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Floreani A, Gabbia D, De Martin S. Are Gender Differences Important for Autoimmune Liver Diseases? Life (Basel) 2024; 14:500. [PMID: 38672770 PMCID: PMC11050899 DOI: 10.3390/life14040500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Gender Medicine has had an enormous expansion over the last ten years. Autoimmune liver diseases include several conditions, i.e., autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and conditions involving the liver or biliary tree overlapping with AIH, as well as IgG4-related disease. However, little is known about the impact of sex in the pathogenesis and natural history of these conditions. The purpose of this review is to provide an update of the gender disparities among the autoimmune liver diseases by reviewing the data published from 1999 to 2023. The epidemiology of these diseases has been changing over the last years, due to the amelioration of knowledge in their diagnosis, pathogenesis, and treatment. The clinical data collected so far support the existence of sex differences in the natural history of autoimmune liver diseases. Notably, their history could be longer than that which is now known, with problems being initiated even at a pediatric age. Moreover, gender disparity has been observed during the onset of complications related to end-stage liver disease, including cancer incidence. However, there is still an important debate among researchers about the impact of sex and the pathogenesis of these conditions. With this review, we would like to emphasize the urgency of basic science and clinical research to increase our understanding of the sex differences in autoimmune liver diseases.
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Affiliation(s)
- Annarosa Floreani
- Scientific Consultant IRCCS Negrar, 37024 Verona, Italy
- University of Padova, 35122 Padova, Italy
| | - Daniela Gabbia
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (D.G.); (S.D.M.)
| | - Sara De Martin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (D.G.); (S.D.M.)
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Taubert R, Engel B. [Treatment of autoimmune hepatitis-First-line, second-line and third-line treatment]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:325-333. [PMID: 38456902 DOI: 10.1007/s00108-024-01679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
Autoimmune hepatitis (AIH) is a rare autoimmune inflammation of the liver mostly with a chronic course, which can also be acutely manifested up to acute liver failure. It affects women 3-4 times more frequently than men and can be diagnosed in all age groups. In one third of the patients a liver cirrhosis is present at the time of diagnosis. It is characterized by a hepatic inflammation pattern, a polyclonal hypergammaglobulinemia of immunoglobulin G and the detection of autoantibodies. A liver biopsy is necessary to make the diagnosis. The AIH is histologically characterized in particular by a lymphoplasmacytic infiltrate in the portal fields. In cases with a relevant disease activity, AIH is typically treated by immunosuppression. The immunosuppressive treatment is associated with a prevention of disease progression to liver cirrhosis and a better survival. The success of treatment is measured by achieving biochemical remission, i.e., normalization of the transaminase and immunoglobulin G levels as a good noninvasive predictor of a histological remission. Another treatment target is an improvement of the symptoms of the patient. The first-line treatment consists of a glucocorticoid, mostly prednisolone or in cases without advanced fibrosis budesonide, and azothioprine. For reduction of steroid-specific treatment side effects the maintenance treatment should be carried out steroid-free whenever possible. In cases of insufficient response to azothioprine or side effects a treatment attempt using antimetabolites, such as 6‑mercaptopurine or mycophenolate mofetil is primarily carried out as second-line treatment. For patients who do not achieve biochemical remission through first-line or second-line treatment, a variety of medications are available for third-line treatment, e.g., rituximab, calcineurin inhibitors or antitumor necrosis factor (anti-TNF) antibodies. Third-line treatment should be carried out in expert centers and registered in the European Reference Network for Rare Liver Diseases in order to improve the currently sparse database for these forms of treatment in the future.
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Affiliation(s)
- Richard Taubert
- Klinik für Gastroenterologie, Hepatologie, Infektiologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Bastian Engel
- Klinik für Gastroenterologie, Hepatologie, Infektiologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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3
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Warner S, Rajanayagam J, Russell E, Lloyd C, Ferguson J, Kelly DA, Hirschfield GM. Biliary disease progression in childhood onset autoimmune liver disease: A 30-year follow-up into adulthood. JHEP Rep 2024; 6:100901. [PMID: 38235169 PMCID: PMC10790098 DOI: 10.1016/j.jhepr.2023.100901] [Citation(s) in RCA: 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: 03/20/2023] [Revised: 08/03/2023] [Accepted: 08/24/2023] [Indexed: 01/19/2024] Open
Abstract
Background & Aims Long-term follow-up studies of paediatric onset autoimmune liver disease (AILD) are invaluable in helping better understand the clinical course of disease. In day-to-day practice clinicians struggle with disease definitions whilst patients and parents lack clear prognostic information. Methods The clinical progression of 159 patients with childhood onset AILD between June 1990 and December 2013 was reviewed, capturing data up to adulthood (ending May 2021). Results Presentation with autoimmune hepatitis (AIH) was dominant (n = 119); biliary presentations accounted for 25%. During follow up, biliary disease progression confirmed by cholangiography and/or liver histology was observed frequently: 19.8% (20/101) patients with childhood onset AIH type 1 (AIH-1) developed biliary features by adulthood and of these 50% phenotypically transitioned to primary sclerosing cholangitis (PSC); the remaining transitioned to an overlap disease phenotype. No patients with AIH type 2 developed biliary progression. Two-thirds of patients with overlap features (14/21) in childhood had phenotypically progressed to PSC by adulthood. Approximately 43% (6/14) of AIH-1 patients requiring a liver transplant in adulthood had explant evidence of biliary disease compared with 11% (1/9) in childhood, whereas 35.7% (5/14) of patients had histology diagnostic of PSC in their explant liver and 7.1% (1/14) had overlap features. All patients with biliary phenotypes (PSC, autoimmune sclerosing cholangitis, overlap) who required a transplant (n = 18) were found to have explant histology consistent with PSC. Twelve of 14 patients with biliary progression developed ulcerative colitis during follow-up with 92% progressing to PSC. Conclusions Three decades of follow-up demonstrated how children presenting with AILD had a significant risk of clinical transformation to PSC. Biliary progression was significantly associated with the development of inflammatory bowel disease. Impact and implications Childhood onset autoimmune liver disease remains very impactful for patients and families. Disease nomenclature can however be confusing. Long-term follow up studies as children become adults is important to help understand how and why disease behaves over time. Understanding more about the long-term course of childhood autoimmune liver disease will help patients, families and doctors striving to improve care and reduce poor clinical outcomes. We followed over 150 patients with childhood onset autoimmune liver diseases into adulthood. We found that amongst patients with classical autoimmune hepatitis, 1 in 5 developed biliary disease over time, mostly consisting of primary sclerosing cholangitis. This was associated with developing inflammatory bowel disease. Our study design was retrospective and has relevant limitations. Defining phenotypes of autoimmune liver diseases is difficult and there is insufficient consensus, especially between adult and childhood physicians. Our data confirms the critical importance of careful long-term follow-up of patients, including safe transition to adult care, as well as robustly demonstrates, using real-world data, how disease nature can change over time. Our study affirms the need for investment in prospective cohort studies.
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Affiliation(s)
- Suz Warner
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Jeremy Rajanayagam
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Emily Russell
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Carla Lloyd
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - James Ferguson
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
| | - Deirdre A. Kelly
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Liver Unit, Birmingham Women’s & Children’s Hospital, Birmingham, UK
| | - Gideon M. Hirschfield
- NIHR Biomedical Research Centre, University Hospitals Birmingham, Birmingham, UK
- Toronto Centre for Liver Disease, Department of Medicine, University of Toronto, Toronto, Canada
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Nastasio S, Sciveres M, Francalanci P, Maggiore G. Pediatric Autoimmune Hepatitis. Pediatr Rep 2024; 16:110-113. [PMID: 38390999 PMCID: PMC10885090 DOI: 10.3390/pediatric16010011] [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] [Received: 10/23/2023] [Accepted: 01/11/2024] [Indexed: 02/24/2024] Open
Abstract
Pediatric autoimmune hepatitis (PAIH) is a rare necro-inflammatory disease of the liver of unknown etiology thought to derive from the dysregulation of the immune response upon exposure to environmental triggers in genetically predisposed individuals [...].
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy
| | - Paola Francalanci
- Division of Pathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Giuseppe Maggiore
- Division of Hepatogastroenterology, and Liver Transplant, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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D'Amato D, Carbone M. Prognostic models and autoimmune liver diseases. Best Pract Res Clin Gastroenterol 2023; 67:101878. [PMID: 38103932 DOI: 10.1016/j.bpg.2023.101878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023]
Abstract
Autoimmune liver diseases (AILDs) are complex diseases with unknown causes and immune-mediated pathophysiology. In primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) disease modifying drugs are available which improve patient quality and quantity of life. In primary sclerosing cholangitis (PSC) no medical therapy is available and the only accepted treatment is liver transplantation (LT). PBC, PSC and AIH possess features that describe the archetype of patients within each disorder. On the other hand, the classical disorders are not homogeneous, and patients within each diagnosis may present with a range of clinical, biochemical, serological, and histological findings. Singularly, they are considered rare diseases, but together, they account for approximately 20% of LTs in Europe and USA. Management of these patients is complex, as AILDs are relatively uncommon in clinical practice with challenges in developing expertise, disease presentation can be sneaky, clinical phenotypes and disease course are heterogeneous. Prognostic models are key tools for clinicians to assess patients' risk and to provide personalized care to patients. Aim of this review is to discuss challenges of the management of AILDs and how the available prognostic models can help. We will discuss the prognostic models developed in AILDs, with a special focus on the prognostic models that can support the clinical management of patients with AILDs: in PBC models based on ursodeoxycholic acid (UDCA) response and markers of liver fibrosis; in PSC several markers including biochemistry, disease stage and radiological semiquantitative markers; and finally in AIH, markers of disease stage and disease activity.
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Affiliation(s)
- Daphne D'Amato
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
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Maggiore G, Bernard O, Mosca A, Jacquemin E. Liver Histology Before Treatment Withdrawal in Autoimmune Hepatitis: Is It Time to Review the ESPGHAN Recommendations? J Pediatr Gastroenterol Nutr 2023; 77:e62-e63. [PMID: 37307301 DOI: 10.1097/mpg.0000000000003857] [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] [Indexed: 06/14/2023]
Affiliation(s)
- Giuseppe Maggiore
- From the Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Olivier Bernard
- Paediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Biliary Diseases and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, APHP, University Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Antonella Mosca
- From the Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emmanuel Jacquemin
- Paediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Inflammatory Biliary Diseases and Autoimmune Hepatitis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, APHP, University Paris-Saclay, Le Kremlin-Bicêtre, France
- Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
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Nastasio S, Mosca A, Alterio T, Sciveres M, Maggiore G. Juvenile Autoimmune Hepatitis: Recent Advances in Diagnosis, Management and Long-Term Outcome. Diagnostics (Basel) 2023; 13:2753. [PMID: 37685291 PMCID: PMC10486972 DOI: 10.3390/diagnostics13172753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023] Open
Abstract
Juvenile autoimmune hepatitis (JAIH) is severe immune-mediated necro-inflammatory disease of the liver with spontaneous progression to cirrhosis and liver failure if left untreated. The diagnosis is based on the combination of clinical, laboratory and histological findings. Prothrombin ratio is a useful prognostic factor to identify patients who will most likely require a liver transplant by adolescence or early adulthood. JAIH treatment consists of immune suppression and should be started promptly at diagnosis to halt inflammatory liver damage and ultimately prevent fibrosis and progression to end-stage liver disease. The risk of relapse is high especially in the setting of poor treatment compliance. Recent evidence however suggests that treatment discontinuation is possible after a prolonged period of normal aminotransferase activity without the need for liver biopsy prior to withdrawal.
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy;
| | - Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
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8
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Ricciuto A, Kamath BM, Hirschfield GM, Trivedi PJ. Primary sclerosing cholangitis and overlap features of autoimmune hepatitis: a coming of age or an age-ist problem? J Hepatol 2023:S0168-8278(23)00162-9. [PMID: 36870613 DOI: 10.1016/j.jhep.2023.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 03/06/2023]
Abstract
Autoimmune liver diseases are siloed into three syndromes that define clinical practice. These classifiers can, and are, challenged by variant presentations across all ages, something inevitable to disease definitions that rely on interpreting inherently variable semi-quantitative/qualitative clinical, laboratory, pathological or radiological findings. Furthermore this remains premised by an ongoing absence of definable disease aetiologies. Clinicians thus encounter individuals with biochemical, serological, and histological manifestations that are common to both primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH), often labelled as 'PSC/AIH-overlap'. In childhood the term 'autoimmune sclerosing cholangitis (ASC)' may be used, and some propose this to be a distinct disease process. In this article we champion the concept that ASC and PSC/AIH-overlap are not distinct entities. Rather, they represent inflammatory phases of PSC frequently manifesting earlier in disease course, most notably in younger patients. Ultimately, disease outcome remains that of a more classical PSC phenotype observed in later life. Thus, we argue that it is now time to align disease names and descriptions used by clinicians across all patient subpopulations, to help care become uniform and ageless. This will enhance collaborative studies and contribute ultimately to rational treatment advances.
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Affiliation(s)
- Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Palak J Trivedi
- National Institute for Health and Care Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Birmingham, UK; Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK.
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Lohse AW, Hørby Jørgensen M. Paediatric autoimmune hepatitis: Time to change the textbooks? J Hepatol 2023; 78:893-895. [PMID: 36841545 DOI: 10.1016/j.jhep.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 02/27/2023]
Affiliation(s)
- Ansgar Wilhelm Lohse
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
| | - Marianne Hørby Jørgensen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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