Christina Weiler-Normann

Genome-Wide Association Study Identifies Variants Associated With Autoimmune Hepatitis Type 1

BACKGROUND & AIMS Autoimmune hepatitis (AIH) is an uncommon autoimmune liver disease of unknown etiology. We used a genome-wide approach to identify genetic variants that predispose individuals to AIH. METHODS We performed a genome-wide association study of 649 adults in The Netherlands with AIH type 1 and 13,436 controls. Initial associations were further analyzed in an independent replication panel comprising 451 patients with AIH type 1 in Germany and 4103 controls. We also performed an association analysis in the discovery cohort using imputed genotypes of the major histocompatibility complex region. RESULTS We associated AIH with a variant in the major histocompatibility complex region at rs2187668 (P = 1.5 × 10(-78)). Analysis of this variant in the discovery cohort identified HLA-DRB1*0301 (P = 5.3 × 10(-49)) as a primary susceptibility genotype and HLA-DRB1*0401 (P = 2.8 × 10(-18)) as a secondary susceptibility genotype. We also associated AIH with variants of SH2B3 (rs3184504, 12q24; P = 7.7 × 10(-8)) and CARD10 (rs6000782, 22q13.1; P = 3.0 × 10(-6)). In addition, strong inflation of association signal was found with single-nucleotide polymorphisms associated with other immune-mediated diseases, including primary sclerosing cholangitis and primary biliary cirrhosis, but not with single-nucleotide polymorphisms associated with other genetic traits. CONCLUSIONS In a genome-wide association study, we associated AIH type 1 with variants in the major histocompatibility complex region, and identified variants of SH2B3and CARD10 as likely risk factors. These findings support a complex genetic basis for AIH pathogenesis and indicate that part of the genetic susceptibility overlaps with that for other immune-mediated liver diseases.

FOXP3+ regulatory T cells in autoimmune hepatitis are fully functional and not reduced in frequency.

BACKGROUND & AIMS The pathogenesis of autoimmune hepatitis (AIH) is not understood, but it was suggested that AIH may be related to a numerical or functional impairment of CD4+CD25+FOXP3+ regulatory T cells (Treg), which are important mediators of immune tolerance to self-antigens. However, the role of Treg in AIH is not clear, since earlier studies reporting Treg impairment had used only CD25 as marker that cannot unambiguously distinguish Treg from activated effector T cells. METHODS We assessed the frequency and suppressor function of Treg using current staining protocols that can distinguish Treg from activated effector T cells. RESULTS The frequency of CD4+CD25(high)CD127(low)FOXP3+ Treg cells in blood of AIH patients was not reduced compared to healthy subjects, as shown by flow cytometry and confirmed by quantifying Treg-specific demethylation of the FOXP3 gene. Moreover, the suppressor function of Treg isolated from AIH patients was similar to that of Treg isolated from healthy subjects, indicating that Treg function was not impaired in AIH patients. However, we observed that the Treg frequency was significantly higher in those AIH patients with active disease than in those who were in a state of remission, suggesting that the Treg frequency may increase with the degree of inflammation. Indeed, analysis of FOXP3+ Treg in liver histology revealed that the intrahepatic Treg frequency was higher in AIH patients than in NASH patients and correlated with the inflammatory activity of the liver. CONCLUSIONS The frequency and function of circulating Treg cells is not impaired in AIH.

Infliximab as a rescue treatment in difficult-to-treat autoimmune hepatitis

BACKGROUND & AIMS Autoimmune hepatitis is a chronic inflammatory liver disease that leads to liver cirrhosis and corresponding complications, if left untreated. Current standard treatment with azathioprine and prednisolone induces remission in the vast majority of patients. However, for those patients not responding to standard treatment or not tolerating these drugs, few alternatives can be used and their effectiveness might be limited. We sought to analyze the safety and efficacy of off-label treatment with infliximab in a cohort of eleven patients with difficult-to-treat autoimmune hepatitis. METHODS Patients with difficult-to-treat autoimmune hepatitis who could not be brought into remission with standard treatment, either due to drug intolerance or to insufficient drug impact, were treated off-label with infliximab for a minimum of six months. Patient files were reviewed retrospectively. RESULTS Treatment with infliximab led to reduction of inflammation, evidenced by a decrease in transaminases (mean AST prior treatment 475 U/L ± 466, mean AST during treatment 43 U/L ± 32) as well as in immunoglobulins (pretreatment mean IgG 24.8 mg/dl ± 10.1, mean IgG during treatment 17.38 mg/dl ± 6). Infectious complications occurred in seven out of eleven patients and close monitoring was necessary. CONCLUSIONS Infliximab may be considered as rescue therapy in patients with difficult-to-treat autoimmune hepatitis, albeit treatment may be associated with infectious complications.

Drug induced liver injury and its relationship to autoimmune hepatitis.

Department of Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, GermanySee Article, pages 820–827Drug-induced liver injury (DILI) is a leading cause of acute liverfailure [1] and is of major importance to the pharmaceuticalindustry, as it is the most frequent reason for withdrawal of sub-stances from the market. More than 1000 different drugs and her-bal remedies have been described to cause DILI. Some drugscause a dose-dependent toxicity which can be anticipated – awell known example is acetaminophen. The vast majority of DILIcases cannot be foreseen and are, therefore, termed idiosyncratic.Oxidative stress, reactive metabolites, mitochondrial toxicity,modulation of drug metabolizing transporters, induction of apop-tosis or necrosis, as well as immunoallergic reactions to proteinadducts may all be involved in DILI, but for most of the drugsthe specific mechanisms contributing to DILI are unknown [2].A classification of hepatocellular, mixed or cholestatic liver injuryis used in the clinic to describe damage and severity of liverinjury but its value in predicting the outcome of DILI is unclear.DILI can range from asymptomatic elevation of liver enzymesto fulminant hepatic failure [1]. Its over-all mortality dependson the drug used, the timely detection of DILI including theappropriate action taken, as well as individual cofactors andcomorbidities such as the presence of diabetes mellitus [3]. Mor-tality rates of approximately 10% [1] have been reported but maybe highly overestimated since most mild drug reactions will notbe registered. In most patients, DILI leads to a complete recovery.However, up to 1% of all patients with DILI may develop liver cir-rhosis subsequently [4].DILI is a rare event with an estimated incidence of 1 per10,000 to 1 per 100,000 treated patients [5]. Some risk factorshave been identified: the daily amount of the drug causing thereaction (intake of >50 mg daily increases risk), a predominantlyhepatic metabolism of the drug (>50%) [6], and mitochondrialdysfunction that may be the underlying cause of the increasedrisk of DILI in diabetes patients [7]. Genetic polymorphismswithin genes relevant to drug metabolism [8] are being identifiedand may be used to stratify the risk of DILI to certain drugs in thefuture.A question relevant to daily clinical practice is, if re-exposureto the same or to other drugs may cause a second DILI episode.Re-exposure to the same drug generally should be avoided dueto the considerable mortality rate reported after re-exposure todrugs such as halothane (up to 50% due to a combination of mito-chondrial and immune-mediated injury) [9]. Nonetheless, fordrugs that are urgently needed in case of life threatening disease,such as in tuberculosis, careful re-exposure can be undertakenafter the resolution of the first DILI episode with acceptable risk[10]. The risk of re-exposure to a different drug that may belongto the same class of drugs or be completely unrelated is not wellstudied. To this end, the study presented by Lucena et al. in thisissue adds valuable and reassuring information[11]. In this study,the Spanish DILI registry of patients with probable or highlyprobable idiosyncratic DILI was searched for patients who suf-fered from a second DILI episode. Only a small number of patients(9 patients, 1.21%) from the cohort of patients with prior DILIdeveloped a second episode of liver injury and none of thepatients’ required liver transplantation or had a fatal outcome.Of particular interest, the majority of patients (8 out of 9) expe-riencing a second DILI episode had a similar (hepatocellular)damage pattern. The drugs responsible for the second DILI epi-sode were structurally related to the drug of the first DILI episodein 4 out of 9 cases and, in 2 cases, the target of the drug was thesame. This may point toward an immune-mediated drug injurydirected against similar protein adducts forming haptens. Indeed,4 out of the 9 patients (44%) were diagnosed with so called ‘‘auto-immune (AIH) DILI’’ since these patients fulfilled the criteria forprobable or definite AIH, according to the revised and simplifiedscore of the international autoimmune hepatitis study group[12,13]. This number was considerably higher than in patientswith a first DILI episode, where only 12/733 (1.6%) patients werediagnosed with ‘‘AIH DILI’’ [11], suggesting that immune-medi-ated reactions become the main mechanisms leading to DILI afterre-exposure to different drugs.There is no consensus on the nomenclature of immune-med-iated DILI and we will propose some definitions and respectivediagnoses at the end of this article. Until then, the diagnosesgiven in the publications cited will be used.In clinical practice, the differentiation between immune-med-iated DILI and AIH may be challenging. There are no pathogno-monic features of AIH and the diagnosis is made according to aclinical, biochemical, serological, and histological pattern whichhas to be confirmedby the response to immunosuppressive treat-ment [14]. This difficulty in differentiating between AIH and drugJournal of Hepatology 2011 vol. 55

Transient elastography in autoimmune hepatitis: Timing determines the impact of inflammation and fibrosis.

BACKGROUND & AIMS There is an unmet need for the non-invasive monitoring of fibrosis progression in patients with autoimmune hepatitis (AIH). The aim of this study was to assess the diagnostic performance of transient elastography in patients with AIH and to investigate the impact of disease activity on its diagnostic accuracy. METHODS Optimal cut-offs were defined in a prospective pilot study (n=34) and the diagnostic performance of transient elastography validated in an independent second cohort (n=60). To explore the impact of disease activity on liver stiffness, patients were stratified according to biochemical response and the time interval between start of immunosuppression and transient elastography. RESULTS Liver stiffness strongly correlated with histological fibrosis stage (pilot study: ρ=0.611, p<0.001; validation cohort: ρ=0.777, p<0.0001). ROC curves defined an area under the receiver operating curve of 0.95 for diagnosing cirrhosis at the optimal cut-off of 16kPa. The performance of transient elastography was impaired when patients were analysed in whom transient elastography was performed within 3months from start of treatment. In this setting, liver stiffness correlated with histological grading (ρ=0.558, p=0.001), but not with staging. In contrast, using the cut-off of 16kPa, the accuracy for diagnosing cirrhosis was excellent in patients treated for 6months or longer (area under the receiver operating curve 1.0). CONCLUSIONS Liver inflammation has a major impact on liver stiffness in the first months of AIH treatment. However, transient elastography has an excellent diagnostic accuracy for separating severe from non-severe fibrosis after 6months of immunosuppressive treatment. LAY SUMMARY Transient elastography is a special ultrasound scan, which assesses liver stiffness as a surrogate marker for liver fibrosis/scarring. Transient elastography has been shown to be a reliable non-invasive method to assess liver fibrosis in various chronic liver diseases, it takes less than 5min and has a high patient acceptance. The current study validated for the first time this technique in a large cohort of patients with autoimmune hepatitis (AIH) and demonstrates that it is a reliable tool to detect liver fibrosis in treated AIH. For the monitoring of potential disease progression under treatment, the validation of liver stiffness as non-invasive marker of liver fibrosis will greatly improve patient care in autoimmune hepatitis.

A case of difficult-to-treat autoimmune hepatitis successfully managed by TNF-alpha blockade.

To the Editor: We would like to report on a case of difficult-to-treat autoimmune hepatitis (AIH) that responded well to treatment with infliximab therapy.

Efficacy of 6-Mercaptopurine as Second-Line Treatment for Patients With Autoimmune Hepatitis and Azathioprine Intolerance

BACKGROUND & AIMS Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease that requires long-term immunosuppressive therapy. Although most patients have an excellent response to standard therapy (azathioprine in combination with corticosteroids), approximately 10%-15% have intolerance or an insufficient response to azathioprine treatment. We investigated whether 6-mercaptopurine (6-MP) is an effective second-line therapy for patients with AIH. METHODS We performed a retrospective study of 22 patients with AIH who were switched to 6-MP therapy after treatment with the combination of azathioprine and prednisolone at 2 tertiary care institutions in Europe (Germany and the United Kingdom) before November 15, 2014. We performed statistical analyses of data on clinical and biochemical responses collected 4 weeks after 6-MP treatment and then at regular physician visits. RESULTS A total of 15 of 20 patients with prior azathioprine intolerance (75%) responded to 6-MP treatment; 8 of these patients had a complete response and 7 had partial remission, based on biochemical features. In these 15 patients, 6-MP was well tolerated, whereas the 5 remaining patients had to be switched to different immunosuppressive regimes because of 6-MP intolerance. The 2 patients with insufficient response to azathioprine treatment also showed no response to 6-MP. CONCLUSIONS In patients with AIH and azathioprine intolerance, 6-MP seems to be an effective and well-tolerated second-line treatment. 6-MP might be ineffective in patients with insufficient response to azathioprine.

Health-related quality of life, depression, and anxiety in patients with autoimmune hepatitis

BACKGROUND & AIMS Improving health related quality of life (HrQoL) in patients with chronic diseases such as autoimmune hepatitis (AIH) should be a major treatment goal. However, little is known on the HrQoL in patients with AIH, and the topic is not given attention in current practice guidelines. We therefore conducted a single center study evaluating HrQoL in 103 consecutive outpatients with AIH. METHODS Patient-reported HrQoL data were analysed in relation to clinical disease parameters and compared to representative data of the German population as well as control patients. RESULTS Based on patient-reported data, a major depressive syndrome (10.8%) was found to be five times more frequent in AIH patients compared to the general population (p<0.001). The rate of severe symptoms of anxiety was also found to be significantly increased compared to the general population (p=0.006). In seven of the eleven patients who scored for a major depressive syndrome a psychiatric comorbidity had not been diagnosed before. Major factors associated with depression and anxiety were concerns with regard to the progression of the liver disease. CONCLUSIONS This study identified--for the first time--a high rate of previously unrecognized severe symptoms of depression and anxiety in patients with AIH. Of importance for daily clinical practice, the factors associated with these symptoms may in part be amenable to targeted counselling and adequate treatment of the disease, thereby offering the chance to improve the care and HrQoL of AIH-patients.

Long-term follow-up of patients with difficult to treat type 1 autoimmune hepatitis on Tacrolimus therapy

ABSTRACT Introduction: Autoimmune hepatitis (AIH) is an immune-mediated liver disease, which requires long-term immunosuppression. Ten to fifteen percent of patients experience insufficient/intolerance response to standard therapy. Although alternate immunosuppression has been applied, there is little long-term data reported on safety, efficacy, steroid-dose reduction and disease evolution in patients with difficult AIH who were on Tacrolimus therapy. Materials and methods: Clinical, biochemical, immunological profiles, treatment response and side effects of 17 AIH patients treated with Tacrolimus between 2003 and 2014 were analyzed from two tertiary referral liver centers. Results: Tacrolimus was started on 16/17 (94%) patients due to insufficient response to standard therapy. The median duration of treatment was 24 months and patients were followed up for median of 60 months. Tacrolimus dosage was 2 mg/day (median). During first year of therapy, there was a significant improvement in immunoglobulin G and Aspartate transaminase level. 9/17 (52%) compliant and definite AIH patients remained on Tacrolimus at end of follow-up and prednisolone dose reduction was achieved from 10 to 5 mg. All patients are alive and one patient underwent liver transplantation. 4/17 (24%) patients developed overlap with primary sclerosing cholangitis over follow-up period. No significant side effects were observed with Tacrolimus therapy. Conclusion: Tacrolimus could be used in compliant patients with difficult to treat AIH in experienced centers. Its use is safe and can improve liver biochemistry, IgG and reduce steroid requirement. However, due to the lack of immunomodulatory effect, unmet need for effective immune-regulatory therapies still remain for AIH patients.

Association of autoimmune hepatitis and systemic lupus erythematodes: A case series and review of the literature

Liver test abnormalities have been described in up to 60% of patients with systemic lupus erythematodes (SLE) at some point during the course of their disease. Prior treatment with potentially hepatotoxic drugs or viral hepatitis is commonly considered to be the main cause of liver disease in SLE patients. However, in rare cases elevated liver enzymes may be due to concurrent autoimmune hepatitis (AIH). To distinguish whether the patient has primary liver disease with associated autoimmune clinical and laboratory features resembling SLE - such as AIH - or the elevation of liver enzymes is a manifestation of SLE remains a difficult challenge for the treating physician. Here, we present six female patients with complex autoimmune disorders and hepatitis. Patient charts were reviewed in order to investigate the complex relationship between SLE and AIH. All patients had coexisting autoimmune disease in their medical history. At the time of diagnosis of AIH, patients presented with arthralgia, abdominal complaints, cutaneous involvement and fatigue as common symptoms. All patients fulfilled the current diagnostic criteria of both, AIH and SLE. Remission of acute hepatitis was achieved in all cases after the initiation of immunosuppressive therapy. In addition to this case study a literature review was conducted.