing technology, and biomarker discovery using multiomics platforms.
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Affiliation(s)
- Giacomo Mulinacci
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Laura Cristoferi
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Andrea Palermo
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Martina Luca
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Alessio Gerussi
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, Center for Autoimmune Liver Diseases, University of Milan Bicocca, Milan, Italy - .,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
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15
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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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16
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O’Brien C, Malik M, Jhaveri K. MR Imaging in Primary Sclerosing Cholangitis and Other Cholangitis. Radiol Clin North Am 2022; 60:843-856. [DOI: 10.1016/j.rcl.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Evaluation of Inhibitory Antibodies against the Muscarinic Acetylcholine Receptor Type 3 in Patients with Primary Biliary Cholangitis and Primary Sclerosing Cholangitis. J Clin Med 2022; 11:jcm11030681. [PMID: 35160133 PMCID: PMC8836427 DOI: 10.3390/jcm11030681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/16/2022] [Accepted: 01/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) constitute rare chronic inflammatory biliary diseases which likely comprise genetic, environmental and autoimmune factors. Specific inhibitory (auto-) antibodies against the muscarinic acetylcholine receptor type 3 (mAChR3 auto-ab) may contribute to the pathogenesis of chronic biliary inflammation by modulating mAChR3− mediated signaling. Aims: The aim of this study was to analyze the prevalence and relevance of inhibitory mAChR3 auto-ab (mAChR3inh+ auto-ab) in a large cohort of PBC patients from two independent tertiary centers in Berlin and Leipzig in comparison to a large PSC cohort. Baseline parameters and response rates to standard treatment with ursodeoxycholic acid (UDCA) were characterized with respect to the individual mAChR3 auto-ab status. Methods: In total, the study population comprised 437 PBC patients, 187 PSC patients and 80 healthy controls. Clinical and laboratory baseline characteristics were retrieved from medical records. The response to ursodeoxycholic acid (UDCA) therapy after 12 months of treatment was available in 176 PBC and 45 PSC patients. Results: The prevalence of mAChR3inh+ auto-ab was significantly higher among PBC patients (11.2%, 49/437; p = 0.008 vs. healthy controls) and PSC patients (33.6%, 63/187; p < 0.0001 vs. healthy controls) compared to healthy controls (2.5%, 2/80), respectively. PBC patients with mAChR3inh+ auto-ab exhibited significantly higher levels of alkaline phosphatase (ALP) and bilirubin, which constitute established parameters for PBC risk stratification. Moreover, mAChR3inh+ PBC patients tended to show decreased response rates to UDCA therapy compared to PBC patients without mAChR3inh+ auto-ab (mAChR3− PBC). In contrast, PSC patients with mAChR3inh+ auto-ab showed no significant differences in laboratory findings compared to mAChR3 auto-ab negative (mAChR3−) PSC patients. Conclusion: MAChR3inh+ auto-ab might be involved in the pathogenesis and treatment response of chronic biliary inflammation in patients with PBC but not in patients with PSC.
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18
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Diagnosis of Primary Sclerosing Cholangitis Beyond Childhood is Associated with Worse Outcomes. J Clin Exp Hepatol 2022; 12:110-117. [PMID: 35068791 PMCID: PMC8766535 DOI: 10.1016/j.jceh.2021.03.006] [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: 06/23/2020] [Accepted: 03/16/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The elucidation of differences between adult and pediatric-onset primary sclerosing cholangitis (PSC) may inform clinical decision making, and whether results of adult PSC clinical trials can be extrapolated to pediatric subjects. METHODS A single-center retrospective analysis of PSC subjects diagnosed during the epoch 2000-13 was conducted. Demographic, clinical, and laboratory data were compared between PSC subjects diagnosed between 0-18 (pediatric) and 19+ (adult) years of age. An adverse outcome was defined as PSC-related death, liver transplant, or malignancy. Survival without any of these was defined as event-free survival. RESULTS Analyses of 28 pediatric-diagnosed and 59 adult-diagnosed subjects revealed that incidence of early portal hypertension (PHT; P = 0.2), laboratory parameters of liver disease severity, and fibrosis grade at diagnosis were comparable between adult and pediatric PSC subjects. Adult-diagnosed PSC subjects had higher incidences of adverse outcomes compared to pediatric-diagnosed PSC subjects (P = 0.02). The age group 0-18 years (n = 30) had significantly better event-free survival compared to the age group more than 40 years (n = 25; P = 0.03). The prevalence of PHT in adult PSC subjects was 2.6 that of pediatric PSC subjects. PHT adversely affected outcomes in both adult (P < 0.001) and pediatric (P = 0.01) subjects. Adult PSC subjects were more likely to develop biliary complications (BCs; P = 0.001), ascites (P = 0.004), and variceal bleed (P = 0.03). Adult PSC subjects were more likely to have extra-hepatic co-morbidities (P < 0.001). Adult subjects had a longer follow-up duration compared to pediatric subjects (P = 0.06). CONCLUSION Despite having a comparable clinical, laboratory, and histologic biomarkers of liver disease severity at the time of diagnosis, adult PSC subjects had a worse outcome compared to pediatric PSC subjects. Possible reasons for this finding include higher incidence of PHT, BCs, extra-hepatic co-morbidities, and longer duration of follow-up.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- ERCP, endoscopic cholangiopancreatography
- GGT, gamma-glutamyl transferase
- GI, gastrointestinal
- IBD, inflammatory bowel disease
- INR, international normalized ratio
- MR imaging, magnetic resonance imaging
- MRCP, magnetic resonance cholangiopancreatography
- PHT, portal hypertension
- PSC, primary sclerosing cholangitis
- age
- cholangitis
- outcome
- primary
- sclerosing
- x ULN, times upper limit of normal
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19
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Floreani A, De Martin S. Treatment of primary sclerosing cholangitis. Dig Liver Dis 2021; 53:1531-1538. [PMID: 34011480 DOI: 10.1016/j.dld.2021.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive fibro-stenotic strictures and destruction of the biliary tree. Currently, there is no effective treatment which can delay its progression or ameliorate the transplant-free survival. Moreover, a major chontroversy in PSC is whether to use UDCA. More recently, novel pharmacological agents emerged aiming at: i) modulation of bile composition; ii) immunomodulation; iii) targeting the gut microbiome; iv) targeting fibrosis. Successful PSC therapy, however, will be most likely a personalized combination of different drugs plus endoscopic treatment. This review aims at offering an overview on the experimental pharmacological strategies currently exploited for PSC treatment.
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Affiliation(s)
- Annarosa Floreani
- Scientific Consultant, Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy; Senior Scholar, University of Padova, Padova, Italy.
| | - Sara De Martin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Italy
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20
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Selvaraj EA, Ba-Ssalamah A, Poetter-Lang S, Ridgway GR, Brady JM, Collier J, Culver EL, Bailey A, Pavlides M. A Quantitative Magnetic Resonance Cholangiopancreatography Metric of Intrahepatic Biliary Dilatation Severity Detects High-Risk Primary Sclerosing Cholangitis. Hepatol Commun 2021; 6:795-808. [PMID: 34802195 PMCID: PMC8948671 DOI: 10.1002/hep4.1860] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI‐MRCP) in primary sclerosing cholangitis (PSC) is currently based on qualitative assessment and has high interobserver variability. We investigated the utility and performance of quantitative metrics derived from a three‐dimensional biliary analysis tool in adult patients with PSC. MRI‐MRCP, blood‐based biomarkers, and FibroScan were prospectively performed in 80 participants with large‐duct PSC and 20 healthy participants. Quantitative analysis was performed using MRCP+ (Perspectum Ltd., United Kingdom), and qualitative reads were performed by radiologists. Inter‐reader agreements were compared. Patients were classified into high risk or low risk for disease progression, using Mayo risk score (MRS), Amsterdam‐Oxford model (AOM), upper limit of normal (ULN) alkaline phosphatase (ALP), disease distribution, and presence of dominant stricture. Performance of noninvasive tools was assessed using binomial logistic regressions and receiver operating characteristic curve analyses. Quantitative biliary metrics performed well to distinguish abnormal from normal bile ducts (P < 0.0001). Interobserver agreements for MRCP+ dilatation metrics (intraclass correlation coefficient, 0.90‐0.96) were superior to modified Amsterdam intrahepatic stricture severity score (κ = 0.74) and Anali score (κ = 0.38). MRCP+ intrahepatic dilatation severity showed excellent performance to classify patients into high‐risk and low‐risk groups, using predictors of disease severity as the reference (MRS, P < 0.0001; AOM, P = 0.0017; 2.2 × ULN ALP, P = 0.0007; 1.5 × ULN ALP, P = 0.0225; extrahepatic disease, P = 0.0331; dominant stricture, P = 0.0019). MRCP+ intrahepatic dilatation severity was an independent predictor of MRS >0 (odds ratio, 31.3; P = 0.035) in the multivariate analysis. Conclusion: Intrahepatic biliary dilatation severity calculated using MRCP+ is elevated in patients with high‐risk PSC and may be used as an adjunct for risk stratification in PSC. This exploratory study has provided the groundwork for examining the utility of novel quantitative biliary metrics in multicenter studies.
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Affiliation(s)
- Emmanuel A Selvaraj
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Ahmed Ba-Ssalamah
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, General Hospital of Vienna, Vienna, Austria
| | - Sarah Poetter-Lang
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, General Hospital of Vienna, Vienna, Austria
| | | | - J Michael Brady
- Perspectum Ltd., Oxford, United Kingdom.,Department of Oncology, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Jane Collier
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Emma L Culver
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Adam Bailey
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Michael Pavlides
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.,Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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21
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Schmeltzer PA, Russo MW. Systematic Review of Prognostic Models Compared to the Mayo Risk Score for Primary Sclerosing Cholangitis. J Clin Med 2021; 10:jcm10194476. [PMID: 34640494 PMCID: PMC8509587 DOI: 10.3390/jcm10194476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Primary sclerosing cholangitis (PSC) is a cholestatic liver disease with a variable clinical course that can ultimately lead to end-stage liver disease, cholangiocarcinoma, and the need for liver transplantation. Several prognostic models have been developed to predict clinical outcomes and have been compared to the revised Mayo Risk Score (rMRS). Aim: To conduct a systematic review comparing the rMRS to other non-invasive prognostic tests for PSC. Methods: A systematic review of studies from 2000 to 2020 was performed that compared non-invasive biochemical prognostic models to the rMRS in predicting outcomes in patients with PSC. Results: Thirty-seven studies were identified, of which five studies that collectively included 3230 patients were reviewed. Outcomes included transplant-free survival or composite clinical outcomes. The rMRS was better than the Amsterdam–Oxford model for predicting 1-year transplant-free survival, c-statistics 0.75 and 0.70, respectively. The UK-PSC score outperformed the rMRS for 10-year transplant-free survival, c-statistics 0.85 and 0.69, respectively. An enhanced liver fibrosis score was independently associated with transplant-free survival after adjusting for rMRS. PREsTo predicts 5-year hepatic decompensation with a c-statistic modestly higher than rMRS; 0.90 and 0.85, respectively. Conclusion: Newer prognostic models, including the UK-PSC score and PREsTo, are more accurate at predicting clinical endpoints in PSC compared to the rMRS. Time frames and clinical endpoints are not standard among studies.
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Berzigotti A, Tsochatzis E, Boursier J, Castera L, Cazzagon N, Friedrich-Rust M, Petta S, Thiele M. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021; 75:659-689. [PMID: 34166721 DOI: 10.1016/j.jhep.2021.05.025] [Citation(s) in RCA: 1007] [Impact Index Per Article: 251.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 02/07/2023]
Abstract
Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years.
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Sjöblom N, Boyd S, Manninen A, Knuuttila A, Blom S, Färkkilä M, Arola J. Chronic cholestasis detection by a novel tool: automated analysis of cytokeratin 7-stained liver specimens. Diagn Pathol 2021; 16:41. [PMID: 33957930 PMCID: PMC8101247 DOI: 10.1186/s13000-021-01102-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background The objective was to build a novel method for automated image analysis to locate and quantify the number of cytokeratin 7 (K7)-positive hepatocytes reflecting cholestasis by applying deep learning neural networks (AI model) in a cohort of 210 liver specimens. We aimed to study the correlation between the AI model’s results and disease progression. The cohort of liver biopsies which served as a model of chronic cholestatic liver disease comprised of patients diagnosed with primary sclerosing cholangitis (PSC). Methods In a cohort of patients with PSC identified from the PSC registry of the University Hospital of Helsinki, their K7-stained liver biopsy specimens were scored by a pathologist (human K7 score) and then digitally analyzed for K7-positive hepatocytes (K7%area). The digital analysis was by a K7-AI model created in an Aiforia Technologies cloud platform. For validation, values were human K7 score, stage of disease (Metavir and Nakunuma fibrosis score), and plasma liver enzymes indicating clinical cholestasis, all subjected to correlation analysis. Results The K7-AI model results (K7%area) correlated with the human K7 score (0.896; p < 2.2e− 16). In addition, K7%area correlated with stage of PSC (Metavir 0.446; p < 1.849e− 10 and Nakanuma 0.424; p < 4.23e− 10) and with plasma alkaline phosphatase (P-ALP) levels (0.369, p < 5.749e− 5). Conclusions The accuracy of the AI-based analysis was comparable to that of the human K7 score. Automated quantitative image analysis correlated with stage of PSC and with P-ALP. Based on the results of the K7-AI model, we recommend K7 staining in the assessment of cholestasis by means of automated methods that provide fast (9.75 s/specimen) quantitative analysis. Supplementary Information The online version contains supplementary material available at 10.1186/s13000-021-01102-6.
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Affiliation(s)
- Nelli Sjöblom
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 3, 00290, Helsinki, Finland.
| | - Sonja Boyd
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 3, 00290, Helsinki, Finland
| | - Anniina Manninen
- Aiforia Technologies Oy, Tukholmankatu 8, 000290, Helsinki, Finland
| | - Anna Knuuttila
- Aiforia Technologies Oy, Tukholmankatu 8, 000290, Helsinki, Finland
| | - Sami Blom
- Aiforia Technologies Oy, Tukholmankatu 8, 000290, Helsinki, Finland
| | - Martti Färkkilä
- Department of Gastroenterology, University of Helsinki and Helsinki University Hospital, 00290, Helsinki, Finland
| | - Johanna Arola
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 3, 00290, Helsinki, Finland
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Elkilany A, Geisel D, Müller T, Fischer A, Denecke T. Gadoxetic acid-enhanced MRI in primary sclerosing cholangitis: added value in assessing liver function and monitoring disease progression. Abdom Radiol (NY) 2021; 46:979-991. [PMID: 32918576 PMCID: PMC8257540 DOI: 10.1007/s00261-020-02731-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 11/12/2022]
Abstract
PURPOSE To investigate the added value of gadoxetic acid-enhanced MRI in monitoring liver function and disease progression in patients with primary sclerosing cholangitis (PSC). METHODS We retrospectively identified 104 consecutive patients (75 males; mean age 41.98 ± 12.5 years) with confirmed diagnosis of PSC who underwent 227 gadoxetic acid-enhanced MRI examinations between January 2008 and May 2019. Relative enhancement (RE) of the liver was correlated with the results of liver function tests (LFTs), scoring models (Model for End-Stage Liver Disease (MELD) score, Mayo Risk Score (MRS), Amsterdam-Oxford model (AOM)), and qualitative MRI findings. In addition, results were analyzed separately for excretory MRI examinations (n = 164) and nonexcretory examinations (n = 63) depending on excretion of gadoxetic acid into the common bile duct in the hepatobiliary phase (HBP). RESULTS There was a significant correlation of RE with MRS (r = - 0.652), MELD score (r = - 0.474), AOM (r = - 0.468), and LFTs (P < 0.001). RE and albumin were significantly higher in the excretory group whereas scoring models, bilirubin, aspartate aminotransferase, alkaline phosphatase, and international normalized ratio were lower (P < 0.001). RE was lower in segments with absent HBP gadoxetic acid excretion into dilated bile ducts, reduced HBP parenchymal enhancement, atrophy, T2 hyperintensity, and bile duct abnormalities (P < 0.001). CONCLUSION Relative enhancement of the liver in gadoxetic acid-enhanced MRI can be used to evaluate global and regional liver function and monitor disease progression in patients with PSC. Hepatobiliary phase gadoxetic acid biliary excretion appears to be a reproducible qualitative parameter for evaluating disease severity that can be easily integrated into routine clinical practice.
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Affiliation(s)
- Aboelyazid Elkilany
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Dominik Geisel
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tobias Müller
- Division of Gastroenterology and Hepatology, Department of Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Fischer
- Division of Gastroenterology and Hepatology, Department of Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Leipzig, Leipzig, Germany
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25
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Engel B, Taubert R, Jaeckel E, Manns MP. The future of autoimmune liver diseases - Understanding pathogenesis and improving morbidity and mortality. Liver Int 2020; 40 Suppl 1:149-153. [PMID: 32077605 DOI: 10.1111/liv.14378] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune liver diseases (AILD), namely autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), are rare diseases. These days, patients with PBC almost never require liver transplantation. When treated early with ursodeoxycholic acid patients have a normal life expectancy if the disease is diagnosed at an early stage and the patients respond to treatment. Patients with AIH often go into remission with first-line therapy including corticosteroids alone or in combination with azathioprine. Nevertheless, about one quarter of patients already developed cirrhosis at diagnosis. Those who do not respond to first line standard of care (SOC) have significant liver-related morbidity and mortality. No approved second- or third-line treatments are available and the drugs are selected based on limited case series and personal experience. Larger trials are needed to develop efficient therapies for difficult-to-treat AIH patients. No treatment has been found to alter the natural course of disease in patients with PSC except for liver transplantation. Identifying PSC patients at risk of developing cholangiocarcinoma (CCA) is another unmet need. Current research in all AILD including AIH, PBC and PSC, focuses on improving our understanding of the underlying disease process and identifying new therapeutic targets to decrease morbidity and mortality.
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Affiliation(s)
- Bastian Engel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
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26
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Shung DL, Assis DN. Machine Learning in a Complex Disease: PREsTo Improves the Prognostication of Primary Sclerosing Cholangitis. Hepatology 2020; 71:8-10. [PMID: 31850533 PMCID: PMC11925712 DOI: 10.1002/hep.31069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/10/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Dennis L Shung
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - David N Assis
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, CT
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27
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Goode EC, Hirschfield GM, Rushbrook SM. Reply. Hepatology 2020; 71:399-400. [PMID: 31550385 DOI: 10.1002/hep.30963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Elizabeth C Goode
- Norfolk and Norwich University Hospital, Norwich, United Kingdom.,Academic Department of Medical Genetics, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Wellcome Trust Sanger Institute, Hinxton, Cambridge, United Kingdom.,Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Cambridge Transplant Centre, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, United Kingdom.,Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Centre for Rare Diseases, Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, United Kingdom.,Toronto Centre for Liver Disease, University Health Network and University of Toronto, Toronto, Canada
| | - Simon M Rushbrook
- Norfolk and Norwich University Hospital, Norwich, United Kingdom.,Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Emerging therapies in primary sclerosing cholangitis: pathophysiological basis and clinical opportunities. J Gastroenterol 2020; 55:588-614. [PMID: 32222826 PMCID: PMC7242240 DOI: 10.1007/s00535-020-01681-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a progressive liver disease, histologically characterized by inflammation and fibrosis of the bile ducts, and clinically leading to multi-focal biliary strictures and with time cirrhosis and liver failure. Patients bear a significant risk of cholangiocarcinoma and colorectal cancer, and frequently have concomitant inflammatory bowel disease and autoimmune disease manifestations. To date, no medical therapy has proven significant impact on clinical outcomes and most patients ultimately need liver transplantation. Several treatment strategies have failed in the past and whilst prescription of ursodeoxycholic acid (UDCA) prevails, controversy regarding benefits remains. Lack of statistical power, slow and variable disease progression, lack of surrogate biomarkers for disease severity and other challenges in trial design serve as critical obstacles in the development of effective therapy. Advances in our understanding of PSC pathogenesis and biliary physiology over recent years has however led to a surge of clinical trials targeting various mechanistic compartments and currently raising hopes for imminent changes in patient management. Here, in light of pathophysiology, we outline and critically evaluate emerging treatment strategies in PSC, as tested in recent or ongoing phase II and III trials, stratified per a triad of targets of nuclear and membrane receptors regulating bile acid metabolism, immune modulators, and effects on the gut microbiome. Furthermore, we revisit the UDCA trials of the past and critically discuss relevant aspects of clinical trial design, including how the choice of endpoints, alkaline phosphatase in particular, may affect the future path to novel, effective PSC therapeutics.
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29
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Trivedi PJ. Risk stratification in primary sclerosing cholangitis: It's time to move on from replicating imperfection and break the glass ceiling. J Hepatol 2019; 71:867-870. [PMID: 31515045 DOI: 10.1016/j.jhep.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/18/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK; Institute of Applied Health Research, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth, UK.
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