Autoimmune Hepatitis


Article Author:
Catherine Linzay
Bashar Sharma


Article Editor:
Sudha Pandit


Editors In Chief:
Sisira Reddy
Joseph Nahas


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/28/2019 11:58:50 AM

Introduction

Autoimmune hepatitis refers to chronic and progressive inflammation of the liver from an unknown cause. Proposed mechanism for the development of autoimmune hepatitis is thought to be the interplay of genetic predisposition, an environmental trigger, and failure of the native immune system resulting in chronic inflammation of hepatocytes and subsequent fibrosis of the liver. [1][2][3]There are two known types of autoimmune hepatitis. Type 1 is distinguished by the presence of anti-smooth muscle antibodies (ASMA) with or without anti-nuclear antibodies (ANA). Type 2 autoimmune hepatitis presents with positive anti-liver/anti-kidney microsome (anti-LMK) type 1 antibodies or anti-liver cytosol (anti-LC) type 1 antibodies.

Etiology

There is no specific evidence of the cause. Sixty percent of patients have chronic hepatitis but without serologic evidence of a viral infection. The disease is associated with anti-smooth muscle autoantibodies. [4]

Epidemiology

Epidemiological data on autoimmune hepatitis is scarce and very likely unreported and underrecognized. Of the two types of autoimmune hepatitis, 80% of cases are diagnosed as type 1. Seventy-five percent of type 1 autoimmune hepatitis is known to manifest in young or middle-aged females. Autoimmune hepatitis is more common in females than males with a ratio of 3.6:1. [5][2]Due to the lack of exact epidemiological data, the true incidence and prevalence in the United States are unknown. However, it is reported that 100,000 to 200,000 individuals are affected each year.  Based on European studies, the incidence of autoimmune hepatitis is 0.9-2/100,000 populations per year and the prevalence of 11-25/100,000 per year. Type 2 autoimmune hepatitis is most commonly diagnosed in children and young adults and usually presents with fulminant hepatic failure.

Pathophysiology

The etiology of autoimmune hepatitis is unknown. Current proposition for pathogenesis is thought to be secondary to a failure of immune tolerance in a genetically susceptible individual leading to a T-cell mediated inflammation caused by various environmental triggers. Common triggers include infections, medications, and toxins. Certain human leukocyte antigen (HLA) haplotypes are more susceptible to the development of autoimmune hepatitis. Susceptible alleles are different in different ethnic groups. Among White North Americans and Northern Europeans, susceptible alleles are located on the short arm of chromosome 6, specifically within the region of DRB-1. Nitrofurantoin and minocycline are well-documented culprits of drug-induced autoimmune hepatitis. Tumor necrosis factor-alpha drugs have been more recently linked to autoimmune hepatitis.

Histopathology

The hallmark histologic feature of autoimmune hepatitis is interface hepatitis. However, it is nondiagnostic as it is present in most cases of viral hepatitis. Various histological findings are associated with autoimmune hepatitis, but all of them are nonspecific.

The specimen of liver biopsy should include 6 portal triads for autoimmune hepatitis diagnosis. Typical autoimmune hepatitis biopsy includes mononuclear inflammatory infiltrate mostly plasma cells, located primarily in the portal tracts. This inflammation leads to piecemeal necrosis of hepatocytes leading to the destruction of limiting plate (interface hepatitis), bridging fibrosis (connecting portal and central area of hepatocytes), regenerating nodules, and finally cirrhosis. Twenty-five percent of cases show changes in bile ducts such as ductopenia, cholangitis.

These histologic findings are nonspecific for autoimmune hepatitis. Thus, a scoring system was developed for the diagnosis of autoimmune hepatitis. In 1993, the International Autoimmune Hepatitis Group (IAIHG) initially proposed criteria that classified patients as “probable” or “definite” for autoimmune hepatitis based on multiple factors: gender, the presence of transaminitis, the presence of autoantibodies, and a history of autoimmune disease in first-degree relatives. These criteria also took into account whether or not other causes such as viral or alcohol-induced hepatitis had been excluded. In 1999, the scoring system was updated to include response to treatment. Since that time, a simplified scoring system has been introduced and is more conducive to everyday use by clinicians. Using the new scoring system, the sensitivity and specificity for probable autoimmune hepatitis is 91% and 94%, respectively; the sensitivity and specificity of definite autoimmune hepatitis are 75.5% and 100%, respectively.

History and Physical

Autoimmune hepatitis can present in a variety of ways from asymptomatic elevation of liver enzymes noted on routine lab tests to fulminant hepatitis. Clinical manifestations of autoimmune hepatitis depend on how acute liver disease is at presentation, the stage of inflammation, or the complication of liver cirrhosis. The most common features of autoimmune hepatitis are fatigue, malaise, jaundice, abdominal pain, and sometimes, arthralgias.

Features of a failing liver such as ascites, hepatic encephalopathy, and variceal hemorrhage are a rare initial presentation of autoimmune hepatitis. Only a few patients present with acute liver failure. Autoimmune hepatitis may present concurrently with other autoimmune diseases like Graves disease, rheumatoid arthritis, celiac disease, type I diabetes, ulcerative colitis, hemolytic anemia, and immune thrombocytopenia. Specifically, autoimmune hepatitis is present in approximately 10% of individuals with autoimmune polyendocrine syndrome type 1.

About 25% of patients with autoimmune hepatitis are asymptomatic. The most common physical findings in autoimmune hepatitis are hepatomegaly (78%) and jaundice (69%) in patients with severe disease. Another common physical finding is splenomegaly with or without cirrhosis.

Evaluation

Autoimmune hepatitis should be considered in all individuals with both acute and chronic liver disease. Diagnosis of autoimmune hepatitis requires exclusion of other chronic causes of liver disease including Wilson disease, drug-induced hepatitis, nonalcoholic hepatosteatosis (NASH), chronic viral hepatitis, primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC).[6][7][8]

A multi-pronged approach is used to make a diagnosis. This approach includes determining symptoms, laboratory tests, and biopsies, as no single diagnostic test is pathognomonic for autoimmune hepatitis. Marked elevation of serum transaminases (AST, ALT) and gamma-globulin is common; elevation in alkaline phosphatase is less common.  The serum levels of AST, ALT, and gamma globulin reflect disease severity and immediate prognosis at presentation.

The serologic markers required for the diagnosis of autoimmune hepatitis include antinuclear antibody (ANA), smooth muscle antibodies (SMA), and antibodies to liver-kidney microsome type 1 (anti-LKM1). Indirect immunofluorescence detects ANA, SMA, and anti-LKM1.  The diagnostic accuracy, specificity, and sensitivity of these markers are 74%, 99%, and 43%, respectively. Anti-liver cytosol type I, anti-soluble liver antigen (SLA) antibodies and perinuclear antineutrophil cytoplasmic antibodies (pANCA) can also be associated with autoimmune hepatitis. [9]Conversely, anti-mitochondrial antibodies are more commonly seen with primary biliary cirrhosis and are usually absent in autoimmune hepatitis; however, they can be present in those with overlapping syndromes. Atypical perinuclear antineutrophil cytoplasmic antibodies are commonly associated with type-1 autoimmune hepatitis and primary sclerosing cholangitis. Anti-LKM1 are common in type-1 autoimmune hepatitis and mainly observed in children.

Anti-SLA antibodies are more useful from a prognostic standpoint as these are associated with more severe disease, treatment failure, and higher relapse rate. Liver biopsy is required for both diagnosis and staging of autoimmune hepatitis.

Treatment / Management

The treatment guidelines for autoimmune hepatitis are continually evolving. Untreated individuals develop cirrhosis and subsequently die of liver failure two years from diagnosis. [10][11][12] Nonetheless, a handful of cases are reported to have increasing and decreasing clinical stages and may even progress into prolonged spontaneous remission. Therapy for autoimmune hepatitis should begin in patients who fit any or all of the following criteria:

  • Elevated AST and ALT more than ten times the upper limit of normal, or at least five times the upper limit of normal
  • Gamma globulin at least two times the upper limit of normal  
  • Presence of bridging necrosis and multilobular necrosis in liver biopsy.

It is now well established that use of corticosteroids leads to complete remission and in most cases improves mortality. The American Association for the Study of Liver Diseases recommends monotherapy with prednisone or combination therapy with prednisone and azathioprine. However, due to multiple adverse effects of long-term use of prednisone, combination therapy is preferred over monotherapy with prednisone. Monotherapy with prednisone is preferred in cases of pregnancy, intolerance to azathioprine, an absence of thiopurine methyltransferase (TPMT) activity, or severe cytopenia. Immunosuppressive therapy should not be started in patients with preexisting comorbid conditions such as vertebral compression, brittle diabetes, uncontrolled hypertension, psychosis.

For monotherapy, a typical induction dose of prednisone is 60 mg daily for 1 week followed by 40 mg in the second week, and 30 mg daily in third and fourth week. The maintenance dose of prednisone is 20 mg daily until the endpoint or deep clinical remission. The prednisone should be tapered over time and eventually discontinued. The American Association for the Study of Liver Diseases recommends at least 3 years of treatment. Upon completion of prednisone, patients are classified as in remission, relapsed, or treatment failure based on their histological and laboratory response to steroids, and the presence or absence of clinical symptoms. Histologic regression lags by 3 to 6 months, so treatment must be continued despite normalization of liver enzymes. For combination therapy, the induction dose of prednisone is 30 mg daily for 1 week, followed by 20 mg daily for 1 week, followed by 15 mg daily for 2 weeks. The maintenance dose is 10 mg daily until the endpoint. The dose of azathioprine in combination therapy for both induction and maintenance is 30 mg oral daily. 

Budesonide may be used instead of prednisone to reduce the adverse effects associated with steroid treatment. Combination of budesonide and azathioprine is emerging as an alternative first-line therapy. In cases of inadequate or incomplete response, or azathioprine intolerance, mycophenolate mofetil, cyclosporine A, and tacrolimus can be used.

Remission occurs when the patient becomes asymptomatic with normalization of inflammatory markers, transaminases, gamma globulin, and histological improvement in liver biopsy.

Relapse can occur after a patient in remission stops therapy. About 50% of patients have disease relapse within 6 months of discontinuing therapy. Relapse is defined by the elevation of AST (three times the upper limit of normal), the reappearance of histological findings after discontinuing therapy.

Liver cirrhosis can develop in about 7% to 40% of treated patients. Development of cirrhosis is associated with incomplete response, treatment failure, and multiple relapses. Once cirrhosis develops, upper endoscopy should be performed for esophageal varices surveillance. Regular screening for hepatocellular carcinoma should be done with biannual liver ultrasound and alpha-fetoprotein. Overall, management of liver cirrhosis in autoimmune hepatitis is similar regardless of etiology.  Finally, liver transplantation is considered the standard of care in patients presenting with fulminant hepatic failure or those with the progression of disease despite multiple lines of therapy. Patients are also encouraged to avoid alcohol, unregulated herbal supplements, and high amounts of dietary fats.

Differential Diagnosis

  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis E

Pearls and Other Issues

Prognosis can vary widely but appears to be most dependent on treatment. Several randomized, controlled trials have shown that untreated autoimmune hepatitis patients have a 5-year and 10-year survival rate of 50% and 10%, respectively. Sixty percent to 80% of patients will enter remission after the proposed duration of treatment. Approximately 50% of these patients will relapse requiring therapy resumption. Some patients require life-long immunosuppression. Treatment failure occurs in 10% of patients that undergo treatment with prednisone. Those who undergo liver transplantation, approximately a third of patients have a recurrence of autoimmune hepatitis.

Enhancing Healthcare Team Outcomes

The diagnosis and management of autoimmune hepatitis is complex and best done by an interprofessional team that includes a gastroenterologist, pharmacist, internist, and a hepatologist. Specialized gastrointestinal nurses assist in care, education of the patient and family, and coordination of the treatment and followup. It is now well established that use of corticosteroids leads to complete remission and in most cases improves mortality. The American Association for the Study of Liver Diseases recommends monotherapy with prednisone or combination therapy with prednisone and azathioprine. The pharmacist should educate the patients on all the potential complications of steroids and when to seek medical help. At the same time, the primary care provider and nurse practitioner should thoroughly examine the patient for worsening of the liver condition.

The prognosis for most patients with autoimmune hepatitis is guarded. While survival has improved over the past 2 decades, it still is low. Relapse of the condition is common and some patients may benefit from a liver transplant.[13][14] (Level V)

 

 


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Autoimmune Hepatitis - Questions

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In a patient with autoimmune hepatitis, what type of antibody is most specific?



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Which of the following system's sequelae is not expected to be seen during the course of autoimmune hepatitis?



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Which of the following does not present the same way as autoimmune hepatitis?



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Anti-smooth muscle antibodies are found in which of type of hepatitis?



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Which of the following treatments can be used for autoimmune hepatitis?



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A 35-year-old White female presents complaining of a two-week history of a right upper quadrant sharp abdominal pain and nausea. She also has noticed some scleral icterus during this time that appears to have become more pronounced over the last several days. She denies any recent sexual partners or history of intravenous drug use. The patient drinks socially and does not smoke. Vitals show blood pressure 110/75 mmHg, heart rate 89 bpm, temperature 100.2 F, and respiratory rate 19/minute. Pertinent laboratory studies are WBC 7.65, AST 260, ALT 314, alkaline phosphatase 76, total bilirubin 10.9, and hepatitis panel is negative. Autoimmune workup reveals a positive antinuclear antibody and positive anti-smooth muscle antibody. Anti-mitochondrial antibodies are negative. A liver biopsy is obtained and shows only interface hepatitis. Should this patient be started on therapy, and if so, what is the most appropriate therapy to initiate?



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A 55-year-old woman comes in for her first visit after being referred by her primary care provider for an abnormal lab blood test. She has been fairly healthy all her life and is asymptomatic. She is married with two healthy children and currently works in a bank. She takes a daily multivitamin and walks two miles four times a week. Over the last few months, she has been itching all over her body, which is tolerable but worse at night. On routine lab work her CBC, basic metabolic profile was normal. Liver function tests showed total protein 7.8 g/dL, albumin 4.0 g/dL, ALT 21 U/L, AST 19 U/L, total bilirubin 0.2 mg/dL, alkaline phosphatase was 210 U/L. Serum GGT was 76 U/L. Serum vitamin D level was 14 ng/mL. What is the next step in evaluation?



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A 65-year-old male with a history of asthma and hypertension was referred for progressive fatigue, anorexia, weight loss, and dark urine of 1-week duration. He does not have any history of liver disease. His medication included amlodipine for hypertension, albuterol inhalers for asthma, and nitrofurantoin daily for one year for his recurrent urinary tract infections. Labs were significant for alanine transaminase (ALT) 750 IU/L, aspartate aminotransferase (AST) 900 IU/L, total bilirubin 5 mg/dL with a direct fraction of 3.3 mg/dL, alkaline phosphatase (ALP) 200 IU/L. Work up was negative for acute hepatitis A, B, and C. Antinuclear antibody (ANA) and anti-smooth muscle antibodies (ASMA) were positive with elevated gamma globulins. CT abdomen was unremarkable. Liver biopsy revealed interface hepatitis with bridging fibrosis and portal inflammation of plasma cells predominance. What is the most likely risk factor that has contributed to his disease?



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A 17-year-old female with a history of type 1 diabetes on insulin presents with fatigue, malaise, jaundice, and abdominal pain. Her vitals were within normal limits. BMI 20 kg/m2. She denied drinking alcohol or take any over the counter or herbal drugs. Labs were significant for alanine aminotransferase (ALT) 800 IU/L, aspartate aminotransferase (AST) 1000 IU/L, total bilirubin 6.5 mg/dL with a direct fraction of 4 mg/dL, and alkaline phosphatase (ALP) 180 IU/L. Work up was negative for acute hepatitis A, B, C, Wilson disease, and hemochromatosis. The celiac panel was negative. Anti-nuclear antibodies (ANA) and anti-smooth muscle antibodies (ASMA) were positive, with elevated polyclonal gamma globulins. CT abdomen was unremarkable. What would her biopsy likely show?



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A 40-year-old female with a history of type 1 diabetes presents with fatigue, malaise, weight loss, and abdominal pain. Her vitals are within normal limits. Her symptoms started seven days ago, and they have worsened. On physical examination, her liver and spleen are found to be enlarged. Labs are significant for an ALT of 1000 IU/L, AST of 1100 IU/L, total bilirubin of 2.9 mg/dL with a direct fraction of 1.4 mg/dL, and an ALP of 220 IU/L. She has not traveled anywhere recently, denies alcohol intake, and has not taken any medications. CT scan of the abdomen was unremarkable. Which of the following is the most appropriate treatment for this patient?



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A 65-year-old male presented with abdominal pain, malaise, and loss of appetite. His vitals were within normal limits. Labs were significant for alanine aminotransferase (ALT) 600 IU/L, aspartate aminotransferase (AST) 700 IU/L, total bilirubin 4 mg/dL with a direct fraction of 2.5 mg/dL, alkaline phosphatase (ALP) 160 IU/L. Work up was negative for acute hepatitis A, B, C, Wilson disease, and hemochromatosis. Antinuclear antibody (ANA) and anti-soluble liver antigen/liver pancreas antibodies were positive. Polyclonal gamma globulins were elevated. He denied having any alcohol intake, over the counter medications or starting a new drug or herbs. CT abdomen was unremarkable. What is the best next step in management?



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Autoimmune Hepatitis - References

References

Silva J,Brito BS,Silva INN,Nóbrega VG,da Silva MCSM,Gomes HDN,Fortes FM,Pimentel AM,Mota J,Almeida N,Surlo VC,Lyra A,Rocha R,Santana GO, Frequency of Hepatobiliary Manifestations and Concomitant Liver Disease in Inflammatory Bowel Disease Patients. BioMed research international. 2019;     [PubMed]
Palle SK,Naik KB,McCracken CE,Kolachala VL,Romero R,Gupta NA, Racial Disparities in Presentation and Outcomes of Pediatric Autoimmune Hepatitis. Liver international : official journal of the International Association for the Study of the Liver. 2019 Feb 25;     [PubMed]
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Aljumah AA,Al Jarallah B,Albenmousa A,Al Khathlan A,Al Zanbagi A,Al Quaiz M,Al-Judaibi B,Nabrawi K,Al Hamoudi W,Alghamdi M,Fallatah H, The Saudi association for the study of liver diseases and transplantation clinical practice guidelines for management of autoimmune hepatitis. Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2018 Nov;     [PubMed]
Dyson JK,De Martin E,Dalekos GN,Drenth JPH,Herkel J,Hubscher SG,Kelly D,Lenzi M,Milkiewicz P,Oo YH,Heneghan MA,Lohse AW, Review article: unanswered clinical and research questions in autoimmune hepatitis-conclusions of the International Autoimmune Hepatitis Group Research Workshop. Alimentary pharmacology     [PubMed]
Averbukh LD,Wu GY, Role of Biologics in the Development of Autoimmune Hepatitis: A Review. Journal of clinical and translational hepatology. 2018 Dec 28;     [PubMed]
Harrison L,Gleeson D, Stopping immunosuppressive treatment in autoimmune hepatitis (AIH): Is it justified (and in whom and when)? Liver international : official journal of the International Association for the Study of the Liver. 2019 Jan 22;     [PubMed]
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Cao LL,Zhang M,Zhu SS,Dong Y,Xu ZQ,Chen DW,Wang LM,Wang FC,Gan Y,Yan JG,Wang P,Li AQ, [Clinical and pathological characteristics and outcome of 46 children with autoimmune hepatitis]. Zhonghua er ke za zhi = Chinese journal of pediatrics. 2019 Jan 2;     [PubMed]

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