Non-amyloid liver involvement in familial Mediterranean fever: A systematic literature review

EULAR/PReS endorsed recommendations for the management of familial Mediterranean fever (FMF): 2024 update

OBJECTIVES

Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease despite being a rare disease for many rheumatologists. These evidence-based recommendations update the ones issued in 2016 to account for the recent developments in the field and aim to guide rheumatologists and other health professionals in the treatment and follow-up of patients with FMF.

METHODS

A multidisciplinary panel was assembled, including rheumatologists, internists, paediatricians, a nephrologist, an occupational therapist, a physiotherapist, 2 methodologists, and 2 patient representatives, all from the Eastern Mediterranean area and Europe. Several systematic reviews were performed on the pharmacological treatment of FMF and its complications. The previous recommendations were revised considering the updated evidence, and the new levels of evidence were incorporated. The agreement with the recommendations was obtained through a Delphi survey.

RESULTS

The final set comprises 4 overarching principles and 12 recommendations, each presented with its degree of agreement (0-10), level of evidence, and rationale. The degree of agreement was greater than 9/10 in all instances, and the level of evidence improved in most updated statements. Improving adherence is emphasised as an important aspect in several statements. These new recommendations include a priority set, quality indicators, and other suggested implementation strategies.

CONCLUSIONS

This article presents a set of widely accepted recommendations for treating and monitoring FMF, supported by the best available evidence and expert opinion. These recommendations are valuable for guiding physicians in caring for patients with FMF.

Long-term use of colchicine is associated with incident cirrhosis: a real-world cohort study

INTRODUCTION

Chronic effect of colchicine on the liver was not studied enough. We aimed to examine the association between long term colchicine use and incident cirrhosis among new colchicine initiators.

STUDY

Using database of Maccabi Healthcare Services (MHS), we included all patients aged ≥18 years old who initiated colchicine between 1 January 2000 and 31 December 2018 and followed them until the earliest of the following: incident cirrhosis, leaving MHS, death or 31 December 2020. Incident cirrhosis was diagnosed according to ICD-9 code. We defined incident decompensated cirrhosis as the first presentation of cirrhosis, once ascites, encephalopathy and/or variceal bleeding were diagnosed within a period of 90 days before until 90 days after incident cirrhosis. Exposure to colchicine was evaluated in two manners: proportion of months covered (PMC) and mean daily dose (MDD).

RESULTS

A total of 21,773 eligible patients were included. We identified 129 incident cases of cirrhosis. Seventy-six (59%) had decompensated cirrhosis, as a first clinical presentation of cirrhosis. Familial Mediterranean Fever (FMF), BMI > 40, FIBROSIS-4 (FIB-4) score and colchicine PMC were all significantly associated with incident cirrhosis. Patients in '60-80%' PMC group had the highest risk for developing cirrhosis (hazard ratio (HR) 3.68, 95% confidence interval (CI) 2.23-6.07). The risk was higher for patients on colchicine >60 months (HR 6.69, 95% CI 3.56-12.56).

CONCLUSIONS

long term colchicine use is associated with incident cirrhosis, mainly with decompensation at the time of diagnosis. Long term colchicine treatment should be limited to diseases with no other alternative, such as FMF.

R202Q homozygosity of Mediterranean fever gene is associated with atypical clinical phenotype of familial Mediterranean fever

OBJECTIVE

Apart from the classical phenotypes, familial Mediterranean fever (FMF) has several atypical manifestations making its diagnosis quite challenging. Our aim was to address the characteristics of FMF patients and the clinical importance of R202Q variant in a large cohort of patients from Greece.

METHODS

Prospectively collected data from 321 FMF patients were retrospectively reviewed and analyzed. All patients were tested for Mediterranean fever gene/MEFV alterations in exon-2 and exon-10, by non-isotopic RNase-cleavage assay, and subsequent sequencing analysis. Hardy-Weinberg equilibrium (HWE) was used to assess R202Q allelic and genotypic frequencies in relation to FMF HWE.

RESULTS

Among 223 FMF patients with available follow-up data, 54.3 % were females and mean age at diagnosis was 35.4 ± 16.7 years. Regarding genetic analysis, 38.2 % had pathogenic/likely pathogenic variants, 12.1 % had variants of unknown significance, 16.1 % were R202Q homozygotes, while 33.6 % had negative genetic test. As explained by the strong deviation from HWE observed among FMF patients (p < 0.0001), R202Q homozygosity is considered disease-related. R202Q homozygosity was identified mainly among native Greeks (77.8 %) and was associated with a higher age of disease onset (p < 0.001) and a lower occurrence of abdominal pain (p < 0.001) compared to pathogenic/likely pathogenic variants. R202Q homozygosity (10/30, 33.3 %) was associated with atypical disease phenotype (OR: 1.95, 95 %CI: 1.24-3.08, p = 0.004) after adjustment for age, origin and sex.

DISCUSSION AND CONCLUSION

Excess R202Q homozygosity was observed among Greek FMF patients presenting atypical/non-criteria manifestations. In patients with periodic fevers and atypical clinical phenotype, the identification of R202Q homozygosity is linked with the diagnosis of FMF.

Liver Disease Complicating Familial Mediterranean Fever: A Study on 66 Patients Out of 533 Adult From the JIR Cohort

BACKGROUND

Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease, associated with MEFV mutations. FMF patients can experience liver involvement, potentially leading to cirrhosis.

OBJECTIVES

This study aimed to evaluate liver involvement in FMF patients at a French tertiary centre for adult FMF.

METHODS

We conducted an observational study with FMF patients displaying 2 pathogenic MEFV mutations at the National Reference Center for Autoinflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA) in Paris and included in the JIR cohort. MEFV heterozygous patients and those with other liver disease causes were excluded.

RESULTS

Among 533 FMF patients 12.4% had chronic liver abnormalities, with 30% who developed cirrhosis 54 years [36-57] in median after disease onset. Forty-seven per cent were colchicine resistant, and 41% received interleukin-1 inhibitors. Cirrhotic patients experienced delayed hepatopathy diagnosis, prolonged FMF diagnosis delay and late-onset treatment initiation compared to those with only liver function test abnormalities. Colchicine resistance and interleukin-1 inhibitor use were more common in cirrhotic patients. Body mass index and AA amyloidosis rates did not differ significantly between groups. Twenty-one patients had undergone liver biopsies including 14 cirrhotic patients revealing steatohepatitis in 12 cases and probable steatohepatitis in 4. Other lesions, like iron overload and sinusoidal dilatation, were sporadically observed.

CONCLUSION

FMF patients are at risk of chronic liver disease. Regular liver function monitoring is crucial, particularly in case of persistent inflammation, due to the risk of progression to cirrhosis and its associated morbidity and mortality.

Role of non-invasive methods in detecting liver impairment in familial Mediterranean fever adult patients with persistent hepatic cytolysis

Familial Mediterranean fever (FMF) patients may have hepatic cytolysis, although its origin is not formally elucidated. We aimed to evaluate liver involvement in familial Mediterranean fever (FMF) using non-invasive methods. All adult FMF patients harboring two non-ambiguous mutations of the MEFV gene with hepatic cytolysis were identified in a French tertiary adult center for FMF. Liver impairment was explored with FibroMax (a non-invasive method to estimate hepatic steatosis, necrosis, inflammation and fibrosis) and liver ultrasound. Among 520 FMF adult patients, 43 had persistent hepatic cytolysis and 20 patients were included (11 women, median age at inclusion: 49.5 years). According to the FibroMax results, patients were classified as having steatosis, fibrosis, and possible or definite nonalcoholic steato-hepatitis in 10 (50%), 9 (45%) and 7 (35%) of cases, respectively. The score of steatosis did not seem associated with the usual metabolic risk factors. No significant association was found between the cumulated dose of colchicine and any of the scores included in FibroMax. In adult FMF patients with persistent hepatic cytolysis, steatosis is the first cause to consider even in the absence of usual metabolic risk factors, suggesting other mechanisms. Colchicine did not seem to be involved in this toxicity.

Case Report: A Pediatric Case of Familial Mediterranean Fever Concurrent With Autoimmune Hepatitis

Familial Mediterranean fever (FMF) is a hereditary, autoinflammatory disease that causes recurrent fever, arthritis, and serositis. The diagnosis of FMF is based on the presentation of typical clinical symptoms and the Mediterranean fever gene (MEFV) test. However, the challenge lies in diagnosing atypical cases. In this report, we have described a pediatric patient with complex FMF whose diagnosis required trio-whole exome sequencing (WES) and functional validation of a rare MEFV variant. A 3-year-old boy presented with recurrent episodes of elevated liver enzymes and arthralgia. He was diagnosed with autoimmune hepatitis (AIH), and his liver enzymes improved rapidly with steroid treatment. However, he exhibited recurrent arthralgia and severe abdominal attacks. Trio-WES identified compound heterozygous mutations in MEFV (V726A and I692del). Ex vivo functional assays of the patient’s monocytes and macrophages, which had been pre-treated with Clostridium difficile toxin A (TcdA) and colchicine, were comparable to those of typical FMF patients, thereby confirming the diagnosis of FMF. Although he was intolerant to colchicine because of liver toxicity, subsequent administration of canakinumab successfully ameliorated his abdominal attacks. However, it was ineffective against liver injury, which recurred after steroid tapering. Therefore, in this case, the pathogenesis of AIH was probably interleukin-1β (IL-1β)-independent. In fact, AIH might have been a concurrent disease with FMF, rather than being one of its complications. Nevertheless, further studies are necessary to determine whether FMF-induced inflammasome activation contributes to AIH development. Moreover, we must consider the possibility of mixed phenotypes in such atypical patients who present distinct pathologies simultaneously.

The Preferential Use of Anakinra in Various Settings of FMF: A Review Applied to an Updated Treatment-Related Perspective of the Disease

Familial Mediterranean fever (FMF), the most frequent monogenic autoinflammatory disease, is manifested with recurrent and chronic inflammation and amyloid A (AA) amyloidosis, driven by overproduction of interleukin 1 (IL-1) through an activated pyrin inflammasome. Consequently, non-responsiveness to colchicine, the cornerstone of FMF treatment, is nowadays addressed by IL-1- blockers. Each of the two IL-1 blockers currently used in FMF, anakinra and canakinumab, has its own merits for FMF care. Here we focus on anakinra, a recombinant form of the naturally occurring IL-1 receptor antagonist, and explore the literature by using PubMed regarding the utility of anakinra in certain conditions of FMF. Occasionally we enrich published data with our own experience. To facilitate insights to anakinra role, the paper briefs some clinical, genetic, pathogenetic, and management aspects of FMF. The clinical settings of FMF covered in this review include colchicine resistance, AA amyloidosis, renal transplantation, protracted febrile myalgia, on- demand use, leg pain, arthritis, temporary suspension of colchicine, pediatric patients, and pregnancy and lactation. In many of these instances, either because of safety concerns or a necessity for only transient and short-term use, anakinra, due to its short half-life, is the preferred IL-1 blocker.

Prevalence of Familial Mediterranean Fever in Children with Cryptogenic Cirrhosis

BACKGROUND

Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by abdominal and chest pain and recurrent fever due to inflammation in the serosal membranes such as peritoneum, pleura and synovia. In FMF, recurrent inflammatory cytokine production may lead to cirrhosis. The aim of this study was to determine the prevalence of FMF in children with cryptogenic cirrhosis and it was found to be high, to add FMF among the etiological causes of cirrhosis.

MATERIALS AND METHODS

This prospective cohort study conducted at the Hospital of İnönü University, Malatya, Turkey. In this study, 44 patients diagnosed with cryptogenic cirrhosis by biopsy, in the Pediatric Gastroenterology, Hepatology and Nutrition Clinic, were included, after the other reasons that may cause chronic liver disease were excluded. MEVF gene analysis was performed for all patients with cryptogenic cirrhosis.

RESULTS

FMF genetic mutation was detected in 9 (20%) of 44 patients. M694V mutation was detected in one patient (2.27%) and E148Q homozygous mutation was detected in one patient (2.27%). Various other heterozygous mutations were detected in seven other patients. Homozygous and heterozygous R202Q mutations were detected in one patient.

CONCLUSION

We suggest that FMF plays a role in the etiologic differential diagnosis of cryptogenic cirrhosis.

Improvement of Liver Involvement in Familial Mediterranean Fever After the Introduction of Canakinumab: A Case Report

Hepatic involvement in familial Mediterranean fever (FMF) ranges from a nonspecific increase in liver enzymes to cryptogenic cirrhosis, and the liver is mostly involved in patients bearing the M694V MEFV mutation in homozygosis. A 44-year-old Jewish woman with FMF developed nonalcoholic steatohepatitis during colchicine treatment (2,5 mg per day), confirmed by both elastography and liver biopsy. Therefore, combined therapy with the interleukin-1 (IL-1) blocking agent canakinumab (150 mg every four weeks) and colchicine (at a reduced dose of 1.5 mg per day) was started. Three months later, transaminases became normal, and after further six months, there was a marked improvement of liver fibrosis. IL-1 blockade has the power to halt or mitigate liver involvement in FMF patients. However, further experience is required to assess its therapeutic potential in the most severe patients with the hepatic disease who are partially responsive to long-term prophylaxis with colchicine.

How to handle the main drugs to treat autoinflammatory disorders and how we treat common autoinflammatory diseases

This article provides an overview of the main drugs to treat autoinflammatory disorders focusing on the four emblematic diseases within this group which represent, to date, the vast majority of patients with monogenic SAID; i.e. familial Mediterranean fever, mevalonate kinase deficiency, TNF receptor 1 deficiency and cryopyrin-associated periodic syndrome. We will therefore resume the evolutionary risks of the four main IL-1 dependent SAID, there treatments and monitoring tools. After having exposed the general principles, we will detail specific guidelines for the management in everyday clinical practice of patients according to the four main pathologies based on both our expertise and international recommendations. We aim herein to guide practitioners in charge of patients with common SAID towards optimal follow-up with appropriate monitoring of anti-inflammatory drugs.