Grading and staging systems for inflammation and fibrosis in chronic liver diseases

Liver biopsy is an important part of the evaluation of patients with a variety of liver diseases. Besides establishing the diagnosis, the biopsy is often used to assess the severity of the disease in terms of both grade and stage. The stage in most chronic liver diseases relates to the degree of scarring with the end stage being cirrhosis with its clinical complications. The grade relates to the severity of the underlying disease process, with features that vary with the pathogenetic mechanisms. Chronic viral hepatitis has been the object of the most extensive efforts at grading and staging, stimulated by the advent of new forms of therapy. Systems have also been developed for fatty liver disease, allograft rejection and chronic cholestatic diseases, but these have not been as widely used. Simple grading and staging systems for chronic hepatitis, including the IASL, Batts-Ludwig, and Metavir systems, are most appropriate for management of individual patients, while more complex systems such as the Histology Activity Index (HAI) are appropriate for evaluation of large cohorts of patients when statistical analysis is required.

Intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction: early results

Biliary complications are critical problems in liver transplantation. Herein, we retrospectively analyzed the early results of an intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction. Since November 2004, we have used this technique in 66 patients (32 children and 34 adults). In the new technique, a 5- F Kumpe catheter is inserted into the biliary system in 2 steps. One step is completed at the back table; the second step is completed during the recipient operation. Fourteen patients received whole-liver grafts, 25 received a right lobe, and 27 received a left-lateral or a left lobe. The mean graft weight-to-body weight ratio in the living-donor liver transplantations was 1.6% +/- 1.0% (range, 0.8%-4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 60 patients and with a Roux-en-Y hepaticojejunostomy in 6 patients. Five biliary complications occurred in 4 patients. Two of these 4 patients had bile leakage from the anastomotic site during the early postoperative period. Biliary stenoses developed at the anastomotic site in 2 patients and from a nonanastomotic site in 1 patient in the late postoperative period. In conclusion, this new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our complication rate. Transhepatic biliary stenting seems to prevent biliary complications and makes it simple to maintain percutaneous access in the event that problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe means of providing good biliary drainage after liver transplantation.

[A study of the influences of blood sugar levels on the prognosis of fulminating hepatitis patients]

OBJECTIVE

To explore the possible relationship between hypoglycemia and the prognosis of fulminating hepatitis patients.

METHODS

Fasting blood sugar levels of 322 fulminating hepatitis patients were retrospectively analyzed. The blood sugar levels and their clinical significance were appraised together.

RESULTS

In all the samples, 173 were hypoglycemic (53.73%). The mortality rate of the hypoglycemia group was 48.55% (84/173), therefore the blood sugar level was lower and the mortality rate was higher.

CONCLUSION

A higher proportion of fulminating hepatitis patients have hypoglycemia. There is a close relationship between hypoglycemia and the prognosis of the fulminating hepatitis patients. Blood sugar level has an important clinical value in reflecting the degree of liver failure in early fulminating hepatitis patients.

The use of protein tyrosine phosphatase 1B and insulin receptor immunostains to differentiate nonalcoholic from alcoholic steatohepatitis in liver biopsy specimens

Nonalcoholic steatohepatitis (NASH) and alcoholic steatohepatitis (ASH) and typically are indistinguishable, histologically. The diagnosis relies on reporting of alcohol consumption. The metabolic syndrome involving insulin resistance is associated with nonalcoholic fatty liver disease (NAFLD). Protein tyrosine phosphatase 1B (PTP1B) negatively regulates the insulin receptor (IR). Increased PTP1B expression is seen in obesity and possibly is responsible for the insulin resistance seen in the metabolic syndrome. The study objective was to determine whether biopsy specimens with steatohepatitis could be classified accurately as alcoholic or nonalcoholic by immunohistochemical stains. We selected 241 cases of steatohepatitis, comprising 53 and 188 cases of alcoholic and NAFLD, respectively. Specimens were stained with PTP1B and IR (b subunit) and classified as NASH or ASH. The staining pattern predicted 60 cases of ASH and 181 cases of NASH. Results correlated with clinical diagnoses in 70% and 88% of ASH and NASH cases, respectively (odds ratio, 16.6; 95% confidence interval, 8.2-35.4).

Review of 31 Cases of Morphologic Hepatitis in Liver Transplant Patients Not Related to Disease Recurrence

AIMS

We examined the clinical and pathologic features of morphologic hepatitis occurring after liver transplantation (LT) that is unrelated to disease recurrence.

METHODS

Between February 1998 and December 2003, 704 primary LTs were performed at our center. Patients transplanted for diagnoses with low risk of disease recurrence were considered for our study (n = 282). Those with hepatitis C (HCV), hepatitis B (HBV), primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH) were excluded. Those with morphologic hepatitis comprised our case series and had medical records reviewed for clinical associations, duration, and outcome.

RESULTS

Thirty-one cases were identified. They were transplanted for cryptogenic cirrhosis (n = 13), steatohepatitis (n = 12), alpha-1-antitrypsin deficiency (n = 3), tumor (n = 2), and acetaminophen toxicity (n = 1); 22 cases (67%) presented within the first 8 months post-LT (range, 0.5-72 months). Histological activity was mild in 19 and moderate in 12. Associated conditions were identified in 19 patients (57%) with 3 categories being identified: probable drug toxicity (n = 7), systemic infection (n = 4), and mechanical or hemodynamic abnormalities (n = 8). Of the 25 cases that underwent follow-up biopsy 2 to 32 months (mean, 15.5 months) after the index biopsy, 10 cases had resolution and 15 cases had persistence of the infiltrate. One patient had evidence of de novo HBV infection.

CONCLUSIONS

Morphologic hepatitis occurred in 11% of patients at low risk for disease recurrence. Associated conditions could be grouped into three categories: drug toxicity, systemic infection, and mechanical or hemodynamic factors. Most cases did not appear to progress or improved over time, with no allograft loss occurring as a result of chronic hepatitis.

Mechanisms of liver injury: an overview

Liver cirrhosis, an end-result of a wide variety of the liver diseases, is a world wide health problem. Because of its unique organ system, i.e., portal blood supply, bile formation and enterohepatic circulation, drug metabolism system, and sinusoidal lining cells such as Kupffer, endothelial and stellate cells, the liver is a target of a variety of hepatotoxic insults. Current data suggest that hepatocyte apoptosis is an essential feature contributing to liver injury in a wide range of acute and chronic liver diseases. With an improved understanding of the pathophysiological role of apoptosis in liver diseases, we are now entering an era where regulation of liver cell apoptosis is becoming a therapeutic possibility. Inhibition of hepatocyte apoptosis using a variety of different strategies may be therapeutically beneficial in liver injuries, such as alcoholic hepatitis, non-alcoholic steatohepatitis (NASH), viral hepatitis, and cholestatic liver diseases. Considering the link between hepatocyte apoptosis and liver fibrosis, inhibition of hepatocyte apoptosis may also be an anti-fibrotic therapeutic strategy. Moreover, selective induction of apoptosis of activated stellate cells would be a unique approach to induce the resolution the phase of liver fibrosis. These concepts merit further clinical and basic investigation.

[Cut-off period of subclassification and pathological features of severe hepatitis based on clinical and pathological analyses]

BACKGROUND

To explore the cut-off period of subclassification and pathological features of severe hepatitis (SH).

METHODS

Based on combined clinical and pathological analyses, the complete clinical and biopsy or autopsy liver tissues data from 196 cases of patients with severe hepatitis were investigated. Meanwhile, proliferative hepatocytes, cholangioepithelia and collagens were identified by a panel of monoclonal antibodies such as those against albumin, cytokeratin 18,19 and collagen I, III with immunohistochemical method.

RESULTS

The clinical and pathological analyses indicated the cut-off periods of acute, subacute and chronic SH (ASH,SSH and CSH) were (13.4+/-7.2) d, (77.4+/-69.3) d and (80.5+/-63.2) d, respectively. Among all SH cases, one case of ASH patient presented clinical manifestation and pathological changes of ASH for 21 days, however, one patient with SSH was demonstrated 12 day course by histological examination. The time of cut-off period between ASH and SSH in child cases was shorter than that in adult cases. Histologically, ASH liver tissues showed massive and/or submassive necrosis caused by one attack, with congestive sinusoid frameworks and proliferative cholangioepithelium-like hepatocytes, while SSH liver tissues presented combined fresh and old submassive or massive necrosis caused by multiple attacks, accompanied by obviously proliferative bile ducts and sinusoid framework collapse.However, the pathological changes of CSH showed ASH- or SSH-like lesions on the background of chronic liver injury.

CONCLUSION

Our data indicated that the cut-off period between ASH and SSH is in accordance with the Scheme of Viral Hepatitis Prevention and Therapy, China, published in 2000, but excluded a part of child SH cases. In our study, the authors found a few pathological features in ASH and SSH.

[Validation of international autoimmune hepatitis group scoring system for diagnosis of type 1 autoimmune hepatitis in Korea]

BACKGROUND/AIMS

There are no pathognomonic features of autoimmune hepatitis (AIH). Its diagnosis requires the exclusion of various other conditions. The aim of this study was to validate indirectly the International Autoimmune Hepatitis Group (IAHG) scoring system in diagnosing AIH.

METHODS

Twenty-six patients with Type 1 AIH and female patients with chronic hepatitis B (n=34), chronic hepatitis C (n=25), or toxic hepatitis (n=13) were evaluated according to 9 categories of pretreatment minimum required parameters proposed by IAHG. Aggregate scores of AIH to those of non-AIH groups, which were assessed before and after extracting the proportions of etiologic factors, were also compared and evaluated.

RESULTS

While aggregate scores of non-AIH groups, before extracting the proportions of etiologic factors, were 5.2+/-1.8, 5.6+/-1.1, and 7.4+/-1.2 in that order, those of AIH groups were 12.8+/-1.7. These were significantly higher than those of non-AIH groups (p<0.01). All patients in AIH groups and only 1 patient in a non-AIH group showed aggregate scores of more than 10. Aggregate scores after extracting the proportions of etiologic factors were more than 4 in all, except 2, patients. These should have been consistent with 10 if there were no etiologic factors in non-AIH groups.

CONCLUSION

The IAHG scoring system might have a relatively excessive importance to the scores of categories excluding distinct etiologies from AIH. It might be difficult to differentiate AIH from chronic liver diseases of indistinct cause based on the IAHG scoring system.

Circulating soluble vascular adhesion protein 1 accounts for the increased serum monoamine oxidase activity in chronic liver disease

BACKGROUND & AIMS

Vascular adhesion protein 1 (VAP-1) is an endothelial glycoprotein that supports adhesion of lymphocytes to hepatic endothelium and has sequence homology with semicarbazide-sensitive amine oxidases (SSAOs). We investigated whether soluble VAP-1 (sVAP-1) displays SSAO activity and thereby accounts for increased monoamine oxidase activity in the serum of patients with liver diseases.

METHODS

sVAP-1 concentration and SSAO activity were measured in peripheral, hepatic, and portal blood and in bile from patients with liver disease and in peripheral blood of control subjects, using enzyme-linked immunosorbent assay and enzymatic assays.

RESULTS

sVAP-1 concentration (mean [+/-SE], 143. 67 [34.97-92.67] ng/mL) and SSAO activity (18.8 [12.0-24.6] nmol. mL(-1). h(-1)) were significantly increased in chronic liver diseases compared with healthy controls (87.1 [53.5-127] ng/mL [P<0.001] and 10.7 [6.5-12.7] nmol. mL(-1) x h(-1) [P<0.05]) but not in massive necrosis caused by paracetamol poisoning (109 [80.3-140] ng/mL and 8.9 [5.7-12.3] nmol. mL(-1) x h(-1)). sVAP-1 correlated with serum transaminase and bilirubin but not with creatinine. In 5 paired samples, sVAP-1 concentration was higher in hepatic (median, 113 [range, 53-122]) than in portal vein (102 [42-109]; 2P<0.05), and was not detected in bile. There was a highly significant correlation between serum sVAP-1 and SSAO activity in normal subjects, patients with acute liver failure, and those with chronic liver disease (r = 0.895; P<0.001). When serum was depleted of sVAP-1 by immunoaffinity chromatography, SSAO activity was eliminated.

CONCLUSIONS

sVAP-1 levels are increased in chronic liver disease, and sVAP-1 is likely derived from the liver. Serum sVAP-1 displays SSAO activity and accounts for most of the monoamine oxidase activity in human serum.

[Reevaluation of the nomenclature and diagnostic criteria in 477 patients with severe hepatitis]

OBJECTIVE

To explore the possibility of establishing more reasonable nomenclatures and diagnostic criteria for patients with severe hepatitis (SH) through analyzing clinical data of 477 cases of SH.

METHODS

The clinical characteristics and outcomes of SH were analyzed according to different criteria.

RESULTS

Chronic severe hepatitis (CSH) made up 88.5% of total cases of SH. The survival rate in the patients with hepatic encephalopathy was much lower than that without hepatic encephalopathy. About 1/5 of cases of subacute severe hepatitis (SSH) and CSH had neither ascites nor hepatic encephalopathy. When the period of 2 weeks was used in replace of 10 days for the diagnosis for acute severe hepatitis (ASH), the newly added cases were consistent with the characteristics of ASH.

CONCLUSION

We suggest dividing SH into 2 types: encephalopathy and non-encephalopathy by using the nomenclature of fulminant hepatitis and severe type hepatitis, respectively. The late-onset form should be added besides of acute form and subacute form. It seems to use the period of 2 weeks as the new definition of onset time for ASH. The criteria of dividing SH into 3 forms, i.e. ascites, encephalopathy and ascites plus encephalopathy, and the nomenclature recommended by the International Association for the Study of the Liver Subcommittee are not satisfactory when used in clinical cases. The typing of CSH remains to be clarified.

Sequence variability in the putative coding region of TT virus: evidence for two rather than several major types

Recently a new human virus, TT virus (TTV) was identified in the serum of a patient with post-transfusion hepatitis of unknown aetiology. Comparative sequence analysis of a 222 nt fragment of ORF 1 of TTV was performed to assess the genomic variability of this virus. Phylogenetic analysis of the nucleotide sequences of 76 TTV isolates collected in 17 countries segregated them into two major groups: TTV 1 and TTV 2. The TTV 1 group comprised two distinct subgroups, which corresponded to previously described TTV subtypes 1a and 1b. The TTV 2 group was separated into four main branches, two of which included sequences previously provisionally attributed as TTV types 2 and 3. Bootstrap resampling, however, did not support the reliability of this grouping, suggesting that the isolates in the TTV 2 group should be considered as subtypes of a single type rather than different TTV types.

Nomenclature of chronic hepatitis: the new look

The new recommendations for nomenclature, grading, and staging of chronic hepatitis and related biliary and other disorders are attempts to standardize the criteria and simplify the terminology used in making these diagnoses. It is hoped that an emphasis on the etiology as part of the diagnosis will eliminate the previous association with poor prognosis that was implied with a diagnosis of CAH. The inclusion of a system of grading and staging, whether it is numerical or descriptive, simple or complex, matters less than the need for it to communicate important information about the degree of necroinflammatory activity (grade) and the extent of the disease (stage of fibrosis) that are likely factors of prognostic and therapeutic significance.

Present status of autoimmune hepatitis in Japan--correlating the characteristics with international criteria in an area with a high rate of HCV infection. Japanese National Study Group of Autoimmune Hepatitis

BACKGROUND/AIMS

A nationwide survey of autoimmune hepatitis (AIH) was carried out in Japan.

METHODS

Four hundred and ninety-six patients were enrolled by questionnaires sent to 101 hospitals with hepatology specialists.

RESULTS

The clinical features of Japanese AIH were as follows: most patients were middle-aged women; serum autoantibodies, especially antinuclear antibody, were frequently positive, serum IgG level was high, and HLA-DR4 was the major HLA allotype. Liver-kidney microsomal type 1 antibody was positive in nine of 79 patients tested. Eight of these antibody positive patients were also positive for antinuclear antibody and five for anti-smooth muscle antibody. Ninety-two percent of the patients showed piecemeal necrosis and 60% bridging necrosis; plasma cell infiltration in the portal areas was observed in 50% of the patients. Only 12.3% were diagnosed as having liver cirrhosis. A favorable effect of corticosteroid, normalization of serum transaminases, was observed in 89% of 317 patients, who were treated with an initial dose of over 30 mg/day. Sixty-two patients were positive for hepatitis C virus (HCV) markers. In these patients, however, only one patient was liver-kidney microsomal type 1 antibody positive. Corticosteroid was effective in 30 (81%) of 37 HCV-marker-positive patients treated with this agent. Thus the efficacy of corticosteroid did not differ from that in AIH patients without HCV infection (90%). Similarly, interferon treatment was used in 20 patients, all of whom were positive for HCV-RNA, and resulted in 50% efficacy as determined by normalization of the serum transaminase level 6 months after treatment. The International Diagnostic Scoring System for the diagnosis of AIH worked well in these patients, except for HCV-infected individuals, that is, approximately 10% of the total of AIH patients.

Hepatitis

Hepatitis is a diagnosis that can easily be missed by the physician. The morbidity of this disease is significant when one takes into account all the cases that either do not have a typical presentation or are misdiagnosed. The emergency physician bears substantial responsibility in the diagnosis and intervention of patients with hepatitis, and needs to develop a systematic way of approaching the patient with a viral syndrome or other vague complaints that will allow appropriate consideration of this diagnosis.

Autoimmune hepatitis. Definition--classification--histopathology--immunopathogenesis

Autoimmune hepatitis (AIH) is a distinct form of acute and chronic inflammatory liver disease in which immune reactions against host antigens are found to be the major pathological mechanism. If left untreated it carries an unfavourable prognosis, and the diagnosis should be made as soon as possible. The diagnostic approach has been greatly facilitated by the establishment of a panel of marker autoantibodies, which do not define distinct therapeutic groups of AIH, but do allow a subgrouping based on differences in patient populations, some clinical features and prognosis. The characterization of organ-specific components of the liver cell surface as targets of cellular and humoral autoimmune reactions give new insights into the pathogenesis of the disease, even though the primary event triggering the disease remains to be defined. The most important disease-promoting factor seems to be a genetically determined background for autoimmunity. Without this different environmental factors, including viruses, toxins, cytokines and drugs, are only able to induce transient autoimmune phenomena and not autoimmune disease. The histopathology of AIH is in keeping with the present pathogenetic concept. Although there is no pathognomonic feature distinguishing this type of hepatitis from virus-induced forms, some distinct morphological lesions are regarded as characteristic. Clinical research on AIH has benefited greatly from observations of experimental AIH in mice. Recognition of the critical role of autoreactive T-lymphocytes in the pathogenesis and the observation of spontaneous recovery from AIH in the animal model associated with antigen-specific and antigen-non-specific T-cell suppression have made basic contributions to our improved understanding of the natural course of AIH in humans.

[Incidence of post-transfusion hepatitis in Hungary 1987-1993]

The authors describe the epidemiological characteristics of hepatitis cases occurred after administration of blood or blood-preparations in Hungary, based on data collected between January 1987 and December 1993. The epidemiologists of the public health network reported 868 acute posttransfusion hepatitis within this seven years period. The number of the cases decreased year by year, and in accordance with the rapid development of virological diagnostics the rate of cases with uncovered aetiology increased gradually. Nevertheless the aetiology of more than half of the reported cases (466 patients, i.e. 53.6%) remained unknown. The results of the examinations were negative in 167 cases (19.2%), and no etiological examinations were carried out in 299 cases (34.4%). Hepatitis A was reported in 17 cases (2%), hepatitis B in 129 cases (14.9%), whilst non-A, non-B hepatitis was diagnosed in 188 cases based on examinations with an experimental NANB antigen and antibody tests or by exclusion of hepatitis A and B infectious (21.7%); from 1991 67 cases (7.7%) were diagnosed by standard tests as hepatitis C, and Epstein-Barr virus infection was reported in 1 case (0.1%). During the seven years 11 patients of the 868 (1.3%) died in the acute phase of the illness.

[Autoimmune hepatitis and hepatitis C]

From autoimmune hepatitis (AIH) classification which recognizes three types of AIH, we discuss the main relations between hepatitis C virus (HCV) infection and AIH. Type I AIH is associated with antinuclear and antismooth muscle antibodies, and with other autoimmune diseases. There is no relation between type I AIH and HCV. Type I anti-liver kidney microsome and anti-liver cytosol I antibodies represent the hallmark of type II AIH. Among type II AIH, two subgroups emerged: type IIa AIH (10-40%) are true AIH (sensitive to steroids but worsens with interferon alpha), whereas type IIb AIH (60-90%) appear as a particular form of HCV hepatitis. Type IIb AIH have a moderate activity, a low titer of autoantibodies, anti-GOR antibodies but never anti-liver cytosol I, no sensitivity to steroids but are sensitive to interferon alpha. The hallmark of type III AIH are anti-cytosol antibodies, but these AIH have the same characteristics as type I AIH. The classification between true AIH (I, IIa, III) or "pseudo-AIH" due to HCV infection has major therapeutic implications. Steroids or immunosuppressive treatments are effective in type I, IIa and III AIH but have no efficacy in type IIb AIH. Alpha interferon has an efficacy in type IIb AIH, but it has no efficacy and may even worsen hepatitis in type I, IIa and III AIH.

[Evaluation of the new international classification of chronic hepatitis]

Evaluation of the new international classification of chronic hepatitis recommended by International congress of gastroenterologists in 1994 is given. Positive aspects of the classification cover the necessity of indicating etiological trend, process activity, the disease staging. Some negative points are also mentioned.

Chronic hepatitis. An update on terminology and reporting

The terms chronic active hepatitis (CAH), chronic persistent hepatitis (CpH), and chronic lobular hepatitis (CLH) have become obsolete, and their use without further specifications should be discontinued. This recommendation has become necessary because these names have changed from descriptive terms, intended for grading, to terms that are used either as morphologic diagnoses or disease designations or both, depending on individual preferences. Because this practice has caused serious misunderstandings, many authors and two international groups have recommended the use of a clear etiologic terminology. For the reporting practice of pathologists, we recommend that the pathologist routinely sign out biopsy samples with features of chronic hepatitis by indicating etiology, grade, and stage. An example would be autoimmune hepatitis, severe, stage 3. The stage in this case would indicate the presence of well-developed septal fibrosis but no nodular regeneration. Obviously, for the etiologic diagnosis, morphologic findings must be integrated with clinical and laboratory data. If this information is not available, clear morphologic diagnoses should be reported. Thus, instead of CPH, the diagnosis should be portal hepatitis, cause undetermined. This reporting practice eliminates ambiguous terminology and avoids the risk of inappropriate treatment as might occur, for example, when a term such as CAH is used to describe Wilson's disease and is misunderstood to mean autoimmune hepatitis. For a transitional period and to facilitate relearning, the terms CAH, CPH, and CLH can be reported in parentheses behind the etiologic diagnosis.

Segregation of pANCA antigenic recognition by DNase treatment of neutrophils: ulcerative colitis, type 1 autoimmune hepatitis, and primary sclerosing cholangitis

Antineutrophil cytoplasmic antibodies (ANCA) have been identified in the serum of 50-80% of ulcerative colitis (UC) patients. UC-associated ANCA yield a perinuclear staining pattern (pANCA) with alcohol-fixed neutrophils. More recently, pANCA have been detected in the serum of patients with primary sclerosing cholangitis (PSC) and other autoimmune liver diseases. Up to 70% of PSC patient sera and up to 92% of sera from patients with well-defined type 1 autoimmune hepatitis (type 1 AIH) were found to express pANCA. Such expression by patients with PSC and type 1 AIH raises questions concerning the relationship of these pANCA to each other and to that of UC. Differences and similarities in pANCA characteristics are found among the three diseases, suggesting the use of pANCA to define specific disease subgroups. Our recent finding that the UC-associated pANCA reactive antigen was localized within the nuclear domain prompted an examination of whether DNase treatment of neutrophils would alter antigenic recognition by the pANCA of UC, PSC, and type 1 AIH. While loss of antigenic recognition after DNase digestion of neutrophils was a dominant feature of the UC-associated pANCA, the majority of PSC and type 1 AIH pANCA recognized cytoplasmic constituents. These results further support the feasibility of defining and/or distinguishing disease subgroups based on the characterization of respective pANCA.

The validity and importance of subtypes in autoimmune hepatitis: a point of view

OBJECTIVE

To advocate formal subclassification of autoimmune hepatitis into two types based on the presence of mutually exclusive immunoserological markers, target antigen diversity, contrasting genetic predispositions, and differences in clinical profile and behavior.

METHODS

Relevant references in English were identified through a Medline Search (1984-1994) and through a personal library of journals and reprints.

RESULTS

Antinuclear antibodies and/or smooth-muscle antibodies are mutually exclusive of antibodies to liver/kidney microsome type 1. The cytochrome monooxygenase P450 IID6 is the target autoantigen for patients with antibodies to liver/kidney microsome type 1, and patients with these autoantibodies are different from others. The human lymphocyte antigens DR3 and DR4 are risk factors for patients with antinuclear and/or smooth-muscle antibodies, whereas the B14, DR3, and C4A-QO antigens are common in patients with antibodies to liver/kidney microsome type 1. Patients with antibodies to liver/kidney type 1 are younger, and they more commonly have concurrent organ-specific autoantibodies and/or immunological diseases than counterparts with antinuclear and/or smooth-muscle antibodies. They also progress to cirrhosis more frequently.

CONCLUSIONS

Two distinct types of autoimmune hepatitis can be defined by immunoserological markers, genetic predispositions, autoantigen status, and clinical features. Each should be recognized as a valid and independent entity.

[Morphologic classification of chronic hepatitis]

The diagnosis of chronic hepatitis (CH) should include the information on CH etiology, the presence or absence of CH activity as well as its morphological characteristics. CH may be of a viral etiology (the type of the virus should be mentioned in the diagnosis), autoimmune, drug-induced and alcoholic. The etiology can be established by means of the clinicomorphological analysis using immunological and immunohistochemical techniques. Sometimes it is possible to do so after routine staining of biopsies. Portal, lobular and periportal hepatitis are distinguished morphologically. Instead of the indefinite term chronic persisting hepatitis it is recommended to recognize active and non-active hepatitis.

Autoimmune hepatitis: classification, heterogeneity, and treatment

Autoimmune hepatitis, a chronic necroinflammatory disorder of unknown etiology, is characterized by immunologic and autoimmunologic features. It is more prevalent in women than in men, and genetic factors appear to play a major role in the disease. The classification of autoimmune hepatitis is based on circulating autoantibody status; however, heterogeneity is distinguished not only by autoantibodies, but by histologic differences, a variety of clinical features, immunogenetic status, and probably pathogenesis. Presentation extends from the asymptomatic to the severely ill patient. Although patients may present with or without evidence of circulating autoantibodies, hyperglobulinemia is a rather consistent laboratory feature. Because the disease is generally steroid-responsive, therapeutic remission rates of 60-80% have been achieved with prednisone or a combination of prednisone and azathioprine, and many patients can be maintained with these drugs alone or in combination. There are no firm guidelines for decisions regarding withdrawal or reduction of medication. When treatment failures occur, orthotopic liver transplantation may be required.

[Autoimmune hepatitis]

Acute and chronic autoimmune hepatitis are uncommon inflammatory liver diseases, mainly occurring in young women, in association with hypergammaglobulinemia and serum autoantibodies. Different types have been described: type 1 characterized by anti-smooth muscle and anti-nuclear antibodies; type 2 characterized by anti-LKM1 antibodies; type 3 characterized by anti-SLA antibodies. Other types, still not clearly defined, may exist. Autoimmune hepatitis are associated with HLA A1 B8 DR3 and HLA DR4. Without any treatment, the disease leads to cirrhosis and, uncommonly, to fulminant hepatitis. Large doses of corticosteroids usually allow to control the disease. Relapse of hepatitis is frequent after corticosteroid withdrawal. Concomitant administration of immunosuppressive agents such as azathioprine allows to reduce corticosteroid dosage and contributes to maintain the remission of the disease. Liver transplantation may be indicated in cases of severe cirrhosis or fulminant hepatitis.

[Chronic autoimmune type II hepatitis with various extrahepatic clinical manifestations]

We present the case of a patient with autoimmune chronic hepatitis and anti-LKM antibodies, who developed associated autoimmune diseases, cyclic nodose erythema, bilateral peripheric paralysis, idiopathic thrombocytopenic purpura and diabetes mellitus. We describe the first signs of the disease and how three different forms can be differentiated depending on the type of autoantibodies present in the patients' serum. Finally, we list several forms of presentation of the disease, the potential clinical associations with other autoimmune processes and the potential immunological basis for the development of the hepatic lesion.

A practical approach to the liver biopsy

A stepwise practical approach to the histological interpretation of liver biopsy specimens is presented. To avoid bias, liver biopsies are analysed blind initially to arrive at a morphologic diagnosis. The possible differential diagnoses are then considered in order of likelihood. The final diagnosis is made only after clinicopathologic correlation; the importance and necessity of discussion with the referring clinician cannot be overemphasized. Common morphologic categories are given as guide-lines. Helpful histopathologic features for the various differential diagnoses including diagnostic problems and pitfalls are highlighted.

[Problem of chronic hepatitis (classification, pathogenesis and treatment]

Update information is added to classification of chronic hepatitis. A new form--chronic lobular hepatitis is described as well as characteristic features of immune response to hepatitis B virus (HBV). The findings enable the authors not only to relate autoimmune abnormalities to HBV infection, but to consider them an essential component of this infection. The leading role in pathogenesis of viral hepatic lesions is played by cellular immunity. A sound subpopulation analysis of immunocompetent blood cells was carried out for chronic active hepatitis and hepatic cirrhosis in correlation with HBsAg. It is emphasized that a biological cycle of HBV development determines the type and power of the macroorganism immune response and should be allowed for when designing policy of treatment of chronic hepatic viral diseases. Criteria are proposed for deciding on immunomodulators and immunodepressants for chronic viral and autoimmune hepatitis.