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Impact of gender on the long-term outcome and survival of patients with autoimmune hepatitis
Journal of Hepatology 48 (2008) 140–147 www.elsevier.com/locate/jhep
Impact of gender on the long-term outcome and survival of patients with autoimmune hepatitisq Thawab Al-Chalabi, James A. Underhill, Bernard C. Portmann, Ian G. McFarlane, Michael A. Heneghan* Institute of Liver Studies, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
Background/Aims: Autoimmune hepatitis (AIH) predominantly affects women. Reasons for this are unclear and few series have assessed long-term outcomes of men with AIH. Methods: To evaluate the clinical course and outcomes of 51 men from a total of 238 consecutive patients with definite AIH at a single centre from 1971 to 2005. The primary outcome measure was death or liver transplantation. Results: Median age at diagnosis was 39 y in men and 49 y in women (p = 0.0589). HLA A1, B8 and DR3 allotypes and the HLA A1–B8–DR3 haplotype were more frequently expressed in men (63% vs. 45%, p = 0.049; 74% vs. 38%, p < 0.001; 62% vs. 44%, p = 0.058; and 50% vs. 23%, p = 0.003; respectively). There were no significant differences in clinical manifestations at presentation. Over 96% of patients demonstrated a complete initial response to treatment. A greater number of men experienced at least one relapse (71% vs. 55%, p = 0.0591). However, women were significantly more likely to die or require liver transplantation (Log rank test p = 0.024). Conclusions: Men with AIH appear to have a higher relapse rate and younger age of disease onset which may relate to increased prevalence of HLA A1–B8–DR3. Despite this, men have significantly better long-term survival and outcomes than women. 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Keywords: Autoimmune hepatitis; Gender; Cirrhosis; HLA; Autoimmune liver disease
1. Introduction Autoimmune hepatitis (AIH) is a disease of the hepatic parenchyma characterised by progressive inflammatory destruction. It is associated with a female preponderance, the presence of circulating autoantibodies, hypergammaglobulinaemia, interface hepatitis on liver biopsy, and it typically responds to immunosuppressive therapy [1].
Received 4 April 2007; received in revised form 6 July 2007; accepted 14 August 2007; available online 22 October 2007 Associate Editor: M.P. Manns q The authors declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. * Corresponding author. Tel.: +44 207 3464952; fax: +44 207 3463167. E-mail address: [email protected] (M.A. Heneghan).
The observed female gender bias is consistent with many other autoimmune diseases where there is likewise an increased susceptibility in women. Although the reasons behind this are unclear, it is well established that hormones and the hypothalamic–pituitary–gonadal system may modulate the immune response [2–10]. Physiological examples include amelioration of disease activity during pregnancy in patients with multiple sclerosis (MS) and rheumatoid arthritis (RA) [9,10]. In patients with AIH, amelioration of disease activity from the second trimester of pregnancy, followed by post-partum flares, has been demonstrated in two series [11,12]. In one of these series, disease exacerbation during pregnancy was also demonstrated, albeit in only 4/35 (11.4%) pregnancies [12]. Given the alteration of disease behaviour in conditions such as MS and RA under different hormonal environments, it might also be expected that disease expression and clinical outcome differ according to
0168-8278/$32.00 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2007.08.013
T. Al-Chalabi et al. / Journal of Hepatology 48 (2008) 140–147
gender. Indeed, male patients with MS demonstrate more severe disease with an increased rate of cerebellar involvement, higher rates of primary progressive disease and require assisted walking devices after a shorter time period than women [13]. Conversely in RA, disease activity is more severe and long-term outcome poorer in female patients although male patients are more likely to die from extra articular manifestations of the disease [14]. To date, there has been little described pertaining to the influence of gender on the course and outcome of AIH. A report by Czaja et al. [15] investigated outcomes in a large US tertiary referral centre and found no differences in clinical outcome between 144 women and 41 men with AIH, although an increased frequency of concurrent autoimmune diseases and an increased prevalence of human leucocyte antigen (HLA) DR4 in female patients compared to male patients were noted [15]. In view of the paucity of existing data regarding the influence of gender on patients with definite AIH, we have investigated factors affecting susceptibility to the disease, presentation, severity of illness and outcome between men and women who fulfilled diagnostic criteria for definite AIH in a European setting.
2. Methods The medical records of 238 patients (51 male, 187 female) with a diagnosis of definite AIH, median International AIH Group (IAIHG) [1,16] score 22 (range 16–28), who presented between 1971 and 2005 at King’s College Hospital (KCH) were examined from a prospectively obtained database. The influence of gender on presentation, clinical course, response to therapy, incidence of hepatocellular carcinoma and clinical outcome (time to either death or liver transplantation (LT)) was evaluated. Patients were excluded from the study if they scored less than 17 points post-treatment, or less than 15 points pretreatment, using the IAIHG scoring system, or if there was evidence of an overlap syndrome based on histological and/or cholangiographic findings. Viral hepatitis was excluded in all patients and in patients who presented before 1990, retrospective testing for hepatitis C (HCV) antibodies was performed on stored sera. Other causes of liver disease, such as excess alcohol, drugs or herbal remedies, had been excluded by appropriate history and investigations. The study has been approved by the Ethical Committee of King’s College Hospital NHS Trust. Histological material was available in 227 patients. In 11 patients (2 male, 9 female) histological data were unavailable at accession either related to procedural risk, or due to an inadequate specimen being obtained or due to patient reluctance to undergo biopsy. Despite the absence of histology, all 11 scored P17 points, using the IAIHG scoring system [1]. Semi-quantitative histological assessment of the severity of chronic hepatitis was performed by blinded retrospective review of histological specimens by a single pathologist (BCP) according to the method of Batts & Ludwig [17] with grade of necroinflammatory activity classified as 0 = none, 1 = minimal or patchy, 2 = mild, 3 = moderate, 4 = severe and stage of fibrosis classified as 0 = none, 1 = portal only, 2 = periportal, 3 = septal, 4 = cirrhosis. The median interval between first and second liver biopsies was 2 years (range 1–14 years). Histological improvement was defined as a decrease in the grade or stage by at least one, and deterioration by an increase in the grade or stage by at least one. All patients were tested for the following: anti-nuclear (ANA), smooth muscle (SMA), mitochondrial (AMA)
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and liver–kidney microsomal (anti-LKM1) autoantibodies by indirect immunofluorescence on sections of rodent liver, kidney and stomach. HLA allotypes were tested in 150 patients (112 female and 38 male). Time to diagnosis was defined as the time of initial symptom onset or discovery of abnormal liver function tests, to the formal diagnosis of AIH. Follow up began from the time of diagnosis and terminated with either the most recent outpatient appointment at King’s College Hospital, or at the time of death of the patient or liver transplantation. The mode of presentation reflects the acuity of initial illness onset or symptomatology, and was defined as ‘acute’ if symptom onset to diagnosis was 6 6 months,‘insidious’ >6 months, and ‘asymptomatic’ if the diagnosis was made on the incidental finding of abnormal liver tests either during routine health screening or during investigation of a non-hepatic illness. All AIH patients had been initially treated according to a standard protocol with prednisolone at 0.5 mg/kg/day (20–40 mg/day) and azathioprine at 1 mg/kg/day (50–100 mg/day). The steroid dose was subsequently individually tapered to the lowest required to maintain biochemical remission. In patients who sustained complete biochemical and clinical remission for at least 1 year on maintenance therapy, the azathioprine dose (in those who tolerated the drug) was increased to 2 mg/kg/day, the steroids were then gradually withdrawn and (if remission was sustained) treatment was continued with azathioprine alone, as described in a previous study from this centre.[18] Following this publication, it has not been our policy to completely withdraw immunosuppressive therapy from patients with AIH who remain in remission. A complete response to treatment was defined according to the revised criteria of the IAIHG as either or both of the following: marked improvement of symptoms and return of serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT), bilirubin and immunoglobulin values completely to normal within 1 year and sustained for at least a further 6 months on maintenance therapy, or a liver biopsy specimen at some time during this period showing at most minimal activity; or, either or both of the following: marked improvement of symptoms together with at least 50% improvement of all liver test results during the first month of treatment, with AST or ALT levels continuing to fall to less than twice the upper limit of normal within 6 months during any reductions towards maintenance therapy, or a liver biopsy within 1 year showing only minimal activity [1]. Relapse was also defined using the IAIHG criteria as either or both of the following: an increase in serum AST or ALT levels of greater than twice the upper limit of normal or a liver biopsy showing active disease, with or without reappearance of symptoms, after a ‘‘complete’’ response as defined above; or reappearance of symptoms of sufficient severity to require increased (or reintroduction of) immunosuppression, accompanied by any increase in serum AST or ALT levels, after a ‘‘complete’’ response as defined above [1]. A partial or no response to initial therapy was defined according to the original IAIHG criteria [16]. Patients were defined as having achieved remission if they had normal serum biochemistry (globulins/IgG/AST), had no symptoms indicative of a relapse, and (where available) liver biopsies showed only minimal activity with no necrosis [18].
2.1. Statistical analysis For quantitative data, analyses were performed using the Mann– Whitney and Kruskal–Wallis ANOVA tests for comparison of two and more than two independent groups, respectively. Differences in proportions were analysed by the Fisher’s exact test when the number of subjects was < 5, and the v2 test for 2 · 2 tables when the number of subjects in all cells was >5. The r · c v2 test was used to investigate independent categories forming r rows and c columns where appropriate. Data are expressed as medians and ranges. All analyses were performed using StatsDirect statistical software (Camcode, Ashwell, Hertfordshire, England). Univariate and multivariate analysis was calculated using a Cox proportional hazard model with SPSS software (Chicago, Illinios, United States of America). For continuous variables that reached statistical significance on univariate analysis, receiver operator curves (ROC) were constructed. Where the area under the curve was greater than 0.6, the Youden index was calculated. This located a cut off, above and below which a dichotomous variable could be defined as 1 and 0, respectively, thus converting the continuous variable into a categorical variable. Survival analysis was performed using the Kaplan–Meier method and Cox proportional hazard model.
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3. Results
Sex Men Women
50
3.1. Patient demographics and laboratory parameters at presentation 40
The commonest presenting feature in both groups was jaundice. There were no significant differences with respect to clinical manifestations at presentation (jaundice, encephalopathy, arthralgia/flu like symptoms/malaise/lethargy, ascites, pruritus, pale stools, dark urine, rash, haematemesis, or stigmata of chronic liver disease) as shown in Table 3. There were also similar prevalences of other autoimmune diseases and reported occurrences of autoimmune diseases in first degree family members in both groups. Other autoimmune diseases occurred in 16/50 (32%) male patients and 73/186 (39.2%) female patients (p = 0.4387) and in the first degree relatives of 13/51 (25.5%) men compared to 33/183 (18%) women (p = 0.3242). The IAIHG score was higher in female patients compared to men by precisely two points. 3.3. Human leucocyte antigens and autoantibodies Male patients were significantly more likely to express HLA A1 and HLA B8, and had a trend toward Table 1 Patient demographics in men compared to women
Values in bold are significant.
20
10
0 10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
Age at Presentation (years), up to and including value, eg. 20= 11-20
Fig. 1. Age distribution at presentation in men and women with AIH. [This figure appears in colour on the web.]
3.2. Clinical manifestations
Age at diagnosis Median (range) Follow up (years) Median (range) Time to diagnosis (months) Median (range) IAIHG score Median (range)
30
Count
The female to male ratio was approximately 4:1 in our patient cohort. Both groups of patients were followed for a similar length of time (median 14 years, range 1–35 y for males vs. 11 y, range 0.1–30 y for females, p = 0.0773) (Table 1). Female patients tended to be older at presentation (median age 39 y for males vs. 49 y for females, p = 0.0589). The age distribution for men and women is illustrated in Fig. 1. There were no statistically significant differences between the two groups with regard to biochemical parameters other than for gamma GT activity which was significantly higher in male patients compared to female patients at presentation (Table 2). Time to diagnosis and mode of disease onset were similar in men and women (Tables 1 and 3).
Male N = 51
Female N = 187
P value
39 (10–67) 14 (1–35) 3 (0.5–260) 21 (18–26)
49 (5–80) 11 (1–30) 4 (0.25–180) 23 (16–28)
0.059 0.077 0.0638 0.001
increased expression of HLA DR3 compared to female patients (63% vs. 45%, p = 0.049, 74% vs. 38%, p < 0.001 and 62% vs. 44%, p = 0.058, respectively, Table 2). The HLA A1–B8–DR3 haplotype occurred in 50% of men compared to only 23% of women with AIH, p = 0.003. There were no significant differences in the frequency of the HLA DR4 allotype or ANA, SMA, LKM and AMA titres (Table 2). Seven female patients had detectable AMA at a titre of P1:80 (range 1:80–1:5120). None of these patients developed any cholestatic biochemistry or histopathology and none went on to develop any symptoms suggestive of PBC during follow-up (median 12 y, range 4–28 y) and all had an IAIHG score >17 despite deducting four points for AMA positivity16. Information on the presence of other autoantibodies was available in 35 male and 127 female patients. They were present in 13/35 (37%) men and 45/127 (35%) women, respectively; this was not statistically significant. The data were analysed separately for the presence of liver-specific membrane protein (LSP), asioglycoprotein receptor (ASGPR) and GPC, which were present in 5/35 (14%) men and 29/127 (23%) women (not significant). LKM-1 was present in 2/51 (4%) men and 16/187 (9%) women with AIH; this difference was also not statistically significant. 3.4. Response to therapy in men and women with AIH Similar proportions of male and female patients were initiated on standard therapy of either prednisolone monotherapy or prednisolone and azathioprine. More than 95% of patients in both groups demonstrated a
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Table 2 Laboratory data in male patients compared to female patients with AIH
AST IU/L (NR < 50) ALP IU/L (NR < 130) Bilirubin mmol/L (NR 5–17) GGT IU/L (NR 5–50) Albumin g/L (NR 35–42) Globulin g/L Initial IgG g/L (NR < 17) Peak IgG g/L (NR < 17) Initial ANAa (titre) Peak ANA a (titre) Initial ASMA a (titre) Peak ASMA a (titre) INR (NR 0.8–1.2) HLA HLA HLA HLA HLA a
A1 B8 DR3 DR4 A1–B8–DR3
Men median (range)
Women median (range)
612 (34–2319) 168 (70–844) 49 (9–1096) 209 (30–995) 34 (21–55) 46 (28–79) 23.4 (8.1–59.4) 24.2 (9.9–59.4) 40 (0–2000) (61%) 70 (0–5120) (76%) 30 (0–2000) (60%) 80 (0–2560) (81%) 1.4 (0.92–2.46) N = 38 24 (63%) 28 (74%) 24 (63%) 12 (32%) 19 (50%)
628 (23–4603) 212 (23–1677) 67 (7–609) 138 (8–911) 33 (20–48) 48.5 (28–81) 25.9 (4.72–70.7) 27.55 (7.78–70.7) 40 (0–10240) (66%) 160 (10–10240) (78%) 10 (0–2560) (52%) 80 (0–10240) (75%) 1.17 (0.8–2.8) N = 112 50 (45%) 42 (38%) 49 (44%) 41 (37%) 26 (23%)
P value 0.819 0.275 0.993 0.036 0.659 0.823 0.499 0.334 0.574 0.365 0.158 0.850 0.112 0.049 <0.001 0.058 0.596 0.003
Numbers in brackets (%) indicate prevalence of autoantibodies. Values in bold are significant.
complete response to therapy (Table 4). Likewise, maintenance therapy was similar in both groups, with the majority of patients maintained on both azathioprine and prednisolone in combination or on azathioprine monotherapy. One hundred and ninety patients were treated with azathioprine at any time during the follow-up period; an adverse event was recorded in 47 (25%). Side effects included 16 patients with bone marrow toxicity or leucopenia, 15 with documented ‘‘azathioprine intolerance’’, 10 with dermatological complications (skin cancers/solar keratoses/warts), 2 with septic complications (pneumonia/candida) and one patient each with nodular regenerative hyperplasia, severe lethargy reversed with azathioprine withdrawal, alopecia and myalgia.
Table 3 Mode of onset of AIH and presenting signs and symptoms
Mode of onset: Acute Insidious Asymptomatic Signs and symptoms: Jaundice Pale stools/dark urine Flu/lethargy/arthr/my/algia Stigmata chronic liver disease Pruritus Abdominal distension Ascites Upper GI bleed Encephalopathy Rash
Male N = 51
Female N = 187
P value
23 (45.1%) 18 (35.3%) 10 (19.6%)
80 (43.7%) 69 (37.7%) 34 (18.6%)
0.990 0.880 0.987
34 (66.7%) 28 (54.9%) 31 (60.8%) 18 (35.3%) 5 (9.8%) 12 (23.5%) 7 (13.7%) 2 (3.9%) 0 (0%) 4 (8.2%)
127 (70.6%) 80 (44.7%) 97 (54.8%) 60 (33.3%) 33 (18.4%) 52 (29.4%) 24 (13.6%) 8 (4.5%) 4 (2.2%) 14 (8%)
0.718 0.259 0.550 0.925 0.211 0.521 0.990 0.908 0.578 0.990
Male patients were more likely to have at least one relapse than female patients (71.4% male vs. 55.1% female, p = 0.0591) during reduction or withdrawal of treatment (Table 4). Eight female patients and 2 male patients were able to sustain remission for a median of 2 years, range 0.5–19 y, off treatment, having been on treatment for a median of 7 years (range 0.5–23.5 y).
Table 4 Treatment, response to therapy and outcome in male patients versus female patients with AIH Male N = 51
Female N = 187
P value
Initial therapy: Prednisolone alone Prednisolone + azathioprine Other
28 (59.6%) 15 (31.9%) 4 (8.5%)
112 (64.7%) 54 (31.2%) 7 (4.1%)
0.630 0.99 0.254
Maintenance therapy: Prednisolone alone Prednisolone + azathioprine Azathioprine monotherapy Other Off treatment
8 (15.7%) 22 (43.1%) 15 (29.4%) 4 (7.8%) 2 (3.9%)
34 (19.5%) 70 (40.2%) 54 (31%) 8 (4.6%) 8 (4.6%)
0.677 0.834 0.961 0.476 0.990
Response to therapy: Complete response Partial response No response Any relapse P2 relapses
48 (98%) 1 (2%) 0 (0%) 35 (71.4%) 17 (34.7%)
174 (95.6%) 6 (3.3%) 2 (1.1%) 97 (55.1%) 60 (34.1%)
0.734 0.990 0.990 0.059 0.990
7 (13.7%)
48 (25.7%)
n.s.
5 (71%)
28 (58.1%)
n.s
Outcome: Total deaths or liver transplantation Proportion of deaths that are liver related deaths or transplantation
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3.5. Liver histology in men and women with AIH The prevalence of histologically confirmed cirrhosis at presentation was 19/49 (38.8%) in male patients vs. 65/178 (36.5%) in females (p = 0.6769) (Table 5). During follow up the majority of patients in both groups demonstrated histological improvement in relation to necroinflammatory grade. Despite this only, 3.3% of male patients and 7.7% of female patients demonstrated any reduction in fibrosis on follow-up biopsy. There was no improvement in histological stage in any patients with established cirrhosis.
Cum Survival
1.0
(a) Grade: Improvement Deterioration No change (b) Stage: Improvement Deterioration No change
P
19/49 (38.8%)
65/178 (36.5%)
0.677
34/51 (66.7%)
99/187 (52.9%)
0.073
women
0.4
0
20
40
Follow up in Years
Fig. 2. Cumulative overall survival in men and women with AIH Log rank test, p = 0.024, hazard ratio 0.467. [This figure appears in colour on the web.]
(not liver related), pseudomonas sepsis secondary to Epstein Barr virus infection, ischaemic heart disease and sepsis, perforated diverticular abscess, cancer of the pharynx, septicaemia, mesenteric vein thrombosis, carcinoma of the lung, carcinoma of the breast, ruptured oesophagus during endoscopy, cancer of the stomach, and dissecting aneurysm, n = 1 in women. The cause of death was not documented and could not be traced in 1 man and 4 women. For liver related death or need for transplant, the median age at death (interquartile range) was 52.5 years (34.25–67.0) for men and 39 years (33.5–63.0) for women, p = 0.782, and for non-liver related death, median (interquartile range) ages were 67.5 (60.0–75.0) and 70.5 (62.5–78.0) years, respectively. 1.0
men 0.8
women
Cum Survival
Nos. (%) with cirrhosis on index biopsy Nos. (%) having follow-up biopsy Nos. (%) with histological changes in first follow-up biopsy:
Female N = 187
0.6
0.0
Table 5 Liver histology at presentation and at first follow-up biopsy in men and women with AIH Male N = 51
men
0.2
3.6. Differences in survival in men and women with AIH Fig. 2 presents overall survival in patients with AIH. This demonstrates that when comparing overall mortality, or need for liver transplantation, men with AIH appear to have better survival (Log Rank test p = 0.024, hazard ratio 0.467). Despite this, the proportion of patients who required liver transplantation or died as a consequence of liver related deaths is not significantly different, men 5/7 (71%), women 28/48 (58%), p = n.s. (Table 4). Causes of liver related death or transplantation were as follows: women, liver transplantation (OLT) n = 16, decompensated liver disease, n = 6, hepatocellular carcinoma (HCC), n = 3, acute variceal bleed, n = 2, acute hepatitis B infection complicating AIH, n = 1; men, HCC, n = 3, OLT n = 2). Survival curves, based on need for liver transplantation or based on liver related mortality demonstrate no difference in survival, p = 0.109, Fig. 3. The causes of death unrelated to hepatic aetiology include colorectal cancer n = 1 in men, and stroke n = 2, heart failure n = 2, myocardial infarction, portal hypertension during pregnancy
0.8
0.6
0.4
0.2
29/33 (87.9%) 1/33 (3%) 3/33 (9.1%)
76/96 (79.2%) 5/96 (5.2%) 15/96 (15.6%)
0.219 0.562 0.297
0.0 0
1/30 (3.3%) 15/30 (50%) 14/30 (46.7%)
7/91 (7.7%) 46/91 (50.5%) 38/91 (41.8%)
0.314 0.958 0.640
20
40
Follow up in Years
Fig. 3. Cumulative liver related survival in men and women with AIH Log rank test, p = 0.109. [This figure appears in colour on the web.]
T. Al-Chalabi et al. / Journal of Hepatology 48 (2008) 140–147
3.7. Factors associated with reduced survival Univariate and multivariate analysis was performed to evaluate factors associated with reduced survival or need for liver transplantation (Tables 6 and 7). By univariate analysis, female gender approached statistical significance (p = 0.068, HR 2.016, 95% CI 0.949– 4.284) but, overall, reduced survival was associated with factors related to the presence of established cirrhosis at presentation (ascites, haematemesis, stigmata of chronic liver disease, cirrhosis on index biopsy and low albumin) and with older age at presentation (Table 6), while factors associated with a symptomatic presentation were associated with improved survival (jaundice, flu-like symptoms/athralgia/myalgia/malaise, symptomatic presentation, raised AST). Neither HLA allotype (A1, B8, DR3 or DR4) nor the presence of autoantibodies had an effect on outcome. There was also no effect of HLA allotype on outcome when the data were analysed separately for men and women. ROC curves were constructed for age, AST and albumin. However, the areas under the curves were <0.6 in all cases and therefore it was not possible to generate the Youden index to establish a dichotomous variable. Multivariate analysis demonstrated absence of jaundice at presentation, presence of ascites, haematemesis and low necroinflammatory grade at presentation to be factors associated with reduced survival in both groups of patients (Table 7).
Table 6 Univariate analysis of factors associated with reduced survival in male and female patients with AIH a Variable at presentation
P value
Hazard ratio (HR)
95% CI for HR
Female gender Age at diagnosis Jaundice Stigmata of CLD Encephalopathy Flu/lethargy/arthr/my/algia Ascites Haematemesis Time to diagnosis Asymptomatic presentation Acute presentation Alkaline phosphatase Aspartate-amino-transaminase Albumin Bilirubin Cirrhosis on index biopsy Grade on index biopsy Stage on index biopsy Change in grade Change in stage Relapse
0.068 0.018 0.04 0.019 0.132 0.031 0.001 0.001 0.994 0.022 0.092 0.884 0.001 0.01 0.909 0.001 0.005 0.002 0.058 0.560 0.629
2.02 1.02 0.56 1.90 2.98 0.56 2.95 4.66 1.00 2.02 0.63 1.000 0.999 0.94 1.000 2.42 0.66 1.38 1.34 0.93 0.86
0.95–2.28 1.00–1.04 0.33–0.98 1.11–3.26 0.72–12.31 0.33–0.95 1.56–5.58 1.95–11.12 0.99–1.01 1.11–3.70 0.36–1.08 0.999–1.001 0.998–1.000 0.89–0.99 0.998–1.002 1.41–4.14 0.50–0.88 1.13–1.70 0.99–1.80 0.71–1.20 0.46–1.60
a Results have been included if they are significant or where their lack of significance is of clinical interest or in contrast to the significant results. Values in bold are significant.
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Table 7 Multivariate analysis of factors associated with reduced survival in male and female patients with AIH Variable
P value Hazard ratio (HR) 95% CI of HR
Jaundice Ascites Haematemesis Grade on index biopsy
0.018 0.001 0.021 0.001
0.375 5.035 3.884 0.514
0.166–0.845 1.982–12.789 1.227–12.297 0.353–0.749
4. Discussion This large, single, tertiary centre study provided the opportunity to undertake a comprehensive analysis of the influence of gender on outcomes and disease severity in AIH. The most striking difference demonstrated in this study was that men with AIH appeared to have better long-term survival and outcome than their female counterparts. Furthermore, expression of HLA A1, B8, DR3 allotypes and the HLA A1–B8–DR3 haplotype was all increased in male patients compared to female patients. Men with AIH presented at a younger age than women and had higher serum GGT activities at accession. In this patient cohort, clinical presentation, time to diagnosis and clinical course were similar in both groups. The reasons for increased survival in male patients are unclear, but they do not appear to reflect differences in either time to diagnosis, treatment regimen, treatment response or frequency of relapse between the two groups. Reduced survival in women compared to men cannot be accounted for by older age of women at presentation, as women were on average younger than men when they died. In addition, the age at death in women with liver related causes compared to non-liver causes was significantly lower (39 years vs. 70.5 years, p = 0.001). This suggests that the poor prognosis in women is accounted for by reduced survival due to complications from cirrhosis of the liver caused by AIH. It should be noted that the median age at liver related death/OLT is low in both groups of patients and may be accounted for by tertiary referral bias to a transplant centre. However, this bias would affect both sexes and therefore does not account for the decreased survival observed in women. In addition, there was no significant difference in age at liver related death/OLT between men and women with AIH. Despite the greater survival observed in male patients with AIH, they were more likely to suffer a relapse or flare in disease activity than female patients. Gender differences in frequency of disease expression and clinical outcome exist in other autoimmune diseases. In MS, the disease is more severe in men who acquire the disease, compared to women [13], whereas in RA, disease activity is more severe in women, although men are more likely to die from extra-articular
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manifestations of the disease [14]. A proposed mechanism behind these gender differences includes the modulation of the immune system by the hypothalamic–pituitary–gonadal system and by sex hormones. Evidence for the involvement of the hypothalamic–pituitary–gonadal system and sex hormones in immunity is well established. In very simplified terms, androgens appear to inhibit, and oestrogens to enhance, immune activity [8]. Oestrogen also appears to have a biphasic effect and at higher levels, such as those demonstrated in pregnancy, oestrogen is associated with an antiinflammatory mileu [8,19,20]. In AIH, improvement of disease activity has been documented during pregnancy; however, index presentations of AIH and flares of disease activity have been reported during pregnancy and post-partum [12,21]. In this study, our data suggest that female gender in itself is associated with both disease expression and increased disease severity (as demonstrated by reduced survival) compared with male gender. Interestingly, evaluation of HLA haplotypes revealed that the extended haplotype HLA A1–B8–DR3 (associated with increased susceptibility to AIH) [22] was more than twice as prevalent in male patients compared with female patients with AIH. This suggests that increased susceptibility to AIH is conferred by this haplotype, and that without this haplotype, men are even less likely to express the disease. Therefore, women are more likely than men to develop AIH in the absence of HLA A1– B8–DR3. The higher rate of relapse and younger age at presentation in men with AIH in this study are consistent with previous reports in which the HLA A1–B8– DR3 haplotype has been associated with a greater frequency of relapse and younger age of disease onset [22]. However, the presence of the HLA A1–B8–DR3 haplotype or DR3 allotype was not associated with a poorer outcome, even when the data were analysed separately for men and women. These results differ slightly from data on U.S. patients with AIH, in whom men and women had a similar frequency of HLA DR3 but men had a lower prevalence of HLA DR4 [15]. The higher proportion of male patients with HLA DR3 in this study approached but did not reach significance. No statistical difference was detected in the prevalence of HLA DR4 between men and women with AIH in this Northern European cohort. Although differences in survival between the sexes were illustrated in this study, univariate analysis confirmed that the presence of cirrhosis at presentation was associated with a poorer outcome irrespective of gender. Ninety percent (197/220) of the patients in whom grading and staging was possible had moderate to severe disease on index biopsy, and cirrhosis was present in over one-third of patients at diagnosis irrespective of gender. The prevalence of other autoimmune conditions and family history of autoimmune disease in
first degree relatives was similar between male and female patients with AIH. With respect to the more elevated GGT in men compared to women, alcohol history was available in 161 patients (35 male, 126 female). Of these, 106 patients did not consume alcohol at the time of presentation. Of the 55 who did consume alcohol, 13 were male (37% of men) and 42 female (33% of women). The amounts of alcohol consumed were compared using a Mann–Whitney U test, and no significant differences were found (median (IQ range) men 0 IU/week, (0– 10); women 0 IU/week, (0–4), p = 0.562). Unfortunately, because of the retrospective nature of this study, no information regarding body mass index was available on any patients. Thus the reasons behind this elevated GGT in men compared to women cannot be accounted for by differences in alcohol consumption and are not clear. A complete response to treatment was demonstrated in more than 95% of patients in both groups, as evidenced by biochemical parameters and degree of necroinflammation on liver biopsy. Whilst these results represent an exceptionally high rate of treatment responsiveness, it must be reiterated that patients were selected for this study only if they were classified as having definite AIH. This reduces the likelihood of including patients, such as those with overlap features, who would be less likely to achieve remission. However, although treatment response was excellent in both groups, approximately half had histological progression in disease stage and few demonstrated significant regression of fibrosis on biopsy. The length of time between biopsies does not account for this progression in fibrosis, as repeat biopsy occurred at or within 2 years in 67% of patients in whom a second biopsy was performed (median duration between first and second biopsy was 2 years, interquartile range 1–3 years). However, this finding is consistent with other studies in which progression of fibrosis has been demonstrated in patients with a good response to treatment [23]. Indeed, a symptomatic presentation in conjunction with greater inflammatory activity as evidenced by a higher AST level (HR 0.999, p = 0.001) or higher histological necroinflammatory grade (HR 0.66, p = 0.005) were both associated with improved survival. Further comment in relation to the IAIHG scoring system is merited based on our findings. Because of the gender bias in AIH, the IAIHG scoring system has allocated diagnostic points in favour of women. Interestingly, in this analysis of patients with only definite AIH, female patients had median IAIHG scores of exactly 2 points greater value than men. This represents the 2 points awarded them within the scoring system for their gender and implies that the median diagnostic scores would have been identical if the gender weighting had not been allocated by the scoring system. Whether
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diagnostic benefit is actually accrued by the addition of 2 points for female gender is therefore in doubt. Indeed, in a simplified scoring system also proposed by members of the IAIHG, points are allocated for autoantibodies, immuno/gammaglobulins, liver histology and the absence of viral hepatitis without reference to gender, and preliminary data suggest that a less cumbersome scoring system might be applicable in clinical practice [24]. In conclusion, in this study we have identified that male gender confers reduced susceptibility to the development of AIH; response to treatment is excellent in male patients and comparable to female patients. Interestingly, 50% of male patients have the extended HLA haplotype A1–B8–DR3 compared to 23% of women, and this haplotype may explain the higher relapse rate in men. Despite this finding, long-term outcome and prognosis is more favourable in men with AIH compared to women. The reasons for this remain obscure but may reflect either gender alone or the effect of gender on immune responses. References [1] Alvarez F, Berg PA, Bianchi FB, Bianchi L, Burroughs AK, Cancado EL, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol 1999;31:929–938. [2] McMurray RW. Estrogen, prolactin, and autoimmunity: actions and interactions. Int Immunopharmacol 2001;1:995–1008. [3] Giltay EJ, Fonk JC, von Blomberg BM, Drexhage HA, Schalkwijk C, Gooren LJ. In vivo effects of sex steroids on lymphocyte responsiveness and immunoglobulin levels in humans. J Clin Endocrinol Metab 2000;85:1648–1657. [4] Jansson L, Holmdahl R. Estrogen-mediated immunosuppression in autoimmune diseases. Inflamm Res 1998;47:290–301. [5] Kovacs WJ, Olsen NJ. Androgen receptors in human thymocytes. J Immunol 1987;139:490–493. [6] Ostensen M. Sex hormones and pregnancy in rheumatoid arthritis and systemic lupus erythematosus. Ann N Y Acad Sci 1999;876:131–143. [7] Leposavic G, Obradovic´ S, Kosec D, Pejcic´-Karapetrovic´ B, Vidic´-Dankovic´ B. In vivo modulation of the distribution of thymocyte subsets by female sex steroid hormones. Int Immunopharmacol 2001;1:1–12.
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[8] Tanriverdi F, Silveira LF, MacColl GS, Bouloux PM. The hypothalamic–pituitary–gonadal axis: immune function and autoimmunity. J Endocrinol 2003;176:293–304. [9] Vukusic S, Hutchinson M, Hours M, Moreau T, CortinovisTourniaire P, Adeleine P, et al. Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post-partum relapse. Brain 2004;127:1353–1360. [10] Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis. Rheum Dis Clin North Am 1997;23:195–212. [11] Buchel E, Van Steenbergen W, Nevens F, Fevery J. Improvement of autoimmune hepatitis during pregnancy followed by flare-up after delivery. Am J Gastroenterol 2002;97:3160–3165. [12] Heneghan MA, Norris SM, O’Grady JG, Harrison PM, McFarlane IG. Management and outcome of pregnancy in autoimmune hepatitis. Gut 2001;48:97–102. [13] Weinshenker BG, Rice GP, Noseworthy JH, Carriere W, Baskerville J, Ebers GC. The natural history of multiple sclerosis: a geographically based study. 3. Multivariate analysis of predictive factors and models of outcome. Brain 1991;114:1045–1056. [14] Da Silva JA, Hall GM. The effects of gender and sex hormones on outcome in rheumatoid arthritis. Baillieres Clin Rheumatol 1992;6:196–219. [15] Czaja AJ, Donaldson PT. Gender effects and synergisms with histocompatibility leukocyte antigens in type 1 autoimmune hepatitis. Am J Gastroenterol 2002;97:2051–2057. [16] Johnson PJ, McFarlane IG. Meeting report: International Autoimmune Hepatitis Group. Hepatology 1993;18:998–1005. [17] Batts KP, Ludwig J. Chronic hepatitis. An update on terminology and reporting. Am J Surg Pathol 1995;19:1409–1417. [18] Johnson PJ, McFarlane IG, Williams R. Azathioprine for longterm maintenance of remission in autoimmune hepatitis. N Engl J Med 1995;333:958–963. [19] Whitacre CC, Reingold SC, O’Looney PA. A gender gap in autoimmunity. Science 1999;283:1277–1278. [20] Whitacre CC. Sex differences in autoimmune disease. Nat Immunol 2001;2:777–780. [21] Schramm C, Herkel J, Beuers U, Kanzler S, Galle PR, Lohse AW. Pregnancy in autoimmune hepatitis: outcome and risk factors. Am J Gastroenterol 2006;101:556–560. [22] Donaldson PT, Doherty DG, Hayllar KM, McFarlane IG, Johnson PJ, Williams R. Susceptibility to autoimmune chronic active hepatitis: human leukocyte antigens DR4 and A1–B8–DR3 are independent risk factors. Hepatology 1991;13:701–706. [23] Czaja AJ, Carpenter HA. Progressive fibrosis during corticosteroid therapy of autoimmune hepatitis. Hepatology 2004;39:1631–1638. [24] Hennes EM, Zeniya M, Czaja AJ, Pares A, Dalekos G, Krawitt E, et al. Simplified diagnostic criteria for autoimmune hepatitis. Hepatology 2005;42:295A.
Impact of gender on the long-term outcome and survival of patients with autoimmune hepatitisq Thawab Al-Chalabi, James A. Underhill, Bernard C. Portmann, Ian G. McFarlane, Michael A. Heneghan* Institute of Liver Studies, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
Background/Aims: Autoimmune hepatitis (AIH) predominantly affects women. Reasons for this are unclear and few series have assessed long-term outcomes of men with AIH. Methods: To evaluate the clinical course and outcomes of 51 men from a total of 238 consecutive patients with definite AIH at a single centre from 1971 to 2005. The primary outcome measure was death or liver transplantation. Results: Median age at diagnosis was 39 y in men and 49 y in women (p = 0.0589). HLA A1, B8 and DR3 allotypes and the HLA A1–B8–DR3 haplotype were more frequently expressed in men (63% vs. 45%, p = 0.049; 74% vs. 38%, p < 0.001; 62% vs. 44%, p = 0.058; and 50% vs. 23%, p = 0.003; respectively). There were no significant differences in clinical manifestations at presentation. Over 96% of patients demonstrated a complete initial response to treatment. A greater number of men experienced at least one relapse (71% vs. 55%, p = 0.0591). However, women were significantly more likely to die or require liver transplantation (Log rank test p = 0.024). Conclusions: Men with AIH appear to have a higher relapse rate and younger age of disease onset which may relate to increased prevalence of HLA A1–B8–DR3. Despite this, men have significantly better long-term survival and outcomes than women. 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Keywords: Autoimmune hepatitis; Gender; Cirrhosis; HLA; Autoimmune liver disease
1. Introduction Autoimmune hepatitis (AIH) is a disease of the hepatic parenchyma characterised by progressive inflammatory destruction. It is associated with a female preponderance, the presence of circulating autoantibodies, hypergammaglobulinaemia, interface hepatitis on liver biopsy, and it typically responds to immunosuppressive therapy [1].
Received 4 April 2007; received in revised form 6 July 2007; accepted 14 August 2007; available online 22 October 2007 Associate Editor: M.P. Manns q The authors declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. * Corresponding author. Tel.: +44 207 3464952; fax: +44 207 3463167. E-mail address: [email protected] (M.A. Heneghan).
The observed female gender bias is consistent with many other autoimmune diseases where there is likewise an increased susceptibility in women. Although the reasons behind this are unclear, it is well established that hormones and the hypothalamic–pituitary–gonadal system may modulate the immune response [2–10]. Physiological examples include amelioration of disease activity during pregnancy in patients with multiple sclerosis (MS) and rheumatoid arthritis (RA) [9,10]. In patients with AIH, amelioration of disease activity from the second trimester of pregnancy, followed by post-partum flares, has been demonstrated in two series [11,12]. In one of these series, disease exacerbation during pregnancy was also demonstrated, albeit in only 4/35 (11.4%) pregnancies [12]. Given the alteration of disease behaviour in conditions such as MS and RA under different hormonal environments, it might also be expected that disease expression and clinical outcome differ according to
0168-8278/$32.00 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2007.08.013
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gender. Indeed, male patients with MS demonstrate more severe disease with an increased rate of cerebellar involvement, higher rates of primary progressive disease and require assisted walking devices after a shorter time period than women [13]. Conversely in RA, disease activity is more severe and long-term outcome poorer in female patients although male patients are more likely to die from extra articular manifestations of the disease [14]. To date, there has been little described pertaining to the influence of gender on the course and outcome of AIH. A report by Czaja et al. [15] investigated outcomes in a large US tertiary referral centre and found no differences in clinical outcome between 144 women and 41 men with AIH, although an increased frequency of concurrent autoimmune diseases and an increased prevalence of human leucocyte antigen (HLA) DR4 in female patients compared to male patients were noted [15]. In view of the paucity of existing data regarding the influence of gender on patients with definite AIH, we have investigated factors affecting susceptibility to the disease, presentation, severity of illness and outcome between men and women who fulfilled diagnostic criteria for definite AIH in a European setting.
2. Methods The medical records of 238 patients (51 male, 187 female) with a diagnosis of definite AIH, median International AIH Group (IAIHG) [1,16] score 22 (range 16–28), who presented between 1971 and 2005 at King’s College Hospital (KCH) were examined from a prospectively obtained database. The influence of gender on presentation, clinical course, response to therapy, incidence of hepatocellular carcinoma and clinical outcome (time to either death or liver transplantation (LT)) was evaluated. Patients were excluded from the study if they scored less than 17 points post-treatment, or less than 15 points pretreatment, using the IAIHG scoring system, or if there was evidence of an overlap syndrome based on histological and/or cholangiographic findings. Viral hepatitis was excluded in all patients and in patients who presented before 1990, retrospective testing for hepatitis C (HCV) antibodies was performed on stored sera. Other causes of liver disease, such as excess alcohol, drugs or herbal remedies, had been excluded by appropriate history and investigations. The study has been approved by the Ethical Committee of King’s College Hospital NHS Trust. Histological material was available in 227 patients. In 11 patients (2 male, 9 female) histological data were unavailable at accession either related to procedural risk, or due to an inadequate specimen being obtained or due to patient reluctance to undergo biopsy. Despite the absence of histology, all 11 scored P17 points, using the IAIHG scoring system [1]. Semi-quantitative histological assessment of the severity of chronic hepatitis was performed by blinded retrospective review of histological specimens by a single pathologist (BCP) according to the method of Batts & Ludwig [17] with grade of necroinflammatory activity classified as 0 = none, 1 = minimal or patchy, 2 = mild, 3 = moderate, 4 = severe and stage of fibrosis classified as 0 = none, 1 = portal only, 2 = periportal, 3 = septal, 4 = cirrhosis. The median interval between first and second liver biopsies was 2 years (range 1–14 years). Histological improvement was defined as a decrease in the grade or stage by at least one, and deterioration by an increase in the grade or stage by at least one. All patients were tested for the following: anti-nuclear (ANA), smooth muscle (SMA), mitochondrial (AMA)
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and liver–kidney microsomal (anti-LKM1) autoantibodies by indirect immunofluorescence on sections of rodent liver, kidney and stomach. HLA allotypes were tested in 150 patients (112 female and 38 male). Time to diagnosis was defined as the time of initial symptom onset or discovery of abnormal liver function tests, to the formal diagnosis of AIH. Follow up began from the time of diagnosis and terminated with either the most recent outpatient appointment at King’s College Hospital, or at the time of death of the patient or liver transplantation. The mode of presentation reflects the acuity of initial illness onset or symptomatology, and was defined as ‘acute’ if symptom onset to diagnosis was 6 6 months,‘insidious’ >6 months, and ‘asymptomatic’ if the diagnosis was made on the incidental finding of abnormal liver tests either during routine health screening or during investigation of a non-hepatic illness. All AIH patients had been initially treated according to a standard protocol with prednisolone at 0.5 mg/kg/day (20–40 mg/day) and azathioprine at 1 mg/kg/day (50–100 mg/day). The steroid dose was subsequently individually tapered to the lowest required to maintain biochemical remission. In patients who sustained complete biochemical and clinical remission for at least 1 year on maintenance therapy, the azathioprine dose (in those who tolerated the drug) was increased to 2 mg/kg/day, the steroids were then gradually withdrawn and (if remission was sustained) treatment was continued with azathioprine alone, as described in a previous study from this centre.[18] Following this publication, it has not been our policy to completely withdraw immunosuppressive therapy from patients with AIH who remain in remission. A complete response to treatment was defined according to the revised criteria of the IAIHG as either or both of the following: marked improvement of symptoms and return of serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT), bilirubin and immunoglobulin values completely to normal within 1 year and sustained for at least a further 6 months on maintenance therapy, or a liver biopsy specimen at some time during this period showing at most minimal activity; or, either or both of the following: marked improvement of symptoms together with at least 50% improvement of all liver test results during the first month of treatment, with AST or ALT levels continuing to fall to less than twice the upper limit of normal within 6 months during any reductions towards maintenance therapy, or a liver biopsy within 1 year showing only minimal activity [1]. Relapse was also defined using the IAIHG criteria as either or both of the following: an increase in serum AST or ALT levels of greater than twice the upper limit of normal or a liver biopsy showing active disease, with or without reappearance of symptoms, after a ‘‘complete’’ response as defined above; or reappearance of symptoms of sufficient severity to require increased (or reintroduction of) immunosuppression, accompanied by any increase in serum AST or ALT levels, after a ‘‘complete’’ response as defined above [1]. A partial or no response to initial therapy was defined according to the original IAIHG criteria [16]. Patients were defined as having achieved remission if they had normal serum biochemistry (globulins/IgG/AST), had no symptoms indicative of a relapse, and (where available) liver biopsies showed only minimal activity with no necrosis [18].
2.1. Statistical analysis For quantitative data, analyses were performed using the Mann– Whitney and Kruskal–Wallis ANOVA tests for comparison of two and more than two independent groups, respectively. Differences in proportions were analysed by the Fisher’s exact test when the number of subjects was < 5, and the v2 test for 2 · 2 tables when the number of subjects in all cells was >5. The r · c v2 test was used to investigate independent categories forming r rows and c columns where appropriate. Data are expressed as medians and ranges. All analyses were performed using StatsDirect statistical software (Camcode, Ashwell, Hertfordshire, England). Univariate and multivariate analysis was calculated using a Cox proportional hazard model with SPSS software (Chicago, Illinios, United States of America). For continuous variables that reached statistical significance on univariate analysis, receiver operator curves (ROC) were constructed. Where the area under the curve was greater than 0.6, the Youden index was calculated. This located a cut off, above and below which a dichotomous variable could be defined as 1 and 0, respectively, thus converting the continuous variable into a categorical variable. Survival analysis was performed using the Kaplan–Meier method and Cox proportional hazard model.
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3. Results
Sex Men Women
50
3.1. Patient demographics and laboratory parameters at presentation 40
The commonest presenting feature in both groups was jaundice. There were no significant differences with respect to clinical manifestations at presentation (jaundice, encephalopathy, arthralgia/flu like symptoms/malaise/lethargy, ascites, pruritus, pale stools, dark urine, rash, haematemesis, or stigmata of chronic liver disease) as shown in Table 3. There were also similar prevalences of other autoimmune diseases and reported occurrences of autoimmune diseases in first degree family members in both groups. Other autoimmune diseases occurred in 16/50 (32%) male patients and 73/186 (39.2%) female patients (p = 0.4387) and in the first degree relatives of 13/51 (25.5%) men compared to 33/183 (18%) women (p = 0.3242). The IAIHG score was higher in female patients compared to men by precisely two points. 3.3. Human leucocyte antigens and autoantibodies Male patients were significantly more likely to express HLA A1 and HLA B8, and had a trend toward Table 1 Patient demographics in men compared to women
Values in bold are significant.
20
10
0 10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
Age at Presentation (years), up to and including value, eg. 20= 11-20
Fig. 1. Age distribution at presentation in men and women with AIH. [This figure appears in colour on the web.]
3.2. Clinical manifestations
Age at diagnosis Median (range) Follow up (years) Median (range) Time to diagnosis (months) Median (range) IAIHG score Median (range)
30
Count
The female to male ratio was approximately 4:1 in our patient cohort. Both groups of patients were followed for a similar length of time (median 14 years, range 1–35 y for males vs. 11 y, range 0.1–30 y for females, p = 0.0773) (Table 1). Female patients tended to be older at presentation (median age 39 y for males vs. 49 y for females, p = 0.0589). The age distribution for men and women is illustrated in Fig. 1. There were no statistically significant differences between the two groups with regard to biochemical parameters other than for gamma GT activity which was significantly higher in male patients compared to female patients at presentation (Table 2). Time to diagnosis and mode of disease onset were similar in men and women (Tables 1 and 3).
Male N = 51
Female N = 187
P value
39 (10–67) 14 (1–35) 3 (0.5–260) 21 (18–26)
49 (5–80) 11 (1–30) 4 (0.25–180) 23 (16–28)
0.059 0.077 0.0638 0.001
increased expression of HLA DR3 compared to female patients (63% vs. 45%, p = 0.049, 74% vs. 38%, p < 0.001 and 62% vs. 44%, p = 0.058, respectively, Table 2). The HLA A1–B8–DR3 haplotype occurred in 50% of men compared to only 23% of women with AIH, p = 0.003. There were no significant differences in the frequency of the HLA DR4 allotype or ANA, SMA, LKM and AMA titres (Table 2). Seven female patients had detectable AMA at a titre of P1:80 (range 1:80–1:5120). None of these patients developed any cholestatic biochemistry or histopathology and none went on to develop any symptoms suggestive of PBC during follow-up (median 12 y, range 4–28 y) and all had an IAIHG score >17 despite deducting four points for AMA positivity16. Information on the presence of other autoantibodies was available in 35 male and 127 female patients. They were present in 13/35 (37%) men and 45/127 (35%) women, respectively; this was not statistically significant. The data were analysed separately for the presence of liver-specific membrane protein (LSP), asioglycoprotein receptor (ASGPR) and GPC, which were present in 5/35 (14%) men and 29/127 (23%) women (not significant). LKM-1 was present in 2/51 (4%) men and 16/187 (9%) women with AIH; this difference was also not statistically significant. 3.4. Response to therapy in men and women with AIH Similar proportions of male and female patients were initiated on standard therapy of either prednisolone monotherapy or prednisolone and azathioprine. More than 95% of patients in both groups demonstrated a
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Table 2 Laboratory data in male patients compared to female patients with AIH
AST IU/L (NR < 50) ALP IU/L (NR < 130) Bilirubin mmol/L (NR 5–17) GGT IU/L (NR 5–50) Albumin g/L (NR 35–42) Globulin g/L Initial IgG g/L (NR < 17) Peak IgG g/L (NR < 17) Initial ANAa (titre) Peak ANA a (titre) Initial ASMA a (titre) Peak ASMA a (titre) INR (NR 0.8–1.2) HLA HLA HLA HLA HLA a
A1 B8 DR3 DR4 A1–B8–DR3
Men median (range)
Women median (range)
612 (34–2319) 168 (70–844) 49 (9–1096) 209 (30–995) 34 (21–55) 46 (28–79) 23.4 (8.1–59.4) 24.2 (9.9–59.4) 40 (0–2000) (61%) 70 (0–5120) (76%) 30 (0–2000) (60%) 80 (0–2560) (81%) 1.4 (0.92–2.46) N = 38 24 (63%) 28 (74%) 24 (63%) 12 (32%) 19 (50%)
628 (23–4603) 212 (23–1677) 67 (7–609) 138 (8–911) 33 (20–48) 48.5 (28–81) 25.9 (4.72–70.7) 27.55 (7.78–70.7) 40 (0–10240) (66%) 160 (10–10240) (78%) 10 (0–2560) (52%) 80 (0–10240) (75%) 1.17 (0.8–2.8) N = 112 50 (45%) 42 (38%) 49 (44%) 41 (37%) 26 (23%)
P value 0.819 0.275 0.993 0.036 0.659 0.823 0.499 0.334 0.574 0.365 0.158 0.850 0.112 0.049 <0.001 0.058 0.596 0.003
Numbers in brackets (%) indicate prevalence of autoantibodies. Values in bold are significant.
complete response to therapy (Table 4). Likewise, maintenance therapy was similar in both groups, with the majority of patients maintained on both azathioprine and prednisolone in combination or on azathioprine monotherapy. One hundred and ninety patients were treated with azathioprine at any time during the follow-up period; an adverse event was recorded in 47 (25%). Side effects included 16 patients with bone marrow toxicity or leucopenia, 15 with documented ‘‘azathioprine intolerance’’, 10 with dermatological complications (skin cancers/solar keratoses/warts), 2 with septic complications (pneumonia/candida) and one patient each with nodular regenerative hyperplasia, severe lethargy reversed with azathioprine withdrawal, alopecia and myalgia.
Table 3 Mode of onset of AIH and presenting signs and symptoms
Mode of onset: Acute Insidious Asymptomatic Signs and symptoms: Jaundice Pale stools/dark urine Flu/lethargy/arthr/my/algia Stigmata chronic liver disease Pruritus Abdominal distension Ascites Upper GI bleed Encephalopathy Rash
Male N = 51
Female N = 187
P value
23 (45.1%) 18 (35.3%) 10 (19.6%)
80 (43.7%) 69 (37.7%) 34 (18.6%)
0.990 0.880 0.987
34 (66.7%) 28 (54.9%) 31 (60.8%) 18 (35.3%) 5 (9.8%) 12 (23.5%) 7 (13.7%) 2 (3.9%) 0 (0%) 4 (8.2%)
127 (70.6%) 80 (44.7%) 97 (54.8%) 60 (33.3%) 33 (18.4%) 52 (29.4%) 24 (13.6%) 8 (4.5%) 4 (2.2%) 14 (8%)
0.718 0.259 0.550 0.925 0.211 0.521 0.990 0.908 0.578 0.990
Male patients were more likely to have at least one relapse than female patients (71.4% male vs. 55.1% female, p = 0.0591) during reduction or withdrawal of treatment (Table 4). Eight female patients and 2 male patients were able to sustain remission for a median of 2 years, range 0.5–19 y, off treatment, having been on treatment for a median of 7 years (range 0.5–23.5 y).
Table 4 Treatment, response to therapy and outcome in male patients versus female patients with AIH Male N = 51
Female N = 187
P value
Initial therapy: Prednisolone alone Prednisolone + azathioprine Other
28 (59.6%) 15 (31.9%) 4 (8.5%)
112 (64.7%) 54 (31.2%) 7 (4.1%)
0.630 0.99 0.254
Maintenance therapy: Prednisolone alone Prednisolone + azathioprine Azathioprine monotherapy Other Off treatment
8 (15.7%) 22 (43.1%) 15 (29.4%) 4 (7.8%) 2 (3.9%)
34 (19.5%) 70 (40.2%) 54 (31%) 8 (4.6%) 8 (4.6%)
0.677 0.834 0.961 0.476 0.990
Response to therapy: Complete response Partial response No response Any relapse P2 relapses
48 (98%) 1 (2%) 0 (0%) 35 (71.4%) 17 (34.7%)
174 (95.6%) 6 (3.3%) 2 (1.1%) 97 (55.1%) 60 (34.1%)
0.734 0.990 0.990 0.059 0.990
7 (13.7%)
48 (25.7%)
n.s.
5 (71%)
28 (58.1%)
n.s
Outcome: Total deaths or liver transplantation Proportion of deaths that are liver related deaths or transplantation
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3.5. Liver histology in men and women with AIH The prevalence of histologically confirmed cirrhosis at presentation was 19/49 (38.8%) in male patients vs. 65/178 (36.5%) in females (p = 0.6769) (Table 5). During follow up the majority of patients in both groups demonstrated histological improvement in relation to necroinflammatory grade. Despite this only, 3.3% of male patients and 7.7% of female patients demonstrated any reduction in fibrosis on follow-up biopsy. There was no improvement in histological stage in any patients with established cirrhosis.
Cum Survival
1.0
(a) Grade: Improvement Deterioration No change (b) Stage: Improvement Deterioration No change
P
19/49 (38.8%)
65/178 (36.5%)
0.677
34/51 (66.7%)
99/187 (52.9%)
0.073
women
0.4
0
20
40
Follow up in Years
Fig. 2. Cumulative overall survival in men and women with AIH Log rank test, p = 0.024, hazard ratio 0.467. [This figure appears in colour on the web.]
(not liver related), pseudomonas sepsis secondary to Epstein Barr virus infection, ischaemic heart disease and sepsis, perforated diverticular abscess, cancer of the pharynx, septicaemia, mesenteric vein thrombosis, carcinoma of the lung, carcinoma of the breast, ruptured oesophagus during endoscopy, cancer of the stomach, and dissecting aneurysm, n = 1 in women. The cause of death was not documented and could not be traced in 1 man and 4 women. For liver related death or need for transplant, the median age at death (interquartile range) was 52.5 years (34.25–67.0) for men and 39 years (33.5–63.0) for women, p = 0.782, and for non-liver related death, median (interquartile range) ages were 67.5 (60.0–75.0) and 70.5 (62.5–78.0) years, respectively. 1.0
men 0.8
women
Cum Survival
Nos. (%) with cirrhosis on index biopsy Nos. (%) having follow-up biopsy Nos. (%) with histological changes in first follow-up biopsy:
Female N = 187
0.6
0.0
Table 5 Liver histology at presentation and at first follow-up biopsy in men and women with AIH Male N = 51
men
0.2
3.6. Differences in survival in men and women with AIH Fig. 2 presents overall survival in patients with AIH. This demonstrates that when comparing overall mortality, or need for liver transplantation, men with AIH appear to have better survival (Log Rank test p = 0.024, hazard ratio 0.467). Despite this, the proportion of patients who required liver transplantation or died as a consequence of liver related deaths is not significantly different, men 5/7 (71%), women 28/48 (58%), p = n.s. (Table 4). Causes of liver related death or transplantation were as follows: women, liver transplantation (OLT) n = 16, decompensated liver disease, n = 6, hepatocellular carcinoma (HCC), n = 3, acute variceal bleed, n = 2, acute hepatitis B infection complicating AIH, n = 1; men, HCC, n = 3, OLT n = 2). Survival curves, based on need for liver transplantation or based on liver related mortality demonstrate no difference in survival, p = 0.109, Fig. 3. The causes of death unrelated to hepatic aetiology include colorectal cancer n = 1 in men, and stroke n = 2, heart failure n = 2, myocardial infarction, portal hypertension during pregnancy
0.8
0.6
0.4
0.2
29/33 (87.9%) 1/33 (3%) 3/33 (9.1%)
76/96 (79.2%) 5/96 (5.2%) 15/96 (15.6%)
0.219 0.562 0.297
0.0 0
1/30 (3.3%) 15/30 (50%) 14/30 (46.7%)
7/91 (7.7%) 46/91 (50.5%) 38/91 (41.8%)
0.314 0.958 0.640
20
40
Follow up in Years
Fig. 3. Cumulative liver related survival in men and women with AIH Log rank test, p = 0.109. [This figure appears in colour on the web.]
T. Al-Chalabi et al. / Journal of Hepatology 48 (2008) 140–147
3.7. Factors associated with reduced survival Univariate and multivariate analysis was performed to evaluate factors associated with reduced survival or need for liver transplantation (Tables 6 and 7). By univariate analysis, female gender approached statistical significance (p = 0.068, HR 2.016, 95% CI 0.949– 4.284) but, overall, reduced survival was associated with factors related to the presence of established cirrhosis at presentation (ascites, haematemesis, stigmata of chronic liver disease, cirrhosis on index biopsy and low albumin) and with older age at presentation (Table 6), while factors associated with a symptomatic presentation were associated with improved survival (jaundice, flu-like symptoms/athralgia/myalgia/malaise, symptomatic presentation, raised AST). Neither HLA allotype (A1, B8, DR3 or DR4) nor the presence of autoantibodies had an effect on outcome. There was also no effect of HLA allotype on outcome when the data were analysed separately for men and women. ROC curves were constructed for age, AST and albumin. However, the areas under the curves were <0.6 in all cases and therefore it was not possible to generate the Youden index to establish a dichotomous variable. Multivariate analysis demonstrated absence of jaundice at presentation, presence of ascites, haematemesis and low necroinflammatory grade at presentation to be factors associated with reduced survival in both groups of patients (Table 7).
Table 6 Univariate analysis of factors associated with reduced survival in male and female patients with AIH a Variable at presentation
P value
Hazard ratio (HR)
95% CI for HR
Female gender Age at diagnosis Jaundice Stigmata of CLD Encephalopathy Flu/lethargy/arthr/my/algia Ascites Haematemesis Time to diagnosis Asymptomatic presentation Acute presentation Alkaline phosphatase Aspartate-amino-transaminase Albumin Bilirubin Cirrhosis on index biopsy Grade on index biopsy Stage on index biopsy Change in grade Change in stage Relapse
0.068 0.018 0.04 0.019 0.132 0.031 0.001 0.001 0.994 0.022 0.092 0.884 0.001 0.01 0.909 0.001 0.005 0.002 0.058 0.560 0.629
2.02 1.02 0.56 1.90 2.98 0.56 2.95 4.66 1.00 2.02 0.63 1.000 0.999 0.94 1.000 2.42 0.66 1.38 1.34 0.93 0.86
0.95–2.28 1.00–1.04 0.33–0.98 1.11–3.26 0.72–12.31 0.33–0.95 1.56–5.58 1.95–11.12 0.99–1.01 1.11–3.70 0.36–1.08 0.999–1.001 0.998–1.000 0.89–0.99 0.998–1.002 1.41–4.14 0.50–0.88 1.13–1.70 0.99–1.80 0.71–1.20 0.46–1.60
a Results have been included if they are significant or where their lack of significance is of clinical interest or in contrast to the significant results. Values in bold are significant.
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Table 7 Multivariate analysis of factors associated with reduced survival in male and female patients with AIH Variable
P value Hazard ratio (HR) 95% CI of HR
Jaundice Ascites Haematemesis Grade on index biopsy
0.018 0.001 0.021 0.001
0.375 5.035 3.884 0.514
0.166–0.845 1.982–12.789 1.227–12.297 0.353–0.749
4. Discussion This large, single, tertiary centre study provided the opportunity to undertake a comprehensive analysis of the influence of gender on outcomes and disease severity in AIH. The most striking difference demonstrated in this study was that men with AIH appeared to have better long-term survival and outcome than their female counterparts. Furthermore, expression of HLA A1, B8, DR3 allotypes and the HLA A1–B8–DR3 haplotype was all increased in male patients compared to female patients. Men with AIH presented at a younger age than women and had higher serum GGT activities at accession. In this patient cohort, clinical presentation, time to diagnosis and clinical course were similar in both groups. The reasons for increased survival in male patients are unclear, but they do not appear to reflect differences in either time to diagnosis, treatment regimen, treatment response or frequency of relapse between the two groups. Reduced survival in women compared to men cannot be accounted for by older age of women at presentation, as women were on average younger than men when they died. In addition, the age at death in women with liver related causes compared to non-liver causes was significantly lower (39 years vs. 70.5 years, p = 0.001). This suggests that the poor prognosis in women is accounted for by reduced survival due to complications from cirrhosis of the liver caused by AIH. It should be noted that the median age at liver related death/OLT is low in both groups of patients and may be accounted for by tertiary referral bias to a transplant centre. However, this bias would affect both sexes and therefore does not account for the decreased survival observed in women. In addition, there was no significant difference in age at liver related death/OLT between men and women with AIH. Despite the greater survival observed in male patients with AIH, they were more likely to suffer a relapse or flare in disease activity than female patients. Gender differences in frequency of disease expression and clinical outcome exist in other autoimmune diseases. In MS, the disease is more severe in men who acquire the disease, compared to women [13], whereas in RA, disease activity is more severe in women, although men are more likely to die from extra-articular
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manifestations of the disease [14]. A proposed mechanism behind these gender differences includes the modulation of the immune system by the hypothalamic–pituitary–gonadal system and by sex hormones. Evidence for the involvement of the hypothalamic–pituitary–gonadal system and sex hormones in immunity is well established. In very simplified terms, androgens appear to inhibit, and oestrogens to enhance, immune activity [8]. Oestrogen also appears to have a biphasic effect and at higher levels, such as those demonstrated in pregnancy, oestrogen is associated with an antiinflammatory mileu [8,19,20]. In AIH, improvement of disease activity has been documented during pregnancy; however, index presentations of AIH and flares of disease activity have been reported during pregnancy and post-partum [12,21]. In this study, our data suggest that female gender in itself is associated with both disease expression and increased disease severity (as demonstrated by reduced survival) compared with male gender. Interestingly, evaluation of HLA haplotypes revealed that the extended haplotype HLA A1–B8–DR3 (associated with increased susceptibility to AIH) [22] was more than twice as prevalent in male patients compared with female patients with AIH. This suggests that increased susceptibility to AIH is conferred by this haplotype, and that without this haplotype, men are even less likely to express the disease. Therefore, women are more likely than men to develop AIH in the absence of HLA A1– B8–DR3. The higher rate of relapse and younger age at presentation in men with AIH in this study are consistent with previous reports in which the HLA A1–B8– DR3 haplotype has been associated with a greater frequency of relapse and younger age of disease onset [22]. However, the presence of the HLA A1–B8–DR3 haplotype or DR3 allotype was not associated with a poorer outcome, even when the data were analysed separately for men and women. These results differ slightly from data on U.S. patients with AIH, in whom men and women had a similar frequency of HLA DR3 but men had a lower prevalence of HLA DR4 [15]. The higher proportion of male patients with HLA DR3 in this study approached but did not reach significance. No statistical difference was detected in the prevalence of HLA DR4 between men and women with AIH in this Northern European cohort. Although differences in survival between the sexes were illustrated in this study, univariate analysis confirmed that the presence of cirrhosis at presentation was associated with a poorer outcome irrespective of gender. Ninety percent (197/220) of the patients in whom grading and staging was possible had moderate to severe disease on index biopsy, and cirrhosis was present in over one-third of patients at diagnosis irrespective of gender. The prevalence of other autoimmune conditions and family history of autoimmune disease in
first degree relatives was similar between male and female patients with AIH. With respect to the more elevated GGT in men compared to women, alcohol history was available in 161 patients (35 male, 126 female). Of these, 106 patients did not consume alcohol at the time of presentation. Of the 55 who did consume alcohol, 13 were male (37% of men) and 42 female (33% of women). The amounts of alcohol consumed were compared using a Mann–Whitney U test, and no significant differences were found (median (IQ range) men 0 IU/week, (0– 10); women 0 IU/week, (0–4), p = 0.562). Unfortunately, because of the retrospective nature of this study, no information regarding body mass index was available on any patients. Thus the reasons behind this elevated GGT in men compared to women cannot be accounted for by differences in alcohol consumption and are not clear. A complete response to treatment was demonstrated in more than 95% of patients in both groups, as evidenced by biochemical parameters and degree of necroinflammation on liver biopsy. Whilst these results represent an exceptionally high rate of treatment responsiveness, it must be reiterated that patients were selected for this study only if they were classified as having definite AIH. This reduces the likelihood of including patients, such as those with overlap features, who would be less likely to achieve remission. However, although treatment response was excellent in both groups, approximately half had histological progression in disease stage and few demonstrated significant regression of fibrosis on biopsy. The length of time between biopsies does not account for this progression in fibrosis, as repeat biopsy occurred at or within 2 years in 67% of patients in whom a second biopsy was performed (median duration between first and second biopsy was 2 years, interquartile range 1–3 years). However, this finding is consistent with other studies in which progression of fibrosis has been demonstrated in patients with a good response to treatment [23]. Indeed, a symptomatic presentation in conjunction with greater inflammatory activity as evidenced by a higher AST level (HR 0.999, p = 0.001) or higher histological necroinflammatory grade (HR 0.66, p = 0.005) were both associated with improved survival. Further comment in relation to the IAIHG scoring system is merited based on our findings. Because of the gender bias in AIH, the IAIHG scoring system has allocated diagnostic points in favour of women. Interestingly, in this analysis of patients with only definite AIH, female patients had median IAIHG scores of exactly 2 points greater value than men. This represents the 2 points awarded them within the scoring system for their gender and implies that the median diagnostic scores would have been identical if the gender weighting had not been allocated by the scoring system. Whether
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diagnostic benefit is actually accrued by the addition of 2 points for female gender is therefore in doubt. Indeed, in a simplified scoring system also proposed by members of the IAIHG, points are allocated for autoantibodies, immuno/gammaglobulins, liver histology and the absence of viral hepatitis without reference to gender, and preliminary data suggest that a less cumbersome scoring system might be applicable in clinical practice [24]. In conclusion, in this study we have identified that male gender confers reduced susceptibility to the development of AIH; response to treatment is excellent in male patients and comparable to female patients. Interestingly, 50% of male patients have the extended HLA haplotype A1–B8–DR3 compared to 23% of women, and this haplotype may explain the higher relapse rate in men. Despite this finding, long-term outcome and prognosis is more favourable in men with AIH compared to women. The reasons for this remain obscure but may reflect either gender alone or the effect of gender on immune responses. References [1] Alvarez F, Berg PA, Bianchi FB, Bianchi L, Burroughs AK, Cancado EL, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol 1999;31:929–938. [2] McMurray RW. Estrogen, prolactin, and autoimmunity: actions and interactions. Int Immunopharmacol 2001;1:995–1008. [3] Giltay EJ, Fonk JC, von Blomberg BM, Drexhage HA, Schalkwijk C, Gooren LJ. In vivo effects of sex steroids on lymphocyte responsiveness and immunoglobulin levels in humans. J Clin Endocrinol Metab 2000;85:1648–1657. [4] Jansson L, Holmdahl R. Estrogen-mediated immunosuppression in autoimmune diseases. Inflamm Res 1998;47:290–301. [5] Kovacs WJ, Olsen NJ. Androgen receptors in human thymocytes. J Immunol 1987;139:490–493. [6] Ostensen M. Sex hormones and pregnancy in rheumatoid arthritis and systemic lupus erythematosus. Ann N Y Acad Sci 1999;876:131–143. [7] Leposavic G, Obradovic´ S, Kosec D, Pejcic´-Karapetrovic´ B, Vidic´-Dankovic´ B. In vivo modulation of the distribution of thymocyte subsets by female sex steroid hormones. Int Immunopharmacol 2001;1:1–12.
147
[8] Tanriverdi F, Silveira LF, MacColl GS, Bouloux PM. The hypothalamic–pituitary–gonadal axis: immune function and autoimmunity. J Endocrinol 2003;176:293–304. [9] Vukusic S, Hutchinson M, Hours M, Moreau T, CortinovisTourniaire P, Adeleine P, et al. Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post-partum relapse. Brain 2004;127:1353–1360. [10] Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis. Rheum Dis Clin North Am 1997;23:195–212. [11] Buchel E, Van Steenbergen W, Nevens F, Fevery J. Improvement of autoimmune hepatitis during pregnancy followed by flare-up after delivery. Am J Gastroenterol 2002;97:3160–3165. [12] Heneghan MA, Norris SM, O’Grady JG, Harrison PM, McFarlane IG. Management and outcome of pregnancy in autoimmune hepatitis. Gut 2001;48:97–102. [13] Weinshenker BG, Rice GP, Noseworthy JH, Carriere W, Baskerville J, Ebers GC. The natural history of multiple sclerosis: a geographically based study. 3. Multivariate analysis of predictive factors and models of outcome. Brain 1991;114:1045–1056. [14] Da Silva JA, Hall GM. The effects of gender and sex hormones on outcome in rheumatoid arthritis. Baillieres Clin Rheumatol 1992;6:196–219. [15] Czaja AJ, Donaldson PT. Gender effects and synergisms with histocompatibility leukocyte antigens in type 1 autoimmune hepatitis. Am J Gastroenterol 2002;97:2051–2057. [16] Johnson PJ, McFarlane IG. Meeting report: International Autoimmune Hepatitis Group. Hepatology 1993;18:998–1005. [17] Batts KP, Ludwig J. Chronic hepatitis. An update on terminology and reporting. Am J Surg Pathol 1995;19:1409–1417. [18] Johnson PJ, McFarlane IG, Williams R. Azathioprine for longterm maintenance of remission in autoimmune hepatitis. N Engl J Med 1995;333:958–963. [19] Whitacre CC, Reingold SC, O’Looney PA. A gender gap in autoimmunity. Science 1999;283:1277–1278. [20] Whitacre CC. Sex differences in autoimmune disease. Nat Immunol 2001;2:777–780. [21] Schramm C, Herkel J, Beuers U, Kanzler S, Galle PR, Lohse AW. Pregnancy in autoimmune hepatitis: outcome and risk factors. Am J Gastroenterol 2006;101:556–560. [22] Donaldson PT, Doherty DG, Hayllar KM, McFarlane IG, Johnson PJ, Williams R. Susceptibility to autoimmune chronic active hepatitis: human leukocyte antigens DR4 and A1–B8–DR3 are independent risk factors. Hepatology 1991;13:701–706. [23] Czaja AJ, Carpenter HA. Progressive fibrosis during corticosteroid therapy of autoimmune hepatitis. Hepatology 2004;39:1631–1638. [24] Hennes EM, Zeniya M, Czaja AJ, Pares A, Dalekos G, Krawitt E, et al. Simplified diagnostic criteria for autoimmune hepatitis. Hepatology 2005;42:295A.