From the Guidelines
The autoimmune liver workup should include a comprehensive panel of serological tests, imaging studies, and possibly liver biopsy, starting with liver function tests, complete blood count, and coagulation studies, as well as autoimmune serologies including ANA and SMA as screening tests, as recommended by the most recent guidelines 1. The workup should begin with liver function tests (ALT, AST, ALP, GGT, bilirubin), complete blood count, and coagulation studies to assess the extent of liver injury.
- Order autoimmune serologies including antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), as these are recommended as screening tests 1.
- Additional tests such as anti-liver kidney microsomal antibody (anti-LKM), anti-mitochondrial antibody (AMA), and immunoglobulin levels (IgG, IgM, IgA) may be necessary based on clinical judgment.
- Specific tests like anti-soluble liver antigen (anti-SLA) and liver cytosol type 1 antibody may be needed for certain conditions, and viral hepatitis serologies (hepatitis A, B, C) should be included to exclude viral causes. The diagnosis of autoimmune hepatitis (AIH) can be made by excluding liver injury from other causes and integrating laboratory findings, the presence of autoantibodies, and compatible histologic findings, using a revised diagnostic scoring system or a simplified diagnostic scoring system 1. In cases with unclear diagnosis, liver biopsy remains the gold standard, and abdominal ultrasound should be performed to assess liver morphology and rule out biliary obstruction. Early diagnosis is crucial as untreated autoimmune liver diseases can progress to cirrhosis, while appropriate immunosuppressive therapy, such as prednisolone and azathioprine, can effectively control disease activity and prevent progression, with the goal of complete normalization of transaminases and IgG levels 1.
From the Research
Autoimmune Liver Disease Diagnosis
The diagnosis of autoimmune liver disease (ALD) involves a combination of clinical, biochemical, imaging, serological, and histological characteristics 2.
- Autoantibodies are crucial for the correct diagnosis and classification of ALD, including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) 3.
- Serum autoantibodies, together with imaging and histology, are critical to the diagnostic process when ALD is suspected 4.
- The determination of liver-related autoantibodies is a prerequisite to diagnose AIH and PBC, and they are components of the diagnostic scoring system in these diseases 5.
Autoantibody Testing
- Testing for liver-related autoantibodies should be included in the workup of patients with hepatitis or cholestasis of unknown origin 5.
- Autoantibodies can be present in de-novo AIH following liver transplantation, including smooth muscle antibody (SMA), anti-nuclear antibody (ANA), and anti-liver kidney microsomal antigen type-1 (anti-LKM1) 3.
- PBC is specified by antimitochondrial antibodies (AMA) reacting with enzymes of the 2-oxo-acid dehydrogenase complexes and disease-specific ANA mainly reacting with nuclear pore gp210 and nuclear body sp100 3.
Clinical Presentation and Treatment
- AIH is the most common ALD, followed by overlap syndromes, PSC, and PBC 2.
- Jaundice is the most common presentation seen in 60% of patients, and cirrhosis is present in 57.47% of patients 2.
- First-line therapy is immunosuppression for AIH and ursodeoxycholic acid for PBC 6.
- Biochemical response to immunosuppression is seen in 60% of patients with AIH, and low fibrosis score on histopathology predicts a complete response 2.