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Efe C, Kulkarni AV, Terziroli Beretta-Piccoli B, Magro B, Stättermayer A, Cengiz M, Clayton-Chubb D, Lammert C, Bernsmeier C, Gül Ö, la Tijera FHD, Anders M, Lytvyak E, Akın M, Purnak T, Liberal R, Peralta M, Ebik B, Duman S, Demir N, Balaban Y, Urzua Á, Contreras F, Venturelli MG, Bilgiç Y, Medina A, Girala M, Günşar F, Londoño MC, Androutsakos T, Kisch A, Yurci A, Güzelbulut F, Çağın YF, Avcı E, Akyıldız M, Dindar-Demiray EK, Harputluoğlu M, Kumar R, Satapathy SK, Mendizabal M, Silva M, Fagiuoli S, Roberts SK, Soylu NK, Idilman R, Yoshida EM, Montano-Loza AJ, Dalekos GN, Ridruejo E, Schiano TD, Wahlin S. Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome. Hepatology 2022; 76:1576-1586. [PMID: 35567545 PMCID: PMC9348326 DOI: 10.1002/hep.32572] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series. APPROACH AND RESULTS We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up. CONCLUSIONS SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.
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Affiliation(s)
- Cumali Efe
- Department of GastroenterologyHarran University HospitalŞanlıurfaTurkey
| | - Anand V Kulkarni
- Department of Hepatology and Liver TransplantationAsian Institute of Gastroenterology HospitalsHyderabadIndia
| | | | - Bianca Magro
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Albert Stättermayer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Mustafa Cengiz
- Department of GastroenterologyGülhane Training and Research HospitalAnkaraTurkey
| | | | - Craig Lammert
- Department of Medicine IndianaUniversity School of MedicineIndianapolisIndianaUSA
| | - Christine Bernsmeier
- Department of BiomedicineUniversity of BaselBaselSwitzerland.,University Centre for Gastrointestinal and Liver DiseasesBaselSwitzerland
| | - Özlem Gül
- Department of GastroenterologyKırıkkale UniversityKırıkkaleTurkey
| | | | - Margarita Anders
- Hepatology and Liver Transplant UnitHospital AlemánCiudad Autónoma de Buenos AiresArgentina
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - Mete Akın
- Department of GastroenterologyAkdeniz University Faculty of MedicineAntalyaTurkey
| | - Tugrul Purnak
- Division of GastroenterologyHepatology and NutritionMcGovern Medical SchoolHoustonTexasUSA
| | - Rodrigo Liberal
- Gastroenterology and Hepatology DepartmentCentro Hospitalar e Universitário de São JoãoPortoPortugal.,World Gastroenterology Organization (WGO) Porto Training CenterPortoPortugal
| | - Mirta Peralta
- Hepatology SectionHospital Francisco J MuñizCiudad Autónoma de Buenos AiresArgentina.,Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina
| | - Berat Ebik
- Department of GastroenterologyGazi Yaşargil Education and Research HospitalDiyarbakirTurkey
| | - Serkan Duman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Nurhan Demir
- Department of GastroenterologyHaseki Training and Research HospitalIstanbulTurkey
| | - Yasemin Balaban
- Department of GastroenterologyFaculty of MedicineHacettepe UniversityAnkaraTurkey
| | - Álvaro Urzua
- Gastroenterology and Hepatology UnitHospital Clínico Universidad de ChileSantiago de ChileChile
| | | | | | - Yılmaz Bilgiç
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Adriana Medina
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Marcos Girala
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Fulya Günşar
- Department of GastroenterologyEge University School of MedicineİzmirTurkey
| | | | - Theodoros Androutsakos
- Department of PathophysiologyNational and Kapodistrian University of AthensMedical SchoolAthensGreece
| | - Ayelen Kisch
- Hepatology SectionHospital Bonorino UdaondoCiudad Autónoma de Buenos AiresArgentina
| | - Alper Yurci
- Department of GastroenterologyErciyes University School of MedicineKayseriTurkey
| | - Fatih Güzelbulut
- Department of GastroenterologyHaydarpaşa Numune Education and Research HospitalİstanbulTurkey
| | - Yasir Furkan Çağın
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Enver Avcı
- Department of GastroenterologyKTO Karatay University Medical School Affiliated Konya Medicana HospitalKonyaTurkey
| | - Murat Akyıldız
- Department of GastroenterologyKoc University School of MedicineIstanbulTurkey
| | | | - Murat Harputluoğlu
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Rahul Kumar
- Department of Gastroenterology and HepatologyChangi General HospitalMedicine Academic Clinical ProgrammeSing Health Duke-NUS Academic Medical CentreSingapore
| | - Sanjaya K Satapathy
- Department of Internal MedicineDonald and Barbara Zucker School of MedicineNorthwell HealthManhassetNew YorkUSA
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Stuart K Roberts
- Department of GastroenterologyAlfred HealthMelbourneVictoriaAustralia.,Central Clinical SchoolDepartment of MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Neşe Karadağ Soylu
- Department of PathologyInönü University Faculty of MedicineMalatyaTurkey
| | - Ramazan Idilman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Eric M Yoshida
- Division of GastroenterologyUniversity of British Columbia and Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal MedicineNational Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)General University Hospital of LarissaLarissaGreece
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina.,Hepatology SectionDepartment of MedicineCentro de Educación Médica e Investigaciones Clínicas, CEMICCiudad Autónoma de Buenos AiresArgentina
| | - Thomas D Schiano
- Division of Liver Diseasesthe Mount Sinai Medical CenterNew YorkNew YorkUSA
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI DiseasesKarolinska Institutet and Karolinska University HospitalStockholmSweden
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Pape S, Snijders RJALM, Gevers TJG, Chazouilleres O, Dalekos GN, Hirschfield GM, Lenzi M, Trauner M, Manns MP, Vierling JM, Montano-Loza AJ, Lohse AW, Schramm C, Drenth JPH, Heneghan MA, Alvarez F, Andrade R, Arikan C, Assis D, Bardou-Jacquet E, Biewenga M, Cancado E, Cazzagon N, Chazouillères O, Colloredo G, Cuarterolo M, Dalekos G, Debray D, Robles-Díaz M, Drenth J, Dyson J, Efe C, Engel B, Ferri S, Fontana R, Gatselis N, Gerussi A, Halilbasic E, Halliday N, Heneghan M, Hirschfield G, van Hoek B, Hørby Jørgensen M, Indolfini G, Iorio R, Jeong S, Jones D, Kelly D, Kerkar N, Lacaille F, Lammert C, Leggett B, Lenzi M, Levy C, Liberal R, Lleo A, Lohse A, Ines Lopez S, de Martin E, McLin V, Mieli-Vergani G, Milkiewicz P, Mohan N, Muratori L, Nebbia G, van Nieuwkerk C, Oo Y, Ortega A, Páres A, Pop T, Pratt D, Purnak T, Ranucci G, Rushbrook S, Schramm C, Stättermayer A, Swain M, Tanaka A, Taubert R, Terrabuio D, Terziroli B, Trauner M, Valentino P, van den Brand F, Villamil A, Wahlin S, Ytting H, Zachou K, Zeniya M. Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group. J Hepatol 2022; 76:841-849. [PMID: 35066089 DOI: 10.1016/j.jhep.2021.12.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/18/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment. METHODS A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis. RESULTS The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'. CONCLUSIONS These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints. LAY SUMMARY Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Romée J A L M Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht 6229HX, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Oliver Chazouilleres
- Hepatology Department, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Saint-Antoine Hospital Assistance Publique-Hôpitaux de Paris, Paris, France; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly Medical School, Larissa, Greece
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Marco Lenzi
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; 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)
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Canada
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
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Scheiner B, Mandorfer M, Schwabl P, Payer BA, Bucsics T, Bota S, Aichelburg MC, Grabmeier-Pfistershammer K, Stättermayer A, Ferenci P, Trauner M, Peck-Radosavljevic M, Reiberger T. The Impact of PNPLA3 rs738409 SNP on Liver Fibrosis Progression, Portal Hypertension and Hepatic Steatosis in HIV/HCV Coinfection. PLoS One 2015; 10:e0143429. [PMID: 26599080 PMCID: PMC4658167 DOI: 10.1371/journal.pone.0143429] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Faster fibrosis progression and hepatic steatosis are hallmarks of HIV/HCV coinfection. A single nucleotide polymorphism (SNP) of the PNPLA3-gene is associated with development of non-alcoholic steatohepatitis and a worse outcome in alcoholic liver disease. However, the role of PNPLA3 rs738409 SNP on liver fibrosis and steatosis, portal hypertension, and virological response in HIV/HCV coinfection remains unclear. METHODS In this cross-sectional study PNPLA3 (rs738409) and IL28B (rs12979860) SNPs were determined in 177 HIV/HCV coinfected patients. Liver fibrosis and steatosis-staged by liver biopsy and transient elastography using the Controlled Attenuation Parameter (CAP)-and portal hypertension (hepatic venous pressure gradient, HVPG) were compared across PNPLA3 genotypes. RESULTS 75 (42.4%) patients tested positive for a PNPLA3 minor/major risk allele (G/C:66; G/G:9) showed comparable fibrosis stages (median F2 vs. F2; p = 0.292) and similar amounts of hepatic steatosis (CAP: 203.5 ± 41.9 vs. 215.5 ± 59.7 dB/m; p = 0.563) as compared to patients without a PNPLA3 risk allele. Advanced liver fibrosis was neither associated with PNPLA3 (p = 0.253) nor IL28B-genotype (p = 0.628), but with HCV-GT3 (p = 0.003), higher BMI (p = 0.008) and higher age (p = 0.007). Fibrosis progression rate (0.27 ± 0.41 vs. 0.20 ± 0.26 units/year; p = 0.984) and HVPG (3.9 ± 2.6 vs. 4.4 ± 3.0 mmHg; p = 0.472) were similar in patients with and without PNPLA3 risk alleles. SVR rates to PEGIFN/RBV therapy were similar across PNPLA3 genotypes. CONCLUSIONS The presence of a PNPLA3 risk allele had no independent impact on liver disease or virological response rates to PEGIFN/RBV therapy in our cohort of HIV/HCV coinfected patients.
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Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
| | - Berit Anna Payer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maximilian C. Aichelburg
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Katharina Grabmeier-Pfistershammer
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Albert Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna HIV & Liver Study Group, Medical University of Vienna, Vienna, Austria
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