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466  Hepatology 2012
antibodies (LKM), soluble liver antigen antibodies (SLA) or ANA. In cholestatic
cases cholangiography detects sclerosing cholangitis. In an overlap syndrome the
classical appearance of the individual disease component is mixed with features of
another autoimmune liver disease. Immunoglobulins are usually elevated in all
autoimmune liver diseases.
Regarding a therapeutic strategy the leading disease component is treated. In an
overlap syndrome presenting as hepatitis, immunosuppression with prednisone (or
combination therapy with azathioprine) is initiated. In cholestatic disease
ursodeoxycholic acid is administered. Both treatments can be combined when
biochemistry and histology suggest a relevant additional disease component
(Chazouilleres 1998). Validated therapeutic guidelines for overlap syndromes are
not available. It is important to realize that treatment failure in AIH may be related
to an incorrect diagnosis or an overlap syndrome of autoimmune liver diseases
(Potthoff 2007). Several studies show that treatment of the AIH component of
overlapping syndromes is important to avoid progression to cirrhosis (Chazouilleres
2006, Gossard 2007, Silveira 2007, Al-Chalabi 2008).
Liver transplantation
In approximately 10% of AIH patients liver transplantation remains the only life-saving option (Strassburg 2004). The indication for liver transplantation in AIH is
similar to that in other chronic liver diseases and includes clinical deterioration,
development of cirrhosis, bleeding esophageal varices and coagulation
abnormalities despite adequate immunosuppressive therapy (Neuberger 1984,
Sanchez-Urdazpal 1991, Ahmed 1997, Prados 1998, Tillmann 1999, Vogel 2004).
There is no single indicator or predictor for the necessity of liver transplantation.
Candidates for liver transplant are usually patients who do not reach remission
within 4 years of continuous therapy. Indicators of a high mortality associated with
liver failure are histological evidence of multilobular necrosis and progressive
hyperbilirubinemia. In Europe, 4% of liver transplants are for AIH (Strassburg
2009). The long-term results of liver transplantation for AIH are excellent. The 5-year survival is up to 92% (Sanchez-Urdazpal 1991, Prados 1998, Ratziu 1999) and
well within the range of other indications for liver transplantation. The European
liver transplant database indicates 76% survival in 5 years and 66% survival after 10
years (1647 liver transplantations between 1988 and 2007). When these numbers are
considered it is necessary to realize that patients undergoing liver transplantation
usually fail standard therapy and may therefore have a reduced life expectancy after
liver transplant compared to those who achieve stable complete remission on drug
therapy.
Recurrence and de novo AIH after liver transplantation
The potential of AIH to recur after liver transplantation is beyond serious debate
(Schreuder 2009). The first case of recurrent AIH after liver transplant was reported
in 1984 (Neuberger 1984), and was based upon serum biochemistry, biopsy findings
and steroid reduction. Studies published over the years indicate that the rate of
recurrence of AIH ranges between 10-35%, and that the risk of AIH recurrence is
perhaps as high as 68% after 5 years of follow-up (Wright 1992, Devlin 1995, Götz
1999, Milkiewicz 1999, Manns 2000, Vogel 2004). It is important to consider the
criteria upon which the diagnosis of recurrent AIH is based. When transaminitis is
Autoimmune Liver Diseases: AIH, PBC and PSC  467
chosen as a practical selection parameter many patients with mild histological
evidence of recurrent AIH may be missed. It is therefore suggested that all patients
with suspected recurrence of autoimmune hepatitis receive a liver biopsy,
biochemical analyses of aminotransferases as well as a determination of
immunoglobulins and autoantibody titers (Vogel 2004). Significant risk factors for
the recurrence of AIH have not yet been identified although it appears that the
presence of fulminant hepatic failure before transplantation protects against the
development of recurrent disease. Risk factors under discussion include steroid
withdrawal, tacrolimus versus cyclosporine, HLA mismatch, HLA type, and LKM-1
autoantibodies. An attractive risk factor for the development of recurrent AIH is the
presence of specific HLA antigens that may predispose toward a more severe
immunoreactivity. In two studies recurrence of AIH appeared to occur more
frequently in HLA-DR3-positive patients receiving HLA-DR3-negative grafts.
However, this association was not confirmed in all studies. There have not been
conclusive data to support the hypothesis that a specific immunosuppressive
regimen represents a risk factor for the development of recurrent AIH (Gautam
2006). However, data indicate that patients transplanted for AIH require continued
steroids in 64% versus 17% of patients receiving liver transplants for other
conditions (Milkiewicz 1999).
Based on these results and other studies it would appear that maintenance of
steroid medication in AIH patients is indicated to prevent not only cellular rejection
but also graft-threatening recurrence of AIH (Vogel 2004). Steroid withdrawal
should therefore be performed only with great caution. The recurrence of AIH is an
important factor for the probability of graft loss. Apart from hepatitis C and primary
sclerosing cholangitis a recent report found AIH recurrence to represent the third
most common reason for graft loss (Rowe 2008). Transplanted patients therefore
require a close follow-up and possibly an immunosuppressive regimen including
steroids, although this is controversial and not backed by prospective studies
(Campsen 2008).
In addition to AIH recurrence the development of de novo autoimmune hepatitis
after liver transplantation has been reported (Kerkar 1998, Jones 1999a, Salcedo
2002). The pathophysiology of this is also elusive. From a treatment point of view
de novo  autoimmune hepatitis, which appears to occur mostly in patients
transplanted with PBC but may just be the serendipitous occurrence of AIH, is
responsive to steroid treatment (Salcedo 2002).
Primary biliary cirrhosis
Introduction
Primary biliary cirrhosis (PBC) is a chronic inflammatory, cholestatic disease of the
liver with an unknown cause. The clinical observation of a broad array of immune-mediated symptoms and phenomena suggests the disease to be of autoimmune
etiology, in the course of which progressive and irreversible destruction of small
interlobular and septal bile ducts progressively and irreversibly ensues (Table 5). As
in other autoimmune diseases PBC affects women in over 80% of cases and is
associated with varying extrahepatic autoimmune syndromes in up to 84%. These
extrahepatic manifestations of immune-mediated disease include the dry gland
syndrome (sicca syndrome with xerophthalmia and xerostomia) but also collagen
468  Hepatology 2012
diseases, autoimmune thyroid disease, glomerulonephritis and ulcerative colitis
(Table 6).
Table 5. Clinical profile of primary biliary cirrhosis (PBC).
Sex  90% female
Age   40-59 years
pruritus
jaundice
skin pigmentation
Elevation  alkaline phosphatase (AP), aspartate aminotransferase (AST), bilirubin, IgM
antimitochondrial antibodies (AMA)
associated immune-mediated syndromes
Liver biopsy
-  cellular bile duct infiltration
-  granulomas possible
-  copper deposits
Table 6. Extrahepatic immune-mediated syndromes in PBC and overlap with
rheumatic diseases.
dry gland “sicca” syndrome
Sjögren’s syndrome
rheumatoid arthritis
autoimmune thyroid disease
renal tubular acidosis
mixed connective tissue disease (MCTD)
polymyositis
polymyalgia rheumatica
pulmonary fibrosis
CREST syndrome
systemic lupus erythematosus (SLE)
pernicious anemia
ulcerative colitis
exogenous pancreatic insufficiency
myasthenia gravis
The striking female predominance (Donaldson 1996, Mackay 1997, Uibo 1999)
and familiar clustering of PBC (Kato 1981, Jones 1999b, Tsuji 1999) suggest that
inheritable genetic factors play a role in this disease. This has focussed attention on
the immunogentics of PBC in order to further define host risk factors (Manns 1994).
Studies have suggested an instability of lymphocytic DNA in PBC patients (Notghi
1990). Immunogentic analyses, however, have only come up with relatively weak
associations with specific human leukocyte antigen haplotypes. An additional
hypothesis is an alteration of bile acid composition and bile fluid composition,
which would indicate a role for transporter proteins in the development of PBC.
Bicarbonate rich bile is believed to be protective for biliary epithelium.
Definition and prevalence of PBC
Primary biliary cirrhosis is an inflammatory, primarily T cell-mediated chronic
destruction of intrahepatic microscopic bile ducts of unknown etiology (Strassburg
2000). It affects women in 80% of cases who exhibit elevated immunoglobulin M,
antimitochondrial antibodies directed against the E2 subunit of pyruvate
Autoimmune Liver Diseases: AIH, PBC and PSC  469
dehydrogenase (PDH-E2), a cholestatic liver enzyme profile with elevated alkaline
phosphatase, gamma glutamyltransferase as well as serum bilirubin levels, and a
variable course of disease leading to cirrhosis over the course of years or decades. A
prominent feature is the presence of extrahepatic immune-mediated disease
associations. In later stages pronounced fatigue, pruritus, marked
hyperbilirubinemia and the consequences of portal hypertension such as ascites,
bleeding esophageal varices, and encephalopathy develop (Strassburg 2004).
The prevalence is estimated at 65 per 100,000 in women and 12 per 100,000 in
men with an incidence of 5 per 100,000 in women and 1 per 100,000 in men. The
prevalence and incidence appear to vary regionally. An increase of PBC incidence
in recent years may be the result of more specific testing of antimitochondrial
antibody reactivity (Strassburg 2004).
Diagnostic principles of PBC
Suspicion of PBC arises when cholestasis and cirrhosis are present in middle-aged
women (Figure 2). Ultrasound is employed to rule out mechanical cholestasis. The
presence of antimitochondrial antibodies (AMA) against PDH-E2 is diagnostic of
PBC. AMA against E2 subunits of members of the inner mitochondrial membrane-expressed oxoacid dehydrogenase complex (PDH, branched chain ketoacid
dehydrogenase [BCKD], and ketoglutarate dehydrogenase [OADC]) are present in
95% of PBC patients. AMA-negative PBC can exhibit antinuclear autoantibodies
with specificity against nuclear dot antigen (SP100), a 210 kDa nuclear membrane
protein (gp210), or nucleoporin p62. In AMA-negative PBC a biopsy is indicated to
contribute to the establishment of the diagnosis; in the presence of AMA against
PDH-E2, histology is used primarily for the staging of cirrhosis and is not necessary
(Strassburg 2004).
Diagnostic role of AMA in PBC
The main aim of AMA determinations is the detection of PBC-specific AMA and
the exclusion of AMA of low diagnostic relevance for the disease. As a screening
test the determination of AMA using indirect immunofluorescence testing on rat
kidney cryostat sections or immobilized Hep-2 cells (Strassburg 1999). The indirect
immunofluorescence on rat kidney sections leads to the staining of the distal and
proximal tubuli (note: proximal staining only is indicative of liver/kidney
microsomal antibodies, LKM). When positive AMA immunofluorescence is
detected, further analysis should include subclassification using molecularly defined
antigen preparations. The detection of PDH-E2, BCKD-E2 can be achieved by
ELISA using recombinant antigen or reference sera. If both are negative, testing
should include OGD-E2. The final step is performed using Western Blot Analyses
to confirm the findings. By Western Blot the indicative 74 kDa (PDH-E2), 52 kDa
(BCKD-E2) and 48 kDa (OGD-E2) bands can be visualized. This multi-step
regimen secures a rational and reliable diagnosis of PBC-specific AMA excluding
those found in drug-induced and infectious diseases.
In the majority of cases the determination of anti-PDH-E2 is sufficient to secure
the diagnosis. Studies will have to evaluate whether the future application of a
single PDH-E2 ELISA as highly specific screening test in suspected PBC represents
an efficient and economic diagnostic approach.
470  Hepatology 2012
Figure 2. Diagnostic algorithm of PBC including clinical presentation, ultrasound and
serology.
Therapeutic principles in PBC
Treatment leading to a cure of PBC is not available (Strassburg 2004).
Ursodeoxycholic acid (UDCA) (15 mg/kg body weight per day) has been shown to
improve serum biochemistry, histology and survival but has no effect on fatigue and
osteoporosis. It has immunomodulatory properties, alters cell signal transduction
and modifies hydrophilicity of the bile. UDCA should not be given in severe
cholestasis and during the first trimester of pregnancy. Immunosuppression in PBC
has shown disappointing results. Symptomatic therapy of the complications of PBC
includes management of pruritus (cholestyramine, induction with rifampicin, opioid
antagonists, serotonin antagonists), ascites (diuretics, beta blockers to control portal
hypertension), osteoporosis (vitamin D and calcium supplementation,
bisphosphonates in some), as well as endoscopic intervention for bleeding
esophageal varices. Fat-soluble vitamin replacement is suggested. When liver
cirrhosis-induced liver failure is progressive liver transplantation remains a
definitive therapeutic option. Ten-year survival rates are 75-80% and recurrence of
PBC after transplant occurs in 10-40%. Recurrence can be expected in 25-30%
(Rowe 2008, Strassburg 2009)
Immunosuppression in PBC
Corticosteroids:  Treatment with prednisolone can improve serum
aminotransferase activities, alkaline phosphatase and elevated immunoglobulins. It
does not lead to significant improvement of bilirubin, pruritus, or histology. In a
Autoimmune Liver Diseases: AIH, PBC and PSC  471
placebo-controlled study with 36 asymptomatic patients for over 1 year osteopenia
and cushingoid side effects were noted (Mitchison 1992).
Azathioprin:  The classical immunosuppressant azathioprin, which has a
pronounced effect in AIH, did not show significant effects in two different studies
and is not used in PBC (Christensen 1985).
Cyclosporin A: In a large study of 346 patients with a median observation time
of 2.5 years this classical transplant immunosuppressant did not show significant
effects on histological progression (Lombard 1993). Contrasting these findings, in a
small study with 20 patients who were treated for 2 years, histology improved,
which should however be viewed with caution (Wiesner 1990). Because of the
possibility of severe side effects cyclosporin A is not a recommended therapeutic
option.
D-penicillamine: Because PBC is characterized by copper accumulation in the
bile ducts the chelator d-penicillamine was studied. D-penicillamine also has
immunosuppressive and antifibrotic properties. It was tested on a total of 748
patients in 6 studies, without leading to a positive therapeutic effect. However, 30%
of patients had severe side effects (Bodenheimer 1985). D-penicillamine in PBC is
not recommended.
Colchicine:  Because of its antifibrotic and anti-inflammatory properties
colchicine was studied in 3 studies in the 1980s. Despite improvement of albumin,
bilirubin, aminotransferases and alkaline phosphatase, an improvement of clinical
symptoms and histology was not observed (Kaplan 1986, Warnes 1987,
Bodenheimer 1988). Severe side effects were not reported but an effect on long-term prognosis was not seen.
Methotrexate: Despite its known hepatotoxicity, methotrexate was used as an
immunosuppressant in PBC. In a placebo-controlled study with 60 patients, low-dose methotrexate (7.5 mg/week) led to an improvement of biochemical parameters
except for bilirubin but no effects were reported regarding necessity of liver
transplantation or survival (Hendrickse 1999). Hepatotoxicity was not observed.
Interstitial pneumonitis, which affects 3-5% of rheumatoid arthritis patients, was
observed in 14% of PBC patients. Methotrexate cannot be recommend outside of
scientific evaluations or studies.
In principle other immunosuppressants (Table 7) such as mycophenolic acid
(mycophenolate mofetil), tacrolimus (FK506) or even monoclonal antibodies
against the interleukin 2 receptor may represent interesting candidate strategies.
However, study data is currently lacking.
Table 7. Effects of immunosuppressants in PBC.
Biochemical
improvement
Histological
improvement
Survival  Side effects/toxicity
Corticosteroids  ++  ++  -  ++
Azathioprine  -  -  +  +
Cyclosporin A  ++  -  ++  ++
D-penicillamine  -  -  -  ++
Colchicine  ++  -  +  -Methotrexate  ++  +  -  +
472  Hepatology 2012
Ursodeoxycholic acid in PBC (UDCA)
In 1981, a positive effect of UDCA was first observed on elevated liver parameters,
the exact mechanism of which was unclear (Leuschner 1996). On one hand UDCA
leads to a modification of the bile acid pool to a more hydrophilic environment with
lower detergent-like properties, and it leads to increased bile flow. On the other
hand an immunomodulatory activity is suggested regarding HLA antigens expressed
on biliary epithelial cells and altered signal transduction (Paumgartner 2002). The
optimal dose in PBC patients appears to be 13-15 mg/kg. In a meta-analysis of 3
studies that looked at 548 patients with this dose, biochemical improvement and a
slower histological progression to fibrosis was observed (Poupon 1997). These
effects were only evident when follow up extended to 4 years. These data rely
heavily on the positive effects of a single study and it is not surprising that a
subsequent meta-analysis of 8 studies with 1114 patients failed to find positive
associations with UDCA therapy (Goulis 1999).
There are a number of problems with this. Doses varied and protocols included
patients with insufficient dosing, and follow up was under 2 years in some cases. In
a recently published analysis of 367 patients from 4 clinical cohorts an initiation of
UDCA therapy in early stages of PBC (stage I-II) and a treatment duration of 2
years led to a retardation of histological progression, which argues for an early
initiation of UDCA therapy after diagnosis even in the absence of fibrosis or
cirrhosis. UDCA was also shown to improve biochemistry, delay portal
hypertension and varices, and currently has no therapeutic alternative (Poupon
2003). No convincing effect was demonstrable on osteopenia and extrahepatic
manisfestations of PBC. An interesting side effect appears to be the significant
reduction of colonic epithelial proliferation. UDCA therapy is not associated with a
higher prevalence of colonic polyps and appears to delay their reappearance after
polypectomy (Serfaty 2003).
Therapy in non-responders and combination strategies
Non-response is usually defined as a failure to lower cholestatic enzyme activities
or to reach normalisation of these parameters. In patients in whom alkaline
phosphatase and gamma glutamyltransferase activities are not lowered by UDCA
therapy, increased morbidity and progression is likely. Alternative therapeutic
strategies can be considered.
Steroids and UDCA: The combination of immunosuppressants and UDCA was
looked at in smaller studies and included the use of prednisolone (Leuschner 1996),
azathioprine (Wolfhagen 1998) and budesonide (Leuschner 1999, Angulo 2000)
(Table 7). In a randomised, controlled study with 30 patients, who received 10 mg
prednisolone/day an improvement of inflammatory activity was reported (Leuschner
1996). A study with 9 mg budesonide/day showed in 39 patients not only
biochemical but also histological improvement (Leuschner 1999). In an open study
with 22 patients a deterioration of osteopenia was noted (Angulo 2000). The
combination of budesonide and UDCA may have additional beneficial effects
related to the activation of the anion exchanger AE2, which may serve to alter
biliary composition and produce a more protective bicarbonate rich bile.
Sulindac and UDCA: In an open study with 23 patients and incomplete response
to UDCA over 12 months treated with UDCA or UDCA and sulindac a trend
Autoimmune Liver Diseases: AIH, PBC and PSC  473
towards histological improvement and biochemical improvement were reported in
the combination group (Leuschner 2002).
Colchicine and UDCA: In 3 studies the combination of colchicine and UDCA
were studied for 24 months in a total of 118 patients (Raedsch 1992, Ikeda 1996,
Poupon 1996). Although mild biochemical improvement was noted, the effect of
longer treatment remains unclear. Because of the biliary elimination of colchicine
combinations with bile acids, there may be potentially toxic effect.
Methotrexate and UDCA: Several pilot studies and 3 randomized studies have
looked at methotrexate in combination with UDCA. In a recent randomized
placebo-controlled protocol with 60 patients a high rate of side effects without
therapeutic benefit was reported (Van Steenbergen 1996, Bach 2003).
Primary sclerosing cholangitis
Diagnosis of primary sclerosing cholangitis (PSC)
PSC is classically characterized by the progressive destruction of large intra- as well
as extrahepatic bile ducts and – contrasting with AIH and PBC – preferentially
affects male patients with a maximum age of around 25-45 (Strassburg 1996).
About 50-75% of the time, PSC is associated with ulcerative colitis. PSC is
clinically characterized by upper quadrant pain, pruritus, anorexia and fever, but up
to 50% of patients lack any symptoms (Weismüller 2008). The diagnosis is
established by a typical biochemical profile of cholestasis with elevations of
bilirubin, alkaline phosphatase and gamma glutamyl transferase, the characteristic
findings upon cholangiography and a typical biopsy showing ring fibrosis around
the bile ducts, which is not present in all patients. Serology regularly identifies
atypical anti-neutrophil cytoplasmic autoantibodies (xANCA) in up to 80% of
patients (Terjung 2000), although these are not disease specific and can also occur
in patients with ulcerative colitis without PSC. There is a significant association of
PSC with cholangiocarcinoma (10-20%) and colorectal cancer (9% in 10 years). In
a subgroup of patients, small bile duct PSC may be present (Broome 2002), which
lacks typical strictures and pruning of the biliary tree upon cholangiography. In
these cases the diagnosis can be established in the presence of the typical
association with ulcerative colitis in male patients by performing a liver biopsy
(Figure 3).
Differential diagnosis: sclerosing cholangitis
The finding of macroductal sclerosing cholangitis can be brought about by a number
of conditions, which include ischemia, liver transplantation complications, and
drugs. Of note are two additional differential diagnoses that require attention
(Figure 4): secondary sclerosing cholangitis (Gelbmann 2007, Esposito 2008, von
Figura 2009, Al-Benna 2011) and IgG4-associated cholangitis (Webster 2009,
Clendenon 2011, Takuma 2011, Zhang 2011).
Secondary sclerosing cholangitis is an entity with severe infection of the biliary
tree that develops in some patients following systemic infections and sepsis who are
treated with aggressive intensive care unit management. IgG4-associated cholangitis
is an immune-mediated entity often with high plasma levels of IgG4 and IgG4
expression in biliary cells obtained upon brush biopsy. The latter can be treated with
474  Hepatology 2012
immunosuppression and should be diagnosed because of an available medical
therapy.
Figure 3. Diagnostic algorithm of PSC including clinical presentation.
Figure 4a. Examples of different entities of sclerosing cholangitis. A. PSC showing
multiple strictures with narrowing (black arrows) and prestenotic dilatation (white arrows) and
an endoscopic aspect of purulent biliary infection at the biliary papilla.
Autoimmune Liver Diseases: AIH, PBC and PSC  475
Figures 4b, 4c. Examples of different entities of sclerosing cholangitis. B. Secondary
sclerosing cholangitis (SSC) with a similar intrahepatic picture but also biliary casts (dotted
arrows) that can be extracted endoscopically (right panel). C. Cholangiogram of autoimmune
(AIC) IgG4-associated cholangitis mimicking PSC. Black arrows show narrowing, white arrows
show dilatations.
Association of PSC with inflammatory bowel disease
A clinical hallmark of PSC is the high number of patients suffering from
inflammatory bowel disease (IBD). In several studies with 605 PSC patients in the
US (Mayo Clinic), UK (King’s College) and in Sweden. IBD was found in 71%,
73% and 81% of PSC cases (Boberg 1998, Bergquist 2002). In our own experience

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Book on hepatitis from page 452 to 465

452  Hepatology 2012
von Herbay A, de Groot H, Hegi U, Stremmel W, Strohmeyer G, Sies H. Low vitamine E
content in plasma of patients with alcoholic liver disease, hemochromatosis and
Wilson's disease. J Hepatol 1994;20:41-6. (Abstract)
Walshe JM. Wilson's disease. New oral therapy. Lancet 1956;i:25-6. (Abstract)
Walshe JM. Copper chelation in patients with Wilson's disease. A comparison of penicillamine
and triethylene tetramine dihydrochloride. Q J Med 1973;42:441-52. (Abstract)
Walshe JM. The management of Wilson's disease with trienthylene tetramine 2HC1 (Trien
2HC1). Prog Clin Biol Res 1979;34:271-80. (Abstract)
Walshe JM. Treatment of Wilson's disease with trientine (triethylenetetramine) dihydrochloride.
Lancet 1982;1:643-7.
Walshe JM, Dixon AK. Dangers of non-compliance in Wilson's disease. Lancet 1986;1:845-7.
(Abstract)
Walshe JM. Diagnosis and treatment of presymptomatic Wilson's disease. Lancet 1988;2:435-7. (Abstract)
Walshe JM. Wilson's disease presenting with features of hepatic dysfunction: a clinical analysis
of eighty-seven patients. Q J Med 1989;70:253-63. (Abstract)
Walshe JM, Yealland M. Chelation treatment of neurological Wilson's disease. Q J Med
1993;86:197-204. (Abstract)
Walshe JM, Munro NA. Zinc-induced deterioration in Wilson's disease aborted by treatment
with penicillamine, dimercaprol, and a novel zero copper diet. Arch Neurol
1995;52:10-1. (Abstract)
Wilson SAK. Progressive lenticular degeneration: a familial nervous disease associated with
cirrhosis of the liver. Brain 1912;34:295-507.
Wilson DC, Phillips MJ, Cox DW, Roberts EA. Severe hepatic Wilson's disease in preschool-aged children. J Pediatr 2000;137:719-22. (Abstract)
Yamaguchi Y, Heiny ME, Gitlin JD. Isolation and characterization of a human liver cDNA as a
candidate gene for Wilson disease. Biochem Biophys Res Commun 1993;197:271-7.
(Abstract)
Autoimmune Liver Diseases: AIH, PBC and PSC  453
27. Autoimmune Liver Diseases: AIH, PBC
and PSC
Christian P. Strassburg
Autoimmune hepatitis (AIH)
Autoimmune hepatitis (AIH) is a chronic inflammatory disease, in which a loss of
tolerance against hepatic tissue is presumed. Autoimmune hepatitis (AIH) was first
described as a form of chronic hepatitis in young women showing jaundice, elevated
gamma globulins and amenorrhea, which eventually led to liver cirrhosis
(Waldenström 1950). He also first described a beneficial effect of steroids in the
patient cohort he reported on and thereby laid the groundwork for the first chronic
liver disease found to be curable by drug therapy. AIH was later recognized in
combination with other extrahepatic autoimmune syndromes, and the presence of
antinuclear antibodies (ANA) led to the term lupoid hepatitis (Mackay 1956).
Systematic evaluations of the cellular and molecular immunopathology, of the
clinical symptoms and of laboratory features has subsequently led to the
establishment of autoimmune hepatitis as a separate clinical entity which is
serologically heterogeneous, treated by a specific therapeutic strategy (Strassburg
2000). An established (Alvarez 1999a) and recently simplified (Hennes 2008b)
revised scoring system allows for a reproducible and standardized approach to
diagnosing AIH in a scientific context. The use  and interpretation of
seroimmunological and molecular biological tests permits a precise discrimination
of autoimmune hepatitis from other etiologies of chronic hepatitis, in particular
from chronic viral infection as the most common cause of chronic hepatitis
worldwide (Strassburg 2002). Today, AIH is a treatable chronic liver disease in the
majority of cases. Much of the same initial treatment strategies of
immunosuppression still represent the standard of care. The largest challenge
regarding treatment is the timely establishment of the correct diagnosis.
Definition and diagnosis of autoimmune hepatitis
In 1992, an international panel met in Brighton, UK, to establish diagnostic criteria
for AIH, because it was recognized that several features including histological
changes and clinical presentation are also prevalent in other chronic liver disorders
(Johnson 1993). In this and in a revised report the group noted that there is no single
454  Hepatology 2012
test for the diagnosis of AIH. In contrast, a set of diagnostic criteria was suggested
in the form of a diagnostic scoring system designed to classify patients as having
probable or definite AIH (Table 1). According to this approach the diagnosis relies
on a combination of indicative features of AIH and the exclusion of other causes of
chronic liver diseases. AIH predominantly affects women at any age, and is
characterized by a marked elevation of serum globulins, in particular
gammaglobulins, and circulating autoantibodies. It should be noted that AIH
regularly affects individuals older than 40 but should be considered in all age groups
(Strassburg 2006). The clinical appearance ranges from an absence of symptoms to
a severe or fulminant presentation (Stravitz 2011) and responds to
immunosuppressive treatment in most cases. An association with extrahepatic
autoimmune diseases such as rheumatoid arthritis, autoimmune thyroiditis,
ulcerative colitis and diabetes mellitus and a family history of autoimmune or
allergic disorders has been reported (Strassburg 1995).
Autoantibodies are one of the distinguishing features of AIH. The discovery of
autoantibodies directed against different cellular targets including endoplasmatic
reticulum membrane proteins, nuclear antigens and cytosolic antigens has led to a
suggested subclassification of AIH based upon the presence of 3 specific
autoantibody profiles. According to this approach, AIH type 1 is characterized by
the presence of antinuclear antibodies (ANA) and/or anti-smooth muscle antibodies
(SMA) directed predominantly against smooth muscle actin. AIH type 2 is
characterized by anti liver-kidney microsomal autoantibodies (LKM-1) directed
against cytochrome P450 CYP2D6 (Manns 1989, Manns 1991) (Figure 1) and with
lower frequency against UDP-glucuronosyltransferases (UGT) (Strassburg 1996).
AIH type 3 (Manns 1987, Stechemesser 1993) is characterized by autoantibodies
against a soluble liver antigen (SLA/LP) identified as UGA suppressor serine
tRNA-protein complex (Gelpi 1992, Wies 2000, Volkmann 2001, Volkmann 2010).
However, this serological heterogeneity does not influence the decision of whom to
treat or of what strategy to employ.
Figure 1: Indirect immunofluorescence showing LKM-1 autoantibodies on rat kidney and
liver cryostat sections. Serum of a patient with autoimmune hepatitis type 2. A. Using rat
hepatic cryostat sections a homogeneous cellular immunofluorescence staining is visualized
excluding the hepatocellular nuclei (LKM-1). B. Typical indirect immunofluorescence pattern of
LKM-1 autoantibodies detecting the proximal (cortical) renal tubules but excluding the distal
tubules located in the renal medulla, which corresponds to the tissue expression pattern of the
autoantigen CYP2D6.
Autoimmune Liver Diseases: AIH, PBC and PSC  455
Although the histological appearance of AIH is characteristic, there is no specific
histological feature  that  can be used to prove the diagnosis (Dienes 1989).
Percutaneous liver biopsy should be performed for grading and staging, as well as
for therapeutic monitoring. Histological features usually include periportal hepatitis
with lymphocytic infiltrates, plasma cells, and piecemeal necrosis. With advancing
disease, bridging necrosis, panlobular and multilobular necrosis may occur and
ultimately lead to cirrhosis. A lobular hepatitis can be present, but is only indicative
of AIH in the absence of copper deposits or biliary inflammation. In addition,
granulomas and iron deposits argue against AIH. A liver biopsy should be obtained
at first diagnosis before therapy for grading, staging and as confirmation of the
diagnosis.
Viral hepatitis should be excluded by the use of reliable, commercially available
tests. The exclusion of ongoing hepatitis A, B and C virus infection is sufficient in
most cases. The exclusion of other hepatotropic viruses such as cytomegalovirus,
Epstein-Barr and herpes group may only be required in cases suspicious of such
infections or if the diagnosis of AIH based on the above-mentioned criteria remains
inconclusive.
The probability of AIH decreases whenever signs of bile duct involvement are
present, such as elevation of alkaline phosphatase, histological signs of
cholangiopathy and detection of AMA. If one or more components of the scoring
system are not evaluated, merely a score pointing to a probable diagnosis can be
compiled (Table 1).
Epidemiology and clinical presentation
Based on limited epidemiological data, the prevalence is estimated to range between
50 and 200 cases per 1 million in Western Europe and North America among the
Caucasian population. The prevalence of AIH is similar to that of systemic lupus
erythematosus, primary biliary cirrhosis and myasthenia gravis, which also have an
autoimmune etiology (Nishioka 1997, Nishioka 1998). Among the North American
and Western European Caucasian population AIH accounts for up to 20% of cases
with chronic hepatitis (Cancado 2000). However, chronic viral hepatitis remains the
major cause of chronic hepatitis in most Western societies. In locales in which viral
hepatitis B and C are endemic, such as in Asia and Africa, the incidence of AIH
appears to be significantly lower. Additional epidemiological analyses are required
to comprehensively elucidate the prevalence and geographical distribution of AIH.
Autoimmune hepatitis is part of the syndrome of chronic hepatitis, which is
characterized by sustained hepatocellular inflammation of at least 6 months duration
and elevation of ALT and AST of 1.5 times the upper normal limit. In about 49% of
AIH patients an acute onset of AIH is observed and rare cases of fulminant AIH
have been reported. In most cases, however, the clinical presentation is not
spectacular and characterized by fatigue, right upper quadrant pain, jaundice and
occasionally also by palmar erythema and spider naevi. In later stages, the
consequences of portal hypertension dominate, including ascites, bleeding
esophageal varices and encephalopathy. A specific feature of AIH is the association
of extrahepatic immune-mediated syndromes including autoimmune thyroiditis,
vitiligo, alopecia, nail dystrophy, ulcerative colitis, rheumatoid arthritis, and also
diabetes mellitus and glomerulonephritis.
456  Hepatology 2012
Table 1. International criteria for the diagnosis of autoimmune hepatitis
(Alvarez 1999).
Parameter  Score
Gender
Female
Male
+ 2
0
Serum biochemistry
Ratio of elevation of serum alkaline phosphatase vs aminotransferase
>3.0
1.5-3
<1.5
- 2
0
+ 2
Total serum globulin, γ-globulin or IgG
(times upper limit of normal)
>2.0
1.5-2.0
1.0-1.5
<1.0
+ 3
+ 2
+ 1
0
Autoantibodies (titers by immunfluorescence on rodent tissues)
Adults
ANA, SMA or LKM-1
>1:80
1:80
1:40
<1:40
+ 3
+ 2
+ 1
0
Antimitochondrial antibody
Positive
Negative
- 4
0
Hepatitis viral markers
negative
positive
+ 3
- 3
History of drug use
Yes
No
- 4
+ 1
Alcohol (average consumption)
<25 gm/day
>60 gm/day
+ 2
- 2
Genetic factors: HLA-DR3 or -DR4  + 1
Other autoimmune diseases  + 2
Response to therapy
complete
relapse
+ 2
+ 3
Liver histology
interface hepatitis
predominant lymphoplasmacytic infiltrate
rosetting of liver cells
none of the above
biliary changes
other changes
+ 3
+ 1
+ 1
- 5
- 3
-3
Seropositivity for other defined autoantibodies  + 2
Interpretation of aggregate scores: definite AIH - greater than 15 before treatment
and greater than 17 after treatment; probable AIH - 10 to 15 before treatment and 12 to
17 after treatment.
Autoimmune Liver Diseases: AIH, PBC and PSC  457
Natural history and prognosis
Data describing the natural history of AIH are scarce. The last placebo-controlled
immunosuppressive treatment trial containing an untreated arm was published in
1980 (Kirk 1980). The value of these studies is limited considering that these
patients were only screened for epidemiological risk factors for viral hepatitis and
were not characterized by standardized diagnostic criteria and available virological
tests. Nevertheless, these studies reveal that untreated AIH had a very poor
prognosis and 5- and 10-year survival rates of 50% and 10% were reported. They
furthermore demonstrated that immunosuppressive treatment significantly improved
survival.
Data reveal that up to 30% of adult patients had histological features of cirrhosis
at diagnosis. In 17% of patients with periportal hepatitis cirrhosis developed within
5 years, but cirrhosis develops in 82% when bridging necrosis or necrosis of
multiple lobules is present. The frequency of remission (86%) and treatment failure
(14%) are comparable in patients with and without cirrhosis at presentation.
Importantly, the presence of cirrhosis does not influence 10-year survival and those
patients require a similarly aggressive treatment strategy (Geall 1968, Soloway
1972).
Almost half of the children with AIH already have cirrhosis at the time of
diagnosis. Long-term follow-up revealed that few children can completely stop all
treatment and about 70% of children receive long-term treatment (Homberg 1987,
Gregorio 1997). Most of these patients relapse when treatment is discontinued, or if
the dose of the immunosuppressive drug is reduced. About 15% of patients develop
chronic liver failure and are transplanted before the age of 18 years.
In elderly patients, a more severe initial histological grade has been reported
(Strassburg 2006). The risk of hepatocellular carcinoma varies considerably
between the different diseases PBC, PSC and AIH. Particular PCS can be
complicated by cholangiocarcinoma, gall bladder carcinoma and hepatocellular
carcinoma. In contrast, occurrence of HCC in patients with AIH is a rare event and
develops only in long-standing cirrhosis.
Who requires treatment?
Autoimmune hepatitis (AIH) is a remarkably treatable chronic liver disease (Manns
2001, Czaja 2010). Untreated, the prognosis of active AIH is dismal with 5- and 10-year survival rates between 50 and 10% and a well recognized therapeutic effect
exemplified by the last placebo-controlled treatment trials (Soloway 1972, Kirk
1980). For these reasons the indication for treatment is given in any patient who has
an established diagnosis of AIH, elevations of aminotransferase activities (ALT,
AST), an elevation of serum immunoglobulin G and histological evidence of
interface hepatitis or necroinflammatory activity. This has recently been discussed
in the newest version of the AIH guidelines for the American Association for the
Study of the Liver (AASLD) (Manns 2010a). These points indicate that an initial
liver biopsy specimen is desirable for confirmation of the diagnosis and for grading
and staging. Biopsies are also helpful for observation of aminotransferase activities
in serum reflecting inflammatory activity in the liver, which is not closely correlated
in all cases.
458  Hepatology 2012
Who does not require treatment?
Only very few patients with an established diagnosis of AIH should not be treated.
Rare cases, in which the initiation of standard therapy should be weighed against
potential side effects, are contraindications with steroids or azathioprine, or for
certain other immunosuppressants (see below). In decompensated liver cirrhosis of
patients on the waiting list for liver transplantation and in individuals with complete
cirrhosis and absent inflammatory activity treatment does not appear beneficial
(Manns 2010a).
Standard treatment strategy
Independent of clinically- or immunoserologically-defined type of AIH, standard
treatment is implemented with predniso(lo)ne alone or in combination with
azathioprine. Both strategies are just as effective (Manns 2001, Manns 2010a). The
basic strategy of this treatment is still based upon the findings of studies of almost 3
decades ago that indicated the effectiveness of steroids in AIH. Since that time no
single multicenter randomized treatment trial in AIH patients has been performed.
All advances of alternative treatment strategies are based on small cohorts and on
the need to develop strategies for difficult-to-treat patients. The use of prednisone or
its metabolite prednisolone, which is used more frequently in European countries, is
equally effective since chronic liver disease does not seem to have an effect on the
synthesis of prednisolone from prednisone. Important is the exact differentiation
between viral infection and autoimmune hepatitis. Treatment of replicative viral
hepatitis with corticosteroids must be prevented as well as administration of
interferon in AIH, which can lead to dramatic disease exacerbation.
Standard induction treatment and suggested follow-up examinations are
summarized in Table 2. Please note that there are differences in preferred regimen
in Europe and the US, which are delineated in the AASLD AIH Guideline (Manns
2010a). Therapy is usually administered over the course of 2 years. The decision
between monotherapy and combination therapy is guided principally by side effects.
Long-term steroid therapy leads to cushingoid side effects. Cosmetic side effects
decrease patient compliance considerably (Table 3). Serious complications such as
steroid diabetes, osteopenia, aseptic bone necrosis, psychiatric symptoms,
hypertension and cataract formation also have to be anticipated in long-term
treatment. Side effects are present in 44% of patients after 12 months and in 80% of
patients after 24 months of treatment. However, predniso(lo)ne monotherapy is
possible in pregnant patients. Azathioprine, on the other hand, leads to a decreased
dose of prednisone. It bears a theoretical risk of teratogenicity. In addition,
abdominal discomfort, nausea, cholestatic hepatitis, rashes and leukopenia can be
encountered. These side effects are seen in 10% of patients receiving a dose of 50
mg per day. From a general point of view, a postmenopausal woman with
osteoporosis, hypertension and elevated blood glucose would be a candidate for
combination therapy. In young women, pregnant women or patients with
hematological abnormalities, prednisone monotherapy may be the treatment of
choice.
Autoimmune Liver Diseases: AIH, PBC and PSC  459
Table 2. Treatment regimen and follow-up examinations of autoimmune hepatitis
regardless of autoantibody type.
Monotherapy  Combination therapy
Prednis(ol)one  60 mg
reduction by 10 mg/week to
maintenance of 20 mg/wk
reduction by 5 mg to 10 mg
find lowest dose in 2.5 mg
decrements
30-60 mg
reduction as in monotherapy
Azathioprine  n.a.
(maintenance with azathioprine:
monotherapy: 2 mg/kg body weight)
1 mg/kg of body weight (Europe)
50 mg (US)
Examination  Before
therapy
During
therapy
before
remission
q 4 weeks
Remission
on therapy
q 3-6
months
Cessation
of therapy
q 3 weeks
(x 4)
Remission
post-therapy
q 3-6
months
Evaluation of
relapse
Physical  +    +  +  +  +
Liver biopsy  +    (+/-)      +
Blood count  +  +  +  +  +
Aminotransferases  +  +  +  +  +  +
Gamma
glutamyltransferase
+  +  +   
Gammaglobulin  +  +  +  +  +  +
Bilirubin  +  +  +  +  +  +
Coagulation studies  +  +  +  +  +
Autoantibodies   +  +/-        +
Thyroid function
tests
+  +/-        +
Table 3. Side effects.
Prednis(ol)one  acne
moon-shaped face
striae rubra
dorsal hump
obesity
weight gain
diabetes mellitus
cataracts
hypertension
Azathioprine  nausea
vomiting
abdominal discomforts
hepatotoxicity
rash
leukocytopenia
teratogenicity (?)
oncogenicity (?)
460  Hepatology 2012
One of the most important variables for treatment success is adherence. The
administration of treatment is essential since most cases of relapse are the result of
erratic changes of medication and/or dose. Dose reduction is aimed at finding the
individually appropriate maintenance dose. Since histology lags 3 to 6 months
behind the normalization of serum parameters, therapy has to be continued beyond
the normalization of aminotransferase levels. Usually, maintenance doses of
predniso(lo)ne range between 10 and 2.5 mg. After 12-24 months of therapy
predniso(lo)ne can be tapered over the course of 4-6 weeks to test whether a
sustained remission has been achieved. Tapering regimens aiming at withdrawal
should be attempted with great caution and only after obtaining a liver biopsy that
demonstrates a complete resolution of inflammatory activity. Relapse of AIH and
risk of progression to fibrosis is almost universal when immunosuppression is
tapered in the presence of residual histological inflammation. Withdrawal should be
attempted with caution to prevent recurrence and subsequent fibrosis progression
and should be discussed with the patient and closely monitored.
Outcomes of standard therapy can be classified into four categories: remission,
relapse, treatment failure and stabilization.
Remission is a complete normalization of all inflammatory parameters including
histology. This is ideally the goal of all treatment regimens and ensures the best
prognosis. Remission can be achieved in 65-75% of patients after 24 months of
treatment. Remission can be sustained with azathioprine monotherapy of 2 mg/kg
bodyweight (Johnson 1995). This prevents cushingoid side effects. However, side
effects such as arthralgia (53%), myalgia (14%), lymphopenia (57%) and
myelosuppression (6%) have been observed. Complete remission is not achieved in
about 20% of patients and these patients continue to carry a risk of progressive liver
injury.
Relapse  is characterized by an increase  in aminotransferase levels and the
reccurrence of clinical symptoms either while on treatment, following tapering of
steroid doses to determine the minimally required dose, or, after a complete
withdrawal of therapy. Relapse can be found in 50% of patients within 6 months of
treatment withdrawal and in 80% after 3 years. Relapse is associated with
progression to cirrhosis in 38% and liver failure in 14%. Relapse requires
reinitiation of standard therapy, consideration of dosing as well as diagnosis, and
perhaps a long-term maintenance dose with predniso(lo)ne or azathioprine
monotherapy.
Treatment failure characterizes a progression of clinical, serological and
histological parameters during standard therapy. This is seen in about 10% of
patients. In these cases the diagnosis of AIH has to be carefully reconsidered to
exclude other etiologies of chronic hepatitis. In these patients experimental
regimens can be administered or ultimately liver transplantation becomes necessary.
Stabilization is the achievement of a partial remission. Since 90% of patients
reach remission within 3 years, the benefit of standard therapy has to be reevaluated
in this subgroup of patients. Ultimately, liver transplantation provides a definitive
treatment option.
Autoimmune Liver Diseases: AIH, PBC and PSC  461
Treatment of elderly patients
The presentation of acute hepatitis, clinical symptoms of jaundice, abdominal pain
and malaise have a high likelihood of attracting medical attention and subsequently
leading to the diagnosis of AIH (Nikias 1994). More subtle courses of AIH may not
lead to clinically relevant signs and may develop unnoticed other than via routine
work-up for other problems or via screening programs. The question of disease
onset in terms of initiation of immune-mediated liver disease versus the clinical
consequences that become noticeable after an unknown period of disease
progression is not easily resolved. Thus, “late onset” AIH may just simply reflect a
less severe course of the disease with a slower progression to cirrhosis. While
LKM-positive patients display a tendency towards an earlier presentation, both
acute and subtle (earlier and late presentation) variants appear to exist in ANA-positive AIH. In practice, the diagnostic dilemma is that AIH is still perceived by
many as a disease of younger individuals and that therefore this differential
diagnosis is less frequently considered in elderly patients with “cryptogenic”
hepatitis or cirrhosis. Another relevant question resulting from these considerations
is the issue of treatment. Standard therapy in AIH consists of steroids alone or a
combination with azathioprine. In maintenance therapy azathioprine monotherapy
can also be administered but induction with azathioprine alone is not effective.
From a general standpoint most internists will use caution when administering
steroids to elderly patients, especially in women in whom osteopenia or diabetes
may be present.
Recommendations for the treatment of AIH suggest that the steroid side effects be
weighed against the potential benefit of therapy, and that not all patients with AIH
are good candidates for steroid treatment (Manns 2001). Controversy exists
surrounding the benefit of therapy in this group of elderly patients. One cohort
reported on 12 patients over 65 out of a total of 54 AIH patients. Cirrhosis
developed after follow-up in 26% irrespective of age although the histological grade
of AIH activity was more severe in the elderly group. 42% of the patients over 65
did not receive therapy and yet deaths were reported only in the younger group
(Newton 1997). In another cohort of 20 patients aged >65 years, a longer time to
establishment of the diagnosis (8.5 vs. 3.5 months) was reported, patients presented
mainly with jaundice and acute onset AIH and showed a response rate to
immunosuppression comparable to that of younger patients (Schramm 2001). The
authors also noted that the prevalence of the HLA-A1-B8 allotype was less frequent
in older patients suggesting a role for immunogenetics.
This point was further elaborated by a recent report analyzing 47 patients with
ANA-positive AIH 60 years and older, as well as 31 patients 30 years and younger
in whom DR4+/DR3- prevalence was 47% (older) versus 13% (younger) patients
(Czaja 2006). In the older patients steroid responsiveness was better, which is in line
with previous findings in the same collective (Czaja 1993). Cirrhosis and
extrahepatic immune-mediated syndromes including thyroid and rheumatologic
disease (47% vs. 26%) were more prevalent in older AIH patients. However,
although more treatment failures were observed in the younger patients (24% vs
5%) the rates of remission, sustained remission and relapse were similar.
Interestingly, an assessment of age-stratified prevalence showed an increase after
the age of 40 from 15% to over 20%.
462  Hepatology 2012
From all this data, AIH in elderly patients appears to be characterized by a distinct
clinical feature, a distinct immunogenetic profile, favourable response rates and
higher rates of cirrhosis present at diagnosis, all of which contribute to the
heterogeneity of AIH. In a  cohort of 164 patients from the UK including 43
individuals 60 years and older AIH was looked at (Al-Chalabi 2006). The age
groups showed no significant differences regarding serum biochemistry,
autoantibody titers, time to establishment of diagnosis, and mode of presentation.
The authors provided a substratification of patients below and above 40 years of age
and reported that older patients had a higher median histological stage and a
comparable median grade but younger patients had more median relapse episodes
and a higher median stage at follow-up biopsy. The most distinguishing clinical sign
was a higher prevalence of ascites in the older group. However, rates of complete,
partial and failed response were similar, and the median number of relapses was
higher in younger patients, which nevertheless did not lead to differences in liver-related deaths in either group (12% vs. 15%). In comparison to the study of ANA-positive AIH patients from the US (Czaja 2006) the differing findings regarding
HLA association are notewothy. In the UK study there was no differential
distribution of HLA-DR3 and -DR4 and this questions the suggested hypothesis of a
primary influence of immunogenetics on the observed clinical distinctions. The
reasons for the clinical differences of AIH in older and younger patients are unclear.
They may include differences in hepatic blood flow and alterations involving the
regulation of cellular immunity during aging (Talor 1991, Prelog 2006). In
summary, these data suggest that AIH in elderly patients should be considered and
treated (Strassburg 2006).
Alternative Treatments
When standard treatment fails or drug intolerance occurs, alternative therapies such
as cyclosporin, tacrolimus, cyclophosphamide, mycophenolate mofetil, rapamycin,
UDCA, and budesonide can be considered (Table 4). The efficacy of most of these
options has not yet been definitively decided and is only reported in small case
studies.
Table 4. Alternative drugs in autoimmune hepatitis.
Compound  Advantage  Disadvantage
Budesonide  High first pass effect
Immunosuppressive action
Inactive metabolites
Cirrhosis (portosystemic
shunts) and side effects
Cyclosporine  Satisfactory experience
Potent immunosuppressant
Transplant immunosuppressant
Renal toxicity
Tacrolimus  Potent immunosuppressant
Transplant immunosuppressant
Renal toxicity
Mycophenolic acid  Favourable toxicity profile
Transplant immunosuppressant
Disappointing
effectiveness
Cyclophosphamide  Effective  Continuous therapy
Hematological side effects
Autoimmune Liver Diseases: AIH, PBC and PSC  463
Budesonide
Budesonide is a synthetic steroid with high first-pass metabolism in the liver, in
principle with limited systemic side effects compared to conventional steroids. In
comparison to prednisone the absolute bioavailability of budesonide is less than 6-fold lower (Thalen 1979) but it has an almost 90% first-pass metabolism in the liver,
a higher affinity to the glucocorticoid receptor, acts as an anti-inflammatory and
immunosuppressive drug and leads to inactive metabolites (6-OH-budesonide, 16-OH-prednisolone). In a pilot study treating 13 AIH patients with budesonide over a
period of 9 months the drug was well tolerated and aminotransferase levels were
normalized (Danielson 1994). However, in a second study budesonide therapy was
associated with a low frequency of remission and high occurrence of side effects
(Czaja 2000). In that study, 10 patients were treated who had previously been
treated with azathioprine and steroids and had not reached a satisfactory remission.
The conclusion of the authors was that budesonide was not a good treatment option
in those patients. A third study with 12 previously untreated patients was published
(Wiegand 2005). In this study remission was induced with budesonide combination
therapy. The authors performed kinetic analyses and reported that in those with high
inflammatory activity and cirrhosis the area under the curve (AUC) of budesonide
was increased. This finding plausibly demonstrates that in patients with
portosystemic shunts in portal hypertension the effect of high hepatic first-pass
metabolism that would limit typical steroid side effects is reduced.
The main advantage of budesonide for the future  treatment of autoimmune
hepatitis would therefore be to replace prednisone in long-term maintenance therapy
and induction therapy to reduce steroid side effects. To this end the first multicenter
placebo-controlled randomised AIH treatment trial in 3 decades was performed with
a total of 207 non-cirrhotic patients from 30 centres in 9 European countries and
Israel (Manns 2010b). In this trial 40 mg prednisone (reduction regimen) and
azathioprine was compared to 3 mg budesonide (TID initially, reduced to BID) in
combination with azathioprine. The data was recently published and shows that
budesonide in combination with azathioprine is efficient in inducing stable
remission, is superior in comparison to a standard prednisone tapering regimen
beginning with 40 mg per day (Manns 2010b) and leads to a substantially superior
profile of steroid-specific side effects. From these data budesonide is emerging as an
alternative first-line treatment strategy for non-cirrhotic patients with AIH (Manns
2010b).
Deflazacort
This alternative corticosteroid has also been studied for immunosuppression in AIH
because of its feature of fewer side effects than conventional glucocorticoids. In a
pilot study 15 patients with AIH type I were treated with deflazacort, who had been
previously treated with prednisone with or without azathioprine until they reached a
biochemical remission. Remission was sustained for 2 years of follow-up. However,
the long-term role of second-generation corticosteroids to sustain remission in AIH
patients with reduced treatment related side effects requires further controlled
studies (Rebollo Bernardez 1999).
464  Hepatology 2012
Cyclosporine A
Cyclosporine A (CyA) is a lipophylic cyclic peptide of 11 residues produced by
Tolypocladium inflatum that acts on calcium-dependent signaling and inhibits T cell
function via the interleukin 2 gene (Strassburg 2008). Out of the alternative AIH
drugs considerable experience has been reported with CyA. In these studies CyA
was successfully used for AIH treatment and was well tolerated (Alvarez 1999b,
Debray 1999). The principal difficulty in advocating widespread use of CyA as
first-line therapy relates to its toxicity profile, particularly with long-term use
(increased risk of hypertension, renal insufficiency, hyperlipidemia, hirsutism,
infection, and malignancy)  (Alvarez 1999b, Debray 1999, Fernandez 1999,
Heneghan 2002).
Tacrolimus
Tacrolimus is a macrolide lactone compound with immunosuppressive qualities
exceeding those of CyA. The mechanism of action is similar to that of CyA but it
binds to a different immunophilin (Strassburg 2008). The application of tacrolimus
in 21 patients treated for 1 year led to an improvement of aminotransferase and
bilirubin levels with a minor increase in serum BUN and creatinine levels (Van
Thiel 1995). In a second study with 11 steroid refractory patients improvement of
inflammation was also observed (Aqel 2004). Although tacrolimus represents a
promising immunosuppressive candidate drug, larger randomized trials are required
to assess its role in the therapy of AIH.
Mycophenolic acid
Mycophenolate has attracted attention as a transplant immunosuppressant with an
important role in the steroid-free immunosuppressive therapy of patients
transplanted for chronic hepatitis C infection. Mycophenolate is a noncompetitive
inhibitor of inosine monophosphate dehydrogenase, which blocks the rate-limiting
enzymatic step in de novo purine synthesis. Mycophenolate has a selective action on
lymphocyte activation, with marked reduction of both T and B lymphocyte
proliferation. In a pilot study 7 patients with AIH type 1 who either did not tolerate
azathioprine or did not respond to standard therapy with a complete normalization
of aminotransferase levels were treated with mycophenolate in addition to steroids.
In 5 out of 7 patients normalization of aminotransferase levels was achieved within
3 months. These preliminary data suggested that mycophenolate may represent a
promising treatment strategy of AIH (Richardson 2000). In a recent retrospective
study 37 patients with AIH and azathioprine failure or intolerance were treated with
mycophenolate (Hennes 2008a). There was no statistically significant benefit for
mycophenolate treatment. Less than 50% reached remission and in the azathioprine
non-responders failure was 75%. Although the toxicity profile of mycophenolate
would suggest its use, the retrospective study data does not indicate an effective
second line therapeutic option.
Cyclophosphamide
The induction of remission with 1-1.5 mg per kg per day of cyclophosphamide in
combination with steroids has been reported. However the dependency of continued
application of cyclophosphamide with its potentially severe hematological side
effects renders it a highly experimental treatment option (Kanzler 1996).
Autoimmune Liver Diseases: AIH, PBC and PSC  465
Anti-TNF α antibodies
There is some emerging evidence that anti-TNF antibodies are capable of inducing
remission in AIH patients in whom standard or alternative therapeutic options have
been exhausted (Efe 2010, Umekita 2011). However, the development of AIH has
also been observed under treatment with anti-TNF antibodies (Ramos-Casals 2008).
Future studies will have to define the role of this therapeutic option in difficult-to-treat cases of AIH.
Ursodeoxycholic acid
Ursodeoxycholic acid is a hydrophilic bile acid with putative immunomodulatory
capabilities. It is presumed to alter HLA class I antigen expression on cellular
surfaces and to suppress immunoglobulin production. Uncontrolled trials have
shown a reduction in histological abnormalities, clinical and biochemical
improvement but not a reduction of fibrosis in 4 patients with AIH type 1 (Calmus
1990, Nakamura 1998, Czaja 1999). However, its role in AIH therapy or in
combination with immunosuppressive therapy is still unclear.
Other alternative treatment strategies include methotrexate, anti-TNF a antibodies,
and rituximab, but there is currently insufficient data on any of these.
Overlap syndromes and treatment
The term overlap syndrome describes a disease condition that is only incompletely
defined (Strassburg 2006). A valid definition is difficult (Boberg 2011). It is
characterized by the coexistence of clinical, biochemical or serological features of
autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), primary sclerosing
cholangitis (PSC), and depending on the definition, also viral hepatitis C (Ben-Ari
1993, Colombato 1994, Duclos-Vallee 1995, Chazouilleres 1998, Angulo 2001,
Rust 2008). In adult patients an overlap of PBC and AIH is most frequently
encountered although it is unclear whether this is true co-existence of both diseases
or an immunoserological overlap characterized by the presence of antinuclear
(ANA) as well as antimitochondrial (AMA) antibodies (Poupon 2006, Gossard
2007, Silveira 2007, Al-Chalabi 2008). In many AMA-negative patients with a
cholestatic liver enzyme profile ANA are present. This has been termed
autoimmune cholangiopathy or AMA-negative PBC (Michieletti 1994).
Apart from coexisting, autoimmune liver diseases can also develop into each
other, i.e., the sequential manifestation of PBC and autoimmune hepatitis. The true
coexistence of AIH and PSC has only been conclusively shown in pediatric patients
(Gregorio 2001). It can be hypothesized whether a general predisposition toward
liver autoimmunity exists which has a cholestatic, a hepatitic and a bile duct facet,
which may be variable depending upon unknown host factors. The diagnosis of an
overlap syndrome relies on the biochemical profile (either cholestatic with elevated
alkaline phosphatase, gamma glutamyltransferase and bilirubin, or hepatitic with
elevated aspartate aminotransferase and alanine aminotransferase levels in addition
to elevated gamma globulins), the histology showing portal inflammation with or
without the involvement of bile ducts, and the autoantibody profile showing AMA
or autoantibodies associated primarily with AIH such as liver-kidney microsomal

Book on hepatitis from page 436 to 451

Book on hepatitis from page 436 to 451

436  Hepatology 2012
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Wilson’s Disease  437
26. Wilson’s Disease
Claus Niederau
Introduction
In 1912, Kinnear Wilson was the first to describe an inherited lethal disease
associated with progressive lenticular degeneration, chronic liver disease and
cirrhosis (Wilson 1912). In the same year, Kayser and Fleischer detected that
patients with Wilson’s Disease (WD) often have brownish corneal copper deposits
now called Kayser-Fleischer rings (Fleischer 1912).
WD is an autosomal recessive error of the metabolism. Its gene ATP7B encodes a
copper-transporting ATPase (Bull 1993, Tanzi 1993, Petrukhin 1993, Yamaguchi
1993). The genetic defect of the ATP7B protein reduces biliary copper excretion
leading to copper accumulation in the cornea and various organs including the liver,
brain and kidney. The alteration of the ATP7B protein also reduces the
incorporation of copper into ceruloplasmin. The corresponding presence of
apoceruloplasmin (ceruloplasmin with no copper incorporation) leads to a decrease
in circulating levels of ceruloplasmin due to the reduced half-life of the apoprotein.
Thus, despite copper accumulation in many organs, circulating levels of copper and
ceruloplasmin are decreased in most WD patients.
The prevalence of WD is rare, estimated at 3 per 100,000 population (Frysman
1990). The clinical presentation may vary. Some WD patients are diagnosed with
liver problems while others present with neurologic or psychiatric symptoms; many
patients show both hepatic and neurological disease (Figure 1). Episodes of
hemolysis and renal abnormalities may also occur. WD typically affects children
and younger adults, and is rarely seen in adults older than 40. WD is fatal unless
appropriately treated. Drugs for treatment of WD are copper chelators such as
penicillamine, and trientine (Walshe 1956). More recently, zinc has been used to
reduce intestinal copper absorption and to detoxify free circulating copper. Patients
with fulminant liver failure or decompensated cirrhosis may have to undergo liver
transplantation (LTX), which cures WD.
Clinical presentation
Screening for WD is useful only in families with an affected member. In all other
circumstances diagnostic procedures are only done when symptoms and findings
suggest WD. These include liver disease, neurological symptoms, renal
438  Hepatology 2012
abnormalities and episodes of hemolysis. WD is diagnosed in the vast majority of
patients between the ages of 5 and 35. There are rare reports of patients diagnosed at
ages 3-5 (Kalach 1993, Wilson 2000) and at ages of up to about 60 years (Gow
2000). Late-onset WD is a frequently overlooked condition (Ferenci 2007).
Diagnostic workup does not rely on a single test but includes identification of
corneal Kayser-Fleischer rings, reduced serum ceruloplasmin and copper as well as
a quantitative determination of liver copper concentration (Scheinberg 1952,
Walshe 1956, Saito 1987, Stremmel 1991, Roberts 2003) (Figure 2).
Figure 1. Clinical course of WD in 53 patients (modified from
Stremmel 1991).
Figure 2. Diagnostic workup for WD.
Genetic tests are usually only done in relatives of a confirmed WD patient. It is
easy to diagnose WD in subjects who present with liver cirrhosis, typical neurologic
manifestations and Kayser-Fleischer rings; many of these patients present at ages 5
to 35 and have decreased serum copper and ceruloplasmin (Sternlieb 1990).
However, a considerable number of WD patients present only with liver disease and
may not have Kayser-Fleischer rings or decreased serum levels of ceruloplasmin
(Steindl 1997). Under these circumstances diagnosis may be difficult; measurement
of 24 hour urinary copper excretion often helps to support the suspicion of WD.
Wilson’s Disease  439
Liver biopsy with measurement of quantitative copper concentration should be done
to corroborate the diagnosis (Stremmel 1991, Roberts 2003).
In general, WD patients diagnosed primarily with liver disease are children and
adolescents and are younger than those diagnosed due to neurological symptoms
(Merle 2007). Many patients who present only with CNS symptoms are 20-40 years
old. Patients with WD may present with a wide spectrum of liver disease ranging
from asymptomatic elevation of serum aminotransferases to fulminant liver failure.
Serum aminotransferases are elevated in most WD patients irrespective of age
(Schilsky 1991). Other WD patients may present with findings and symptoms of
autoimmune hepatitis including autoimmune antibodies and elevated IgG (Scott
1978, Milkiewicz 2000). The clinical picture might also resemble acute or chronic
viral hepatitis, without the viral serum markers. Even liver histology is not
predictive or typical for WD unless copper concentration is measured. Histological
findings may range from fatty liver changes to severe necro-inflammatory and
fibrotic disease and complete cirrhosis. In particular, children and adolescents with
chronic active hepatitis of unknown etiology or autoimmune hepatitis and adult
patients with a suspicion of autoimmune hepatitis  or non-response to
immunosuppressants should be evaluated for WD (Roberts 2003).
WD has to be excluded in patients with fulminant liver failure of unknown
etiology, especially at ages under 35 years; WD patients with such presentation
usually have some sort of liver disease (Rector 1984, Ferlan-Maroult 1999, Roberts
2003) associated with Coombs-negative hemolytic anemia and severely increased
prothrombine time non-responsive to vitamin K and progressive renal failure (Sallie
1992). Some patients have bilirubin levels of more than 40 mg/dl while serum
alkaline phosphatase is normal or just slightly elevated (Berman 1991). In contrast
to many types of toxic liver failure, liver failure in WD usually does not start with
high increases in aminotransferases. In many WD patients AST levels exceed ALT
levels (Emre 2001, Berman 1991). In most cohorts, for unexplained reasons, the
ratio of females to males is approximately 2:1 (Roberts 2003). Serum ceruloplasmin
may be decreased while serum copper and 24-hour urinary excretion of copper is
usually elevated. It is extremely helpful when one can identify Kayser-Fleischer
rings in this situation; these patients need to be studied with a slit lamp by an
experienced ophthalmologist. Patients with acute liver failure need a diagnostic
workup as rapidly as possible; if there is a strong suspicion or diagnosis of WD, the
patient should be transferred to a transplant centre the same day.
Neurological symptoms in WD often resemble those seen in Parkinson’s disease
including tremor and rigor. Many patients report that symptoms start with problems
in handwriting and dysarthria. Neurological symptoms may be associated with
slight behavioural alterations, which may later proceed to manifest psychiatric
disease including depression, anxiety and psychosis. With the progression of CNS
involvement WD patients may develop seizures and pseudobulbar palsy associated
with severe dysphagia, aspiration and pneumonia. Although many older WD
patients present with neurological disease, the diagnostic workup often shows
significant liver involvement or even complete liver cirrhosis.
Renal involvement of WD may present with aminoaciduria and nephrolithiasis
(Azizi 1989, Nakada 1994, Cu 1996). There may be various other non-neurological
and non-hepatic  complications of WD such as osteoporosis and arthritis,
440  Hepatology 2012
cardiomyopathy, pancreatitis, hypoparathyroidism, and miscarriages (for literature
see Roberts 2003).
Kayser-Fleischer rings are caused by corneal copper deposition (Figure 3).
Sometimes, one can see the rings directly as a band of brown pigment close to the
limbus. In other patients the ring can only be identified using a slit lamp. Very
rarely similar rings may be seen in non-WD patients, e.g., in some patients with
neonatal or chronic cholestasis (Tauber 1993). Kayser-Fleischer rings are detectable
in 50-60% of WD patients in most large cohorts (Tauber 1993, Roberts 2003).
Many young WD patients with liver disease do not have such rings (Giacchino
1997) whereas almost all patients with primarily neurologic symptoms do have
them (Steindl 1997). WD patients may also have other less specific eye changes
including sunflower cataracts (Cairns 1963). Kayser-Fleischer rings usually regress
with chelation therapy or after LTX (Stremmel 1991, Schilsky 1994).
Figure 3. Kayser-Fleischer ring in a patient with WD.
Diagnosis
Serum ceruloplasmin
Ceruloplasmin, the major circulating copper transporter, is synthesized and
secreted mainly by hepatocytes. The 132 kd protein consists of six copper atoms per
molecule of ceruloplasmin (holoceruloplasmin) while the remaining part of the
protein does not carry copper (apoceruloplasmin). Ceruloplasmin acts as an acute
phase reactant and may thus be increased by any inflammatory process; it may also
rise in pregnancy and with the use of estrogens and oral contraceptives. One also
needs to remember that the normal range of serum ceruloplasmin is age-dependent:
it is usually low in infants until the age of 6 months; in older children it may be
Wilson’s Disease  441
somewhat higher than in adults. As explained previously, serum levels of
ceruloplasmin are generally decreased in WD; however, this finding alone is
unreliable because low serum ceruloplasmin may be seen without WD and serum
ceruloplasmin may even be increased in severe WD and liver failure. Non-specific
reductions of ceruloplasmin are usually associated with protein deficiency or any
end-stage liver disease. Long-term parenteral nutrition may also lead to decreased
levels of ceruloplasmin. Low serum ceruloplasmin is also a hallmark of Menkes’
disease, a very rare X-linked inborn error of metabolism that leads to a defect in
copper transport due to mutations in ATP7A (Menkes 1999). Very rarely, one
cannot measure serum ceruloplasmin at all. This aceruloplasminemia is a very rare
genetic disease caused by mutations in the ceruloplasmin gene; however, patients
with aceruloplasminemia develop iron and not copper overload (Harris 1998).
Most patients with WD have a serum ceruloplasmin lower than 20 µg/dl; this
finding is diagnostic for WD however only when there are other findings such as a
Kayser-Fleischer corneal ring. In one prospective screening study, ceruloplasmin
was measured in 2867 patients presenting with liver disease: only 17 of them had
reduced ceruloplasmin levels and only 1 of these subjects had WD (Cauza 1997).
Thus decreased ceruloplasmin had a positive predictive value of only 6% in the
2867 patients tested. In two cohorts, about 20% of WD had normal ceruloplasmin
and no Kayser-Fleischer rings (Steindl 1997, Gow 2000). Most reports, however,
show that more than 90% of WD patients have a reduced serum ceruloplasmin
(Walshe 1989, Lau 1990, Stremmel 1991). Measurement of ceruloplasmin as a
single marker cannot reliably differentiate homozygotes from heterozygotes.
Serum copper
Corresponding to the decrease in serum ceruloplasmin, total serum copper is also
usually decreased in WD. Similar to the diagnostic problems in interpreting
ceruloplasmin data in WD patients with fulminant liver failure, serum copper may
also be normal in this situation – even if serum ceruloplasmin is decreased. In acute
liver failure circulating copper may in fact be elevated because it is massively
released from injured hepatocytes. If ceruloplasmin is reduced, a normal or elevated
serum copper usually suggests that there is an increase in free serum copper (not
bound to ceruloplasmin). The free copper concentration calculated from total copper
and ceruloplasmin values has also been proposed as a diagnostic test and for
monitoring of WD. It is elevated above 25 µg/dL in most untreated patients (normal
values are below 10-15  µg/dL). The amount of copper associated with
ceruloplasmin is 3.15 µg of copper per mg of ceruloplasmin. Thus free copper is the
difference between the total serum copper in µg/dL and 3 times the ceruloplasmin
concentration in mg/dl (Roberts 1998).
Increases in serum free copper, however, are not specific for WD and can be seen
in all kinds of acute liver failure as well as in marked cholestasis (Gross 1985,
Martins 1992). The calculation of the free copper concentration critically depends
on the adequacy of the methods used for measuring total serum copper and
ceruloplasmin; often labs simply state that one of the tests is below a certain value,
which makes it impossible to calculate the amount of free copper.
442  Hepatology 2012
Urinary copper excretion
Most WD patients have an increase in urinary copper excretion above 100 µg/24
hours, which is thought to represent the increase in circulating free copper (not
bound to ceruloplasmin). Some studies suggest that about 20% of WD patients may
have 24-hr urinary copper excretion between 40-100 µg/24 h (Steindl 1997,
Giacchino1997, Gow 2000, Roberts 2003). However, some increase in urinary
copper excretion can be found in severe cholestasis, chronic active hepatitis and
autoimmune hepatitis (Frommer 1981). It has been suggested that urinary copper
excretion stimulated by penicillamine may be more useful than the non-stimulating
test. In children 500 mg of oral penicillamine is usually given at the beginning and
then at 12 hours during the 24-hour urine collection. All WD children looked at had
levels above 1600 µg copper/24 h and all patients with other liver diseases including
autoimmune hepatitis and cholestatic liver disease had lower values. It is not clear
whether this test has a similar discriminative power in adults where it has been used
in various modifications (Tu 1967, Frommer 1981).
Hepatic copper concentration
Hepatic copper content above 250 µg/g dry weight liver is still the gold standard for
diagnosis of WD and is not seen in heterozygotes or other liver diseases with the
exception of Indian childhood cirrhosis (Martins 1992). Biopsies (larger than 1 cm
in length) for measurements of hepatic copper determination should be taken with a
disposable Tru-Cut needle, placed dry in a copper-free container and shipped frozen
(Song 2000, Roberts 2003).
Radiolabelled copper
In WD, incorporation of radiolabelled copper into ceruloplasmin is significantly
reduced. This test is rarely used because of the difficulty in obtaining the isotope
and because of legal restrictions.
Liver biopsy findings
Histological findings in WD range from some steatosis and hepatocellular necrosis
to the picture as seen in severe autoimmune hepatitis with fibrosis and cirrhosis.
Patients diagnosed at a young age usually have extensive liver disease; older
patients who first present with neurological symptoms often have abnormalities in
liver biopsy as well (Stremmel 1991, Steindl 1997, Merle 2007). Detection of
copper in hepatocytes, e.g., by staining with rhodamin using routine histochemistry
does not allow a diagnosis of WD (Geller 2000) (Figure 4).
Wilson’s Disease  443
Figure 4. Liver histology (rhodamine staining for copper) in a WD patient.
Neurology and MRI of the CNS
Neurologic symptoms in WD include Parkinson’s-like abnormalities with rigidity,
tremor and dysarthria. In more severely affected patients there may be muscle
spasms, contractures, dysphonia, and dysphagia. In patients with pronounced
neurological  symptoms magnetic resonance imaging (MRI) often identifies
abnormalities in basal ganglia such as hyperintensity on T2 weighted imaging
(Aisen 1995, van Wassanaer 1996). MRI of the CNS is superior to computed
tomography to diagnose WD.
Genetic Studies
The use of mutation analysis in WD is limited by the fact that more than 200
ATP7B mutations have been described (see
www.medgen.med.ualberta.ca/database.html). When the mutation is known in a
specific patient, gene analysis may be useful for family screening or prenatal
analysis (Thomas 1995, Shab 1997, Loudianos 1994). Some populations in Eastern
Europe show predominance of the H1069Q mutation (for literature see Roberts
2003).
Treatment
Before 1948, all patients with Wilson’s Disease died shortly after diagnosis. In
1948, intramuscular administration of the copper chelator BAL (dimercaprol) was
introduced as the first treatment of WD (Cumming 1951, Denny-Brown 1951)
followed by the oral chelators penicillamine  (1955), trientine  (1969) and
tetrathiomolybdate (1984). Other treatment modalities include oral zinc salts (1961)
and liver transplantation (1982). Today, most patients with WD remain on a lifelong
444  Hepatology 2012
pharmacologic therapy usually including a copper chelator and/or a zinc salt (Figure
5). LTX is reserved for fulminant liver failure and irreversible decompensation of
liver cirrhosis. Patients with a successful LTX do not need WD treatment because
LTX heals the biochemical defect. Today, most doctors use oral chelators for initial
treatment of symptomatic patients; many physicians start therapy with penicillamine
while some prefer trientine. Both drugs are probably equally effective, with trientine
having fewer side effects. In patients with advanced neurological disease some
authors recommend tetrathiomolybdate for primary therapy. Combination therapy of
chelators and zinc salts might have additive effects, acting on both urinary copper
excretion and its intestinal absorption. After removal of most accumulated copper
and regression of the most severe clinical problems the chelator dose may be
reduced and later replaced by zinc. Patients presenting without symptoms may be
treated with a rather low dose of a chelator or with a zinc salt from the beginning.
Compliance problems have been shown to regularly cause recurrence of
symptomatic WD and may lead to fulminant liver failure, need for LTX or death.
Table 1. Treatment options in WD.
Penicillamine (600-1800 mg/day)
In case of intolerance to penicillamine:
Trientine (900-2400 mg/day)
For combination of maintenance:
Zinc acetate/sulfate
For neurologic disease − not yet approved:
Tetrathiomolybdate
In acute liver failure/decompensated cirrhosis:
Liver transplantation
Restriction of food with high copper content
(does not substitute for chelators or zinc!)
Penicillamine.  Penicillamine  was the first oral copper chelator shown to be
effective in WD (Walshe 1955). Total bioavailability of oral penicillamine ranges
between 40 and 70% (Bergstrom 1981). Many studies have shown that
penicillamine reduces copper accumulation and provides clinical benefit in WD
(Walshe 1973, Grand 1975, Sternlieb 1980). Signs of liver disease often regress
during the initial 6 months of treatment. Non-compliance has been shown to cause
progression of liver disease, liver failure, death and LTX (Scheinberg 1987).
However, neurological symptoms may deteriorate at the start of penicillamine
treatment; it remains controversial how often this neurological deterioration occurs
and whether it is reversible; the rate of neurological worsening ranges from 10-50%
in different cohorts (Brewer1987, Walshe 1993). Some authors even recommend
not using penicillamine at all in WD patients with neurological disease (Brewer
2006). Penicillamine is associated with many side effects that lead to its
discontinuation in up to 30% of patients (for literature see Roberts 2003). An early
sensitivity reaction may occur during the first 3 weeks including fever, cutaneous
exanthema, lymphadenopathy, neutropenia, thrombocytopenia, and proteinuria. In
such early sensitivity, penicillamine should be replaced by trientine immediately.
Nephrotoxicity is another frequent side effect of penicillamine, which occurs later
Wilson’s Disease  445
and includes proteinuria and signs of tubular damage. In this case penicillamine
should be immediately discontinued. Penicillamine may also cause a lupus-like
syndrome with hematuria, proteinuria, positive antinuclear antibody, and
Goodpasture’s Syndrome. More rarely the drug can damage the bone marrow
leading to thrombocytopenia or total aplasia. Dermatologic side effects include
elastosis perforans serpiginosa, pemphigoid lesions, lichen planus, and aphthous
stomatitis. There have also been reports of myasthenia gravis, polymyositis, loss of
taste, reduction of IgA, and serous retinitis due to administration of penicillamine.
In order to minimize its side effects pencillamine should be started at 250 mg
daily; the dose may be increased in 250 mg steps every week to a maximal daily
amount of 1000 to 1500 mg given in 2 to 4 divided doses daily (Roberts 2003).
Maintenance doses range from 750 to 1000 mg/d given as 2 divided doses. In
children the dose is 20 mg/kg/d given in 2 or 3 divided doses. Penicillamine should
be given 1 hour before or 2 hours after meals because food may inhibit its
absorption. After starting penicillamine therapy serum ceruloplasmin at first may
decrease. Treatment success is checked by measuring 24-hr urinary copper that
should range between 200-500 µg/day. In the long run ceruloplasmin should
increase and free copper should regress towards normal with penicillamine therapy
(Roberts 2003).
Trientine  (triene).  The chemical structure of the copper chelator trientine
(triethylene tetramine dihydrochloride, short name triene) differs from
penicillamine. Trientine has usually been used as an alternative or substitute for
penicillamine, in particular when penicillamine’s major side effects are not tolerable
(Walshe 1982). Triene only rarely has side effects. Similar to penicillamine long-term treatment with trientine may cause hepatic iron accumulation in persons with
WD. Trientine is poorly absorbed from the gastrointestinal tract, and only 1%
appears in the urine (Walshe 1982). Doses range from 750 to 1500 mg/d given in 2
or 3 divided doses; 750 or 1000 mg are given for maintenance therapy (Roberts
2003). In children a dose of 20 mg/kg/d is recommended. Similar to penicillamine,
trientine should be given 1 hour before or 2 hours after meals. The effectiveness of
copper chelation by triene is measured as described for penicillamine. Triene
chelates several metals such as copper, zinc, and iron by urinary excretion and it
effectively removes accumulated copper from various organs in persons with WD as
well as in severe liver disease (Walshe 1979, Scheinberg 1987, Santos 1996, Saito
1991). It is still unclear whether penicillamine is a more effective copper chelator
when compared to triene; probably the difference in effectiveness is small (Walshe
1973, Sarkar 1977). Potential deterioration of neurological disease may also be seen
after starting triene therapy; the worsening however is less frequent and less
pronounced than that seen after starting with penicillamine.
Zinc.  Most physicians substitute penicillamine or triene with zinc  for
maintenance therapy when most copper accumulation has been removed. Zinc can
also be given as initial therapy in asymptomatic patients diagnosed by family
screening. A recent report however shows that WD symptoms may occur despite
zinc prophylaxis in asymptomatic patients (Mishra 2008). In a recent study from
India, 45 WD patients were on both penicillamine and zinc sulfate. The majority of
patients (84%) had neuropsychiatric manifestations. The mean duration of treatment
with penicillamine and zinc, before stopping penicillamine, was 107 months. All
patients had to stop penicillamine due to the financial burden. The patients then only
446  Hepatology 2012
received zinc sulfate for 27 months and 44 of the 45 patients (98%) remained stable.
Only one patient reported worsening in dysarthria (Sinha 2008). Zinc does not act as
an iron chelator but inhibits intestinal copper absorption and has also been
suggested to bind free toxic copper (Brewer 1983, Schilksky 1989, Hill 1987). Zinc
rarely has any side effects. It is still unclear whether zinc as monotherapy is an
effective “decoppering” agent in symptomatic patients. There are some hints that
hepatic copper may accumulate despite zinc therapy including reports about hepatic
deterioration with a fatal outcome (Lang 1993, Walshe 1995). Therefore some
authors use zinc in combination with a chelator. Neurological deterioration is rather
rare under zinc therapy (Brewer 1987, Czlonkowska 1996). The recommended
doses of zinc vary in the literature: according to AASLD practice guidelines dosing
is in milligrams of elemental zinc (Roberts 2003). For larger children and adults,
150 mg/d is administered in 3 divided doses. Compliance with doses given thrice
daily may be problematic; zinc has to be taken at least twice daily to be effective
(Brewer 1998). Other authors recommend using zinc sulfate at 150 mg thrice daily
as a loading dose and 100 mg thrice daily for maintenance. Further
recommendations suggest giving 50 mg as zinc acetate thrice daily in adults. The
type of zinc salt used has been thought to make no difference with respect to
efficacy (Roberts 2003). However, zinc acetate has been suggested to cause the least
gastrointestinal discomfort. When zinc is combined with a chelator the substances
should be given at widely spaced intervals, potentially causing compliance
problems. Effectiveness of the zinc treatment should be checked as described for
penicillamine and zinc (Roberts 2003).
Tetrathiomolybdate. Tetrathiomolybdate is an experimental copper chelator not
approved by FDA or EMA. It has been suggested as the initial treatment of WD
patients with neurological involvement. Early reports say that tetrathiomolybdate
stabilizes the neurological disease and reduces circulating free copper in a matter of
weeks (Brewer 1994, Brewer 1996). A more recent randomized study supports this
view and also suggests that zinc monotherapy is insufficient for treatment of
neurological WD (Brewer 2006).
Vitamin E, other antioxidants and diet. Since serum and hepatic concentrations
of vitamin E levels may be reduced in WD (von Herbay 1994, Sokol 1994) it has
been suggested to complement vitamin E intake. Some authors have also
recommended taking other antioxidants; studies have not proven their effectiveness
as yet.
WD patients should avoid food with high copper content (nuts, chocolate,
shellfish, mushrooms, organ meats, etc). Patients living in older buildings should
also check whether the water runs through copper pipes. Such dietary and lifestyle
restrictions do not replace chelator or zinc therapy (Roberts 2003).
Fulminant hepatic failure and LTX. Most WD patients with fulminant liver
failure need LTX urgently in order to survive (Sokol 1985, Roberts 2003).
However, in a long-term cohort study only two patients died prior to LTX being
available (Stremmel 1991). It is a difficult clinical question whether WD patients
with liver failure can survive without LTX. The prognostic score used to help with
this difficult decision includes bilirubin, AST, and INR (Nazer 1986). In any case,
WD patients with signs of fulminant liver failure need to be transferred immediately
(same day!) to a transplant center.
Wilson’s Disease  447
WD patients with a chronic course of decompensated cirrhosis follow the usual
rules for LTX. LTX cures the metabolic defects and thus copper metabolism returns
to normal afterwards (Groth 1973). Prognosis for WD after LTX is excellent, in
particular when patients survive the first year (Eghtesad 1999). It is still unclear
under which circumstances LTX may be helpful for WD patients with neurological
complications, which do not respond to drug therapy. In some patients CNS
symptoms regress after LTX while other patients do not improve (for literature see
Brewer 2000).
Asymptomatic Patients. All asymptomatic WD subjects - usually identified by
family screening - need to be treated by chelators or zinc in order to prevent life-threatening complications (Walshe 1988, Brewer 1989, Roberts 2003). It is unclear
whether therapy should begin in children under the age of 3 years.
Maintenance Therapy. After initial removal of excessive copper by chelators,
some centres replace the chelators with zinc for maintenance therapy. It is unclear
when such change is advisable and whether it might be better to reduce the dose of
chelators instead of replacing them with zinc. It is generally accepted that
replacement of chelators with zinc should only be done in patients who are
clinically stable for some years, have normal aminotransferase and liver function, a
normal free copper concentration and a 24-hr urinary copper repeatedly in the range
of 200-500 µg while on chelators (Roberts 2003). Long-term treatment with zinc
may be associated with fewer side effects than chelator treatment. Many patients on
trientine, however, do have significant side effects, and this author believes one
does need to replace trientine with zinc in such patients. In any case, therapy either
with a chelator or with zinc needs to be maintained indefinitely; any interruption
may lead to lethal liver failure (Walshe 1986, Scheinberg 1987).
Pregnancy.  Treatment must be maintained during pregnancy because an
interruption has been shown to carry a high risk of fulminant liver failure (Shimono
1991). Maintenance therapy with chelators (penicillamine, trientine) or with zinc
usually results in a good outcome for mother and child, although birth defects have
(rarely) been documented [for literature see Sternlieb 2000). It is recommended that
the doses of both chelators be reduced, if possible by about 50%, in particular
during the last trimester to avoid potential problems in wound healing (Roberts
2003). Zinc does not need to be reduced.
Monitoring of treatment
Monitoring should be done closely during initial treatment in all WD patients to
look for efficacy (Figure 6) and side effects. During the maintenance phase patients
should be checked at least twice a year.
Table 2. Monitoring the treatment efficacy in WD.
Clinical Improvement (Neurologic features, liver disease, hematology)
Regression of Kayser-Fleischer Ring
Circulating free copper <10 µl/dl
24-hr urinary copper excretion (200-500 µg/day on chelators)
Decrease in liver copper content
448  Hepatology 2012
Clinical examinations include neurological, ophthalmologic and psychiatric
consultations (Figure 7). Patients with liver involvement need to be checked
carefully for signs of liver failure.
Laboratory tests include measurements of serum copper and ceruloplasmin,
calculation of free (nonceruloplasmin-bound) copper (see above), and 24-hr urinary
copper excretion (Roberts 2003). While on chelating therapy 24-hr urinary copper
excretion should initially range between 200 and 500 µg; such a value can also
suggest that the patient is adherent to the drug. After removal of copper
accumulation, urinary copper excretion may be lower. Prognosis of WD is
dependent on the initial severity of the disease and then on adherence to the life-long treatment. Patients treated prior to severe and potentially irreversible
neurological and hepatic complications have a good prognosis approaching a
normal life expectancy (Figure 8). Irreversible liver disease often can be treated
successfully by LTX while some patients with severe neurological disease do not
get better despite optimal therapy.
Figure 5. Findings prior to and after beginning chelating therapy in
53 WD patients (modified from Stremmel 1991).
Figure 6. Cumulative survival in 51 WD patients versus a matched
general population (modified from Stremmel 1991).
Wilson’s Disease  449
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