Clinical Theray Resonse and Outcome of Overla Syndromes: Autoimmune Heatitis and Primary Biliary Cirrhosis Comared to Autoimmune Heatitis and Autoimmune Cholangitis Ersan Ozaslan 1, Cumali Efe 1, Sabiye Akbulut 1, Tugrul Purnak 1, Berna Savas 2, Esra Erden 2, Emin Altiarmak 1 1 Numune Education and Research Hosital, Deartment Of Gastroenterology, 2 Ankara Medical Faculty, İbni Sina Hosital, Deartment of Pathology, Ankara, Turkey Corresonding Author: Ersan Ozaslan, Cukurambar Mah. 40. Cad. 5/13, Cankaya Ankara, Turkey Tel: +903122873882, Fax: +903123125026, E-mail: er72@hotmail.com ABSTRACT Background/Aims: We have assessed two different overla syndrome grous in atients with and, with resect to theray resonse and outcome. Methodology: In this retrosective, non-randomized study, a total of 22 overla cases were collected, 12 of those had a simultaneous form of and 10 of those with. Two grous were comared in terms of clinical, biochemical, immunological, histological features and resonse to treatment. The mean follow-u time was 31.7±11.0mo in and 41.1±29.6mo in, resectively. Results: The clinical and laboratory characteristics at resentation were not significantly different between the two grous, excet a higher serum IgM level and lower AIH score in grou comared to grou (<0.05). Firstline treatment was alone in 3 of grou and combination of and immunsuressives in the remaining (n=9) and in all of the (n=10). During follow-u, only one of 10 atients in grou, but six of 12 atients in grou rogressed to liver failure. So, comlete was significantly higher in the than in the grou (%90 vs %50, =0.045). Conclusion: To our results, in cases of / AIC overla, atients with high AIH score and negative AMA should be treated with combined theray of corticosteroids and. However, atients with low AIH score and ositive AMA should use firstly, if no resonse, the addition of corticosteroids should be considered with close monitoring. In this cohort, the rognosis of overla was much worse than that of. KEY WORDS: Autoimmune heatitis; Primary Biliary cirrhosis; Autoimmune cholangitis; AMA-negative rimary biliary cirrhosis; Theray INTRODUCTION Autoimmune heatitis (AIH), rimary biliary cirrhosis (PBC) and rimary sclerosing cholangitis (PSC) are the three imortant autoimmune diseases involving the liver. The term overla syndrome describes variant forms of AIH which resent with characteristics of AIH and PBC or PSC. overla syndrome is the most common tye, in almost 10% of adults with AIH or PBC (1-3). It has been shown that ursodeoxycholic acid () is effective in PBC (4) whereas immunosuressive theray using corticosteroids alone or in association with azathiorine is the gold standart for AIH (5). Outcome and treatment results are less reorted issues of overla syndromes and whether overla syndrome requires immunosuressive theray in addition to remains Heato-Gastroenterology 2010; 57:285-289 H.G.E. Udate Medical Publishing S.A., Athens-Stuttgart controversial (2, 3). Some authors (6, 7) demonstrated a clear sueriority of combination theray, while others (8) found the resonse to theray was enough. Autoimmune cholangitis (AIC) was first reorted as immunocholangitis in 1987 (9) when three women were described who resented with signs and symtoms of PBC, but were AMA-negative and ANA-ositive, and resonded to immunosuressive theray. It is considered a disease of unknown cause that tyically has serum ANA with or without SMA in serum and cholestatic clinical, laboratory, and/or histologic changes in the absence of AMA. This definition was coined to include PBC with nontyical resentation, small-duct rimary sclerosing cholangitis, idioathic adulthood ductoenia, and transitional stages of the classic diseases (10). Although a consensus is still awaited, recent studies
Heato-Gastroenterology 57 (2010) E Ozaslan, C Efe, S Akbulut, et al. TABLE 1 Clinical Features in two Grous of Overla Syndrome Age 43.9±16.5 45.1±15.2 >0.05 Sex, F/M 11/1 10/- >0.05 Other autoimmune diseases 2 (%16.7) 2 (%20) >0.05 Symtoms >0.05 Asymtomatic 3 (%25) 4 (%33.3) Pruritis 8 (%66.7) 5 (%41.3) Fatigue 6 (%50) 5 (%41.3) Jaundice 6 (%50) 6 (%50) Weight loss 2 (%16.7) 3 (%25) Arthritis 2 (%16.7) 3 (%25) Myalgia 4 (%33.3) 2 (%16.7) AIH: autoimmune heatitis, PBC: rimary biliary cirrhosis, AIC: autoimmune cholangitis TABLE 2 Biochemical and Serological Features in two Grous of Overla Syndrome ALT 211.5±248.7 423.8±403.7 >0.05 AST 204.1±295.5 564.3±548.2 >0.05 ALP 490.3±216.5 566.8±492.2 >0.05 GGT 405.8±274.9 414.2±334.0 >0.05 Total bilirubin 4.1±7.0 3.5±3.0 >0.05 IgG 22.9±5.2 26.9±9.5 >0.05 IgM 5.5±0.9 3.7±1.6 <0.05 Albumin 37.7±4.1 40.4±3.9 >0.05 ANA ositive 11 (%91.7) 9 (%90) >0.05 LKM-1 ositive 2 (%16.7) 1 (%10) >0.05 Anti-M2 ositive 12 (%100) 0 <0.05 ds-dna ositive 2 (%16.7) 2 (%20) >0.05 -ANCA ositive 2 (%16.7) 1 (%10) >0.05 IAHG score 10.5±1.3 14.7±2.7 <0.05 AIH: autoimmune heatitis, PBC: rimary biliary cirrhosis, AIC: autoimmune cholangitis IAHG: International Autoimmune Heatitis Grou suort the view that PBC and AIC are variants of one single disease only differing in serum autoantibody attern, and named AIC as AMA-negative PBC (11-13). Concomitant features of AIH and AIC have been reorted very rarely. In a case reort, an AMA-negative woman with mixed biochemical and histological features of AIH and AIC resonded to combined treatment with, rednisone, and azathiorine (14). Alric et al. (15) described seven atients with AIH-AMA negative PBC overla who showed a favorable resonse to combined theray. Therefore, more studies are worthwhile in these rare atient grous of overla syndrome to define the outcomes and otimal theraeutic strategies. In the resent study, we have assessed two different overla syndrome grous in atients with AIH- PBC and. In this retrosective non-randomized study, two grous were comared in terms of clinical, biochemical, immunological, histological features and resonse to treatment. METHODOLOGY Patients and diagnostic criteria Records of the atients with autoimmune liver disease who were followed u at our Gastroenterology Unit from 2001 to 2007 were reviewed. The atients with and overla syndromes were included in the study. In all atients, metabolic causes of liver disease had been ruled out, and heatitis B and C virus serological tests were negative. No atient had history of alcohol abuse, heatotoxic agent or inflammatory bowel disease. Extraheatic biliary lesions had been excluded in all atients by abdominal ultrasound, and also by endoscoic retrograde cholangio-ancreatograhy (ERCP) in four atients of the grou and by magnetic resonance cholangioancreatograhy (MRCP) in two atients of grou. The study grous included only simultaneous forms of overla syndrome and each atient had a minimum follow-u of 1 year. According to these criteria, 22 atients were collected, 12 of those had a simultaneous form of and 10 of those with overla syndrome. Clinical and laboratory arameters were obtained at the initial and at follow-u visits (every 3 to 6 months) after the initiation of theray. overla syndrome was defined by the simultaneous occurrence of AIH and PBC. For diagnosis of each disease, resence of at least 2 of the 3 acceted criteria was required (16). AIH criteria were the following: (I) alanine aminotransferase (ALT) levels at least five times the uer limit of normal values (ULN), (II) serum immunoglobulin G (IgG) levels at least two times the ULN or a ositive test for smooth muscle antibodies (ASMA), (III) a liver biosy showing moderate or severe eriortal or erisetal lymhocytic iecemeal necrosis. In addition, AIH score was determined for each atient (17). PBC criteria were the following: (I) alkaline hoshatase (ALP) levels at least two times the ULN or γ glutamyltransetidase (GGT) levels at least five times the ULN, (II) a ositive test for AMA by immunoflourescence, (III) a liver biosy secimen showing florid bile duct lesions. overla syndrome was defined by the simultaneous occurrence of AIH and AIC. AIH criteria were described above, and moreover AIH score was determined for each atient. AIC criteria were the following: (I) serum ANA and/or smooth muscle (SMA) ositivity and/or hyergammaglobulinemia, (II) serum AMA negativity by IF, (III) biochemical and/or histologic features of cholestatic and heatocellular injury, and (IV) exclusion of chronic viral, metabolic, or toxic liver disease (10).
Running Title????? Heato-Gastroenterology 57 (2010) Follow-u analysis included clinical and laboratory data. Laboratory investigations were serum ALT, AST, ALP, GGT, total bilirubin, albumin, IgG, IgM; if indicated heatitis B and C serology, PTZ, abdominal USG and endoscoy. The AMA and anti- M2 fraction were measured by immunoblotting technique. The other auto-antibodies were measured by immunofluorescence; viral markers were measured by ELISA. Histoathological assessment All of 22 atients included in the study underwent liver biosy before treatment, reeated biosies were available only for two atients. Liver biosy secimens were fixed in formaline and embedded in araffin, and sections were stained with hematoxylin-eosin and Masson s trichrome. All secimens were reviewed by two athologists, and biosies were evaluated according to Metavir, Knodell and Ishak scoring systems (17). Activity of chronic heatitis was assessed by the intensity of eriortal and lobular necroinflammatory lesions whereas stage of fibrosis was evaluated according to the scoring outlines. Biliary changes were evaluated by Ludwig stage (18). Resonse to treatment and follow-u The atients in both grous were treated with or combined theray including lus immunsuresives (e, azathiorine, and/or cyclosorine). Treatment decisions had been based on clinical judgment rather than a fixed study design. Patients were categorized to the main treatment outcomes (19): Comlete is defined as the disaearance of symtoms (fatigue, weight loss, ruritis, arthritis and arthralgia), imrovement of serum aminotransferase less than twice normal or normal level, normal serum bilirubin and gamma globulin levels and normal heatic tissue or minimal inflammation and iecemeal necrosis. Incomlete considered same or no imrovement in clinical, biochemical and histological features after 6 months theray, no worsening of the condition and failure to achieve after 3 years. Treatment failure is defined as worsening clinical, biochemical and histological features in site of theray; increase of serum aminotransferase by %67, develoment of ascites, jaundice and heatic encehaloathy. Statistics Statistical analysis was erformed using SPSS 13.0 for windows. Quantitative data were exressed as median-sd. Comarisons were made by using non-arametric tests: the Mann Whitney rank sum test. Ratios were comared by using the chisquare (χ 2 ) test. Differences with a value <0.05 were considered significant. RESULTS TABLE 3 Histological Features in two Grous of Overla Syndrome Piecemeal necrosis 11 (%91.7) 10 (%100) >0.05 Lymholasmocytic infiltration 9 (%75) 8 (%80) >0.05 Rosette formation 6 (%50) 4 (%40) >0.05 Biliary changes >0.05 Ductal roliferation 6 (%50) 4 (%40) Ductoenia 4 (%33.3) 5 (%50) Florid duct lesion 5 (%41.3) 3 (%30) Cholangitis 3 (%25) 5 (%50) Granulomatosis 5 (%41.3) 6 (%60) Histological stage >0.05 Stage 0 - (%0) 1 (%10) Stage 1 3 (%25) 3 (%30) Stage 2 4 (%33.3) 1 (%10) Stage 3 3 (%25) 5 (%50) Stage 4 2 (%16.7) - (%0) HAI score 10.75±2.3 11.1±2.5 >0.05 AIH: autoimmune heatitis, PBC: rimary biliary cirrhosis, AIC: autoimmune cholangitis, HAI: histological activity index TABLE 4 Theray Resonse in two Grous of Overla Syndrome Follow-u (months) 31.7±11.0 41.1±29.6 >0.05 Theray resonse 6 (%50) 9 (%90) <0.05 Treatment and/or IS and IS >0.05 AIH: autoimmune heatitis, PBC: rimary biliary cirrhosis, AIC: autoimmune cholangitis, IS: immunsuresive theray Clinical, biochemical and histological features and grou 2 were similar for age, sex and main resenting symtoms (Table 1). The results of laboratory tests are summarized in Table 2. The grou showed higher levels of ALT, AST and IgG than grou, but these differences were not statistically significant. The level of total bilirubin was higher in grou but also this difference was not statistically significant. The number of atients ositive for ANA, ASMA, LKM-1, -ANCA, and anti-ds-dna were similar in both grous. However, the IgM levels and the incidence of AMA were significantly different in both grous. The lasma IgM level were higher in the grou (<0,05). In addition, the M2 fraction of AMA was ositive in 12 atients of
4 Heato-Gastroenterology 57 (2010) E Ozaslan, C Efe, S Akbulut, et al. () Case TABLE 5 Detailed Theray Features and Outcome in two Grous of Overla Syndrome theray Follow-u Current theray Comment 1 2 3 4 5 6 7 AZT cirrhosis, translantation 8 9 10 11 12 () Case 1 2 3 4 5 6 7 8 9 10 theray + AZT + AZT * - * cirrhosis Follow-u AZT >Cyc - Current theray colchicin cirrhosis, exitus Comment translantation AZT - ** ** AZT AZT * * *! *! *low dose, 10 mg; ** steroid was stoed due to osteoorosis, diabetes; AZT was stoed due to regnancy;!azt was stoed due to nausea. AIH: autoimmune heatitis, PBC: rimary biliary cirrhosis, AIC: autoimmune cholangitis Remission indicates symtomatic and biochemical normalization in all cases, reeated liver biosy were also available for two cases. grou but in none of the grou (<0,001). According to revised International Autoimmune Heatitis Grou (IAHG) scoring system, the mean AIH score was 10.5±1.3 for atients with and 14.7±2.7 for atients with (<0.05). Only 3 of the subjects in grou, were observed to fulfill the criteria for definite AIH (score >15), while the remaining 7 in and all of the 12 cases of were designed as robable AIH (score: 10-15). Detailed data about scoring were as follows: grou (12 oints in one atient, 11 oints in four, and 10 oints in seven) and grou (20 oints in one atient, 16 oints in two, and 15 oints in two, 14 oints in one, 13 oints in three, and 12 oints in one). Two atients had scleroderma and Sjögren s syndrome in grou; while one atient had systemic luus erythematosus, and one atient had both celiac and autoimmune thyroiditis in grou. Both grous showed no significant differences in histological findings (>0.05) (Table 3). Resonse to treatment and outcome The incidence of resonse to theray was significantly higher in the than in the AIH- PBC (%90 vs %50, =0.045) (Table 4). The mean follow-u time was 31.7±11.0 mo in and 41.1±29.6 mo in resectively. In grou, six atients achieved comlete (50%), three with only and three with associated to rednisone (Table 5). The remaining six atients in grou had liver failure after 10, 13, 14, 20, 26 and 38 months of diagnosis, resectively. At the diagnosis, two of these atients were at stage 4, two of atients were at stage 2, and the others were at stage 3 and 1, liver disease. Two atient in stage 4 had liver failure after 8, 10 months, one of this atient died of uer gastrointestinal bleeding after 6 months, the other atient died of sontaneous bacterial eritonitis after 2 months. Of the remaining 4 atients, one had liver translantation after decomanseted cirrhosis, one was followed-u with decomansated cirrhosis, and two with without cirrhosis. In grou, nine atients achieved comlete (90%), all of with associated to rednisone with azathiorine (Table 5). In grou, only one atient rogressed to liver failure after 26 months of follow u. She had stage 3 liver disease at the time of diagnosis, and liver translantation was erformed 6 month after diagnosis. Steroids could be able to be stoed in all three resonder atients of grou, and in six of grou (Table 5). Azathiorine was stoed in two atients of grou, due to nausea and regnancy, and these were ut on low dose steroids. DISCUSSION Overla syndromes do not have codified definitions. Desite ongoing controversies with regards to the diagnostic criteria, the term of overla syn-
Running Title????? Heato-Gastroenterology 57 (2010) 5 drome actually includes a heterogeneous grou of atients with mixed features of PBC and AIH. (1-3). In this study, for the diagnosis of PBC-AIH overla, we used the strict diagnostic criteria roosed by Chazouillères et al. in 1998 (16). Diagnostic criteria for are still unclear. In this study, for the diagnosis of overla, we used the diagnostic criteria roosed by Czaja et al. (10) and calculated the IAHG score for each atient. Czaja et al. (10) have described autoimmune cholangitis as a variant syndrome on following criteria (1) serum ANA and/or smooth muscle (SMA) ositivity and/or hyergammaglobulinemia, (2) serum AMA negativity by IF, (3) biochemical and/or histologic features of cholestatic and heatocellular injury, and (4) exclusion of chronic viral, metabolic, or toxic liver disease. This definition was coined to include PBC with atyical resentation, small-duct rimary sclerosing cholangitis, idioathic adulthood ductoenia, and transitional stages of the classic diseases. In recent years, the term of AMA-negative PBC has gained oularity to describe autoimmune cholangitis (11, 12). Consensus is still awaited on this issue. So, in a broader definition, our study grous, and, may also be regarded as PBC with heatitic features and AIH with cholestatic features, resectively. In suort of this assumtion, our study disclosed higher levels of serum IgM and AMA ositivity and lower IAHG score in overla comared to. Although serum levels of ALT, AST and IgG were higher in the latter grou, it was not statistically significant. Only 3 out of 10 atients in grou were classified as definite AIH according to the international AIH scoring system (5). All of 12 atients in and remaining 7 atients in grou were classified as robable (mean IAHG score 10.5 vs 14.7). This is not surrising since biliary features have a strong negative imact in this scoring system and a score of definite AIH can be only observed in only rare atients, like reviously reorted (7, 20). Chazouillères et al. (7) and Silveira et al. (19), reorted 15 out of 17 and all of 26 atients as robable AIH, resectively. We could not find any histological feature that could differentiate from. Biliary lesions were very similar in both grous, for ductal roliferation, ductoenia, destructive cholangitis and granuloma. It has been shown that is effective in PBC (4), whereas immunosuressive theray using corticosteroids alone or in association with azathiorine is the gold standart for AIH (5). However, theray of overla syndrome is still controversial and whether overla syndrome requires immunosuressive theray in addition to remains an unresolved issue desite accumulated literature. Some authors (6,7) demonstrated a clear sueriority of combination theray, while the others (8) found the resonse to theray enough. Joshi et al. (8) found that, under theray, biochemical resonse at 24 months and survival of PBC-AIH overla atients (n=12) were similar to atients with ure PBC (n=159) and, uon these results, did not recommend corticosteroids for PBC atients with laboratory features of AIH. Chazouillères et al. (7) reorted the theray resonses of 17 atients with PBC and AIH with either or and immunosuressive agents, such as e, azathiorine and mycohenolate mofetil. The combination of and immunosuressive theray was able to induce biochemical resonse and to sto fibrosis rogression in all atients (6/6), while alone achieved these only in 3 cases (3/11). Furthermore, the atients who did not resond to (n=7) had laboratory imrovement and stabilization of their fibrosis after treatment with the combination regimen. The results of theray resonse in our atients with overla are much more disaointing. Although alone (3/12) or with immunosuresives (3/12) were able induce comlete, half of the grou had an accelerated course under combination theray and rogression occurred in a relatively short eriod of time (10 months to 3 years). Predictive factors of nonresonse to theray were not identified in our study resumably because of small number of atients but it must be stated that three of six non-resonders had more severe histological stage (two in stage 4, one in stage 3). At resent, there is no consensus regarding the otimal theray for AIC because, due to the low revalence of this disease, no controlled theraeutic trials have been undertaken. Gisbert et al. (21) reviewed 106 atients of AIC from 30 uncontrolled studies, where favourable effect of ursodeoxycholic acid on the serum biochemical markers of atients with AIC has been demonstrated in most studies (aroximately 80% of atients). Additionally, a favourable effect of immunosuressive treatment has also been demonstrated in aroximately onehalf of AIC atients. In cases of AIC that exhibit overlaing features with AIH, corticosteroids alone or in combination with azathiorine may be articularly effective. Ben-Ari et al. (22), Sánchez- Pobre et al. (23), Masumoto et al. (24), and Sherlock (25), described four, four, three and five atients resectively, with features of overla between AMA-negative rimary biliary cirrhosis and AIH. Imrovements in clinical and biochemical features in addition to heatic inflammation occurred in all atients but bile duct lesions ersisted. On the other hand, the reorts about theray resonse of atients with to combination of ursodeoxycholic acid and immunosuressive theray, are very rare. Li et al. (14) reorted a atient with autoimmune cholangitis and autoimmune heatitis, treated with combination theray. On treatment, serum aminotransferases and cholestasis markers imroved. A follow-u liver biosy revealed imrovement of both heatic necro-inflammation and bile duct lesions. Alric et al. (15) described
Heato-Gastroenterology 57 (2010) E Ozaslan, C Efe, S Akbulut, et al. seven atients with AIH+AMA negative PBC overla who were treated with standardized treatment by associated to rednisone with azathiorine, a comlete biochemical resonse was observed in four (57%) of the cases and a artial resonse with a decrease of at least a half of biochemical values was achieved in five (71.4%) of atients. Histological evaluation on a second liver biosy was not erformed. Our study illustrates that a combination of corticosteroids and ursodeoxycholic acid are very effective in atients with features of both, with a figure of 90% comlete. The most imressive finding of our study is a marked difference between vs. overla syndromes, with regard to theray resonse and rognosis. The comlete resonse to theray was much better in the cases than those of (%90 vs. %50). The mean follow-u time was 41.1±29.6 mo in and 31.7±11.0 mo in, resectively. During this eriod, only one atient in grou (%10), but four atients in grou (%33) develoed into cirrhosis, with two deaths in the latter grou. Although a firm conclusion can not be drawn, redominant heatic features of cases demonstrated with relatively high transaminases and IAHG score comared to cases, may be an exlanation for favorable theray resonse. But similar histological findings in both two grous weakens this ossibility. Further studies with larger grous may clarify this issue. In conclusion, treatment must be individualized for (including AMA ositive true PBC or AMA negative AIC ) overla cases, until the era of codified diagnostic criteria and validated treatment strategies. We roose that atients with high AIH score and negative AMA should be treated with combined theray of corticosteroids and, however, atients with low AIH score and ositive AMA should use firstly, if no resonse, the addition of corticosteroids should be considered with close monitoring. 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