Prototypes of autoimmune hepatitis and sclerosing cholangitis in childhood

Transcription

1 RIUNIONE MONOTEMATICA AISF 2013 Personalizzazione della Cura in Epatologia ottobre 2013, PISA Prototypes of autoimmune hepatitis and sclerosing cholangitis in childhood La sottoscritta dichiara di non aver avuto negli ultimi 12 mesi conflitto d interesse in relazione a questa presentazione e che la presentazione non contiene discussione di farmaci in studio o ad uso off-label Giorgina Mieli-Vergani King s College London School of Medicine

2 Case 1 3 year-old girl presenting with jaundice bilirubin 150µmol/l AST/ALT 1500/2000 IU/l albumin 33 g/l INR 2.5 family history of IDDM and AI thyroiditis? acute hepatitis: observe fluctuating LFTs specialised centre

3 Case 1 US mildly enlarged spleen anti-lkm1 1/5120, mildly elevated IgG steroids rapid improvement of AST/ALT & INR liver biopsy: severe interface hepatitis multilobular collapse moderately increased fibrosis 20 yrs later: normal LFTs, AI thyroiditis on Rx no signs of portal hypertension Rx: prednisolone 2.5mg/day azathioprine 37.5mg/day

4 Case 2 16 yrs old female, Hispanic, student, from Southern California high IgG transaminases 21X UNV bilirubin 14X UNV ANA, SMA, AMA negative no treatment diagnosis: cryptogenic hepatitis Duchini et al, Am J Gastroenterol 2000;95:3238

5 Case 2 25 years of age: end-stage liver disease liver transplant death Duchini et al, Am J Gastroenterol 2000;95:3238

6 Case 3 15 year-old girl with amenorrhoea, acne, tiredness, decreased school performance bilirubin 65 µmol/l AST/ALT 150/190 IU/l GGT/AP 102/280 IU/l albumin 31 g/l IgG 21 g/l INR 1.2 family history of colitis and rheumatoid arthritis

7 Case 3 OE: splenomegaly, spider nevi US: splenomegaly ANA 1/320; SMA 1/160 liver biopsy: interface hepatitis increased fibrosis? cirrhotic transformation MRCP: normal colonoscopy: normal

8 Case 3 Rx: pred pred + azathioprine normal LFTs & IgG levels, negative autoantibodies for 4 years liver biopsy planned for possible treatment withdrawal

9 Case 4 14 year-old boy with tiredness, mild abdominal pain (no diarrhoea), poor school performance bilirubin 55 µmol/l AST/ALT 102/130 IU/l GGT/AP 90/210 IU/l albumin 38 g/l IgG 29 g/l INR 1.1 family history of colitis

10 US: splenomegaly Case 4 OE: splenomegaly, spider nevi ANA 1/320; SMA 1/160 liver biopsy: interface hepatitis increased fibrosis mild bile duct damage copper binding protein +ve MRCP: intrahepatic cholangiopathy colonoscopy: indeterminate colitis (?UC)

11 Case 4 Rx: pred/azathioprine/udca/mesalazine normal LFTs, but persistently high IgG and positive autoantibodies difficult to control IBD UC diagnosed two years after presentation escalation of IBD treatment (MMF, CI): poor histological control

12 Case 4 progression of bile duct disease jaundice end-stage liver disease liver transplant 8 years after diagnosis persistent UC AISC recurrence 2 years after transplant listed for re-transplant 4 years after recurrence

13 Autoimmune hepatitis - AIH Diagnostic Criteria high IgG autoantibodies (ANA/SMA/LKM1) interface hepatitis Gregorio et al, Hepatology 2001;33: normal cholangiogram

14 Autoimmune hepatitis anti-nuclear antibody type 1 (ANA/SMA positive): 2/3 of patients anti-smooth muscle antibody type 2 (LKM1/LC1 positive): 1/3 of patients anti-liver kidney microsomal type1 anti-liver liver cytosol type1

15 Autoimmune sclerosing cholangitis - AISC Diagnostic Criteria high IgG autoantibodies (ANA/SMA/LKM1) interface hepatitis Gregorio et al, Hepatology 2001;33: abnormal cholangiogram

16 AIH versus AISC Clinical features and mode of presentation AISC AIH-1 AIH-2 ANA/SMA+ LKM1+ median age at diagnosis (yrs) female (%) mode of presentation (%) acute hepatitis (often fluctuating course) 37 insidious onset 37 complications of CLD inflammatory bowel disease (%) Gregorio et al, Hepatology 2001;33:

17 AIH versus AISC Laboratory parameters at presentation AIH AISC bilirubin 35 (4-306) 20 (4-179) albumin 35 (25-47) 39 (27-54) AST 333 ( ) 102 ( ) INR 1.2 ( ) 1.1 ( ) GGT 76 (29-383) 129 (13-948) AP 356 ( ) 303 ( ) AP/AST ratio 1.14 ( ) 3.96 ( ) Gregorio et al, Hepatology 2001;33:

18 AIH versus AISC HLA association 222 Caucasoid patients AIH 1 # 109 AIH 2 # 49 ASC # 64 controls DRB1*03 72% 36% 19% 26% DRB1*07 13% 54% 10% 14% DRB1* % 14% 42% 17%

19 AIH versus AISC standard treatment: prednisolone + UDCA if AISC azathioprine

20 AIH vs AISC Rx response (King s prospective study: 54 pts ) AIH-1 AIH-2 AISC remission rate 97% 87% 89% median time to remission 6 mts 9 mts 2 mts relapse rate 42% 46% 45% cessation of treatment 19% 0% 5% Gregorio et al, Hepatology 2001;33: Scalori et al, Hepatology 2007;46 Suppl 1:555A

21 AIH vs AISC Outcome (King s prospective study: 54 pts ) AIH-1 AIH-2 AISC LT rate 6%* 14%* 27%** recurrence post LT 0% 0% 71% * 8-14 yrs after ** 1-12 yrs after Gregorio et al, Hepatology 2001;33: Scalori et al, Hepatology 2007;46 Suppl 1:555A

22 Evolution from AIH to AISC Index case: AIH + UC Two further cases of AIH have evolved to ASC 13 and 14 years after diagnosis: both with IBD At diagnosis 8 years later

23 AIH vs AISC Transplant-free survival AIH SC Survivor survivors Survival Plot (PL estimates) AIH ASC P<0.009, Log Rank years Times Scalori et al, Hepatology 2007;46 Suppl 1:555A

24 Autoimmune sclerosing cholangitis King s prospective study progression of liver disease and recurrence post transplant are associated to active inflammatory bowel disease