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NAFLD and autoimmune hepatitis: Do not judge a book by its cover

  • George N. Dalekos
    Correspondence
    Corresponding author.
    Affiliations
    Institute of Internal Medicine and Hepatology, 41447 Larissa, Greece

    Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, 41110 Larissa, Thessaly, Greece
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  • Nikolaos K. Gatselis
    Affiliations
    Institute of Internal Medicine and Hepatology, 41447 Larissa, Greece

    Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, 41110 Larissa, Thessaly, Greece
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  • Kalliopi Zachou
    Affiliations
    Institute of Internal Medicine and Hepatology, 41447 Larissa, Greece

    Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, 41110 Larissa, Thessaly, Greece
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  • George K. Koukoulis
    Affiliations
    Department of Pathology, School of Medicine, University of Thessaly, 41110 Larissa, Greece
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Published:February 09, 2020DOI:https://doi.org/10.1016/j.ejim.2020.02.001

      Highlights

      • Diagnosis of NAFLD/AIH variant or AIH instead of NAFLD is challenging.
      • IgG increase and autoimmunity background support a careful evaluation for AIH.
      • A detail assessment of liver autoimmune serology and liver pathology seem mandatory.
      • NAFLD/AIH patients have no sex differences, are older with lower liver biochemistry.
      • Rational approach suggests strict management of both diseases and closer surveillance.

      Abstract

      Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease (almost 25% of the general population). Autoimmune hepatitis (AIH) is a relatively rare liver disease of unknown aetiology characterized by female predominance and large heterogeneity regarding epidemiology, clinical manifestations, genetics, serology and liver pathology. The potential NAFLD/AIH coincidence or an AIH diagnosis alone instead of NAFLD represent a challenge for clinicians, both in making a correct and timely diagnosis but also in the management of these diseases. The diagnosis of both diseases can be challenging as: (a) reliable laboratory tests to confidently diagnose or exclude NAFLD or AIH are missing; (b) physicians and pathologists are much more familiar with a very common disease like NAFLD so, they do not consider an alternative or additional diagnosis; (c) most NAFLD studies do not investigate the patients for all autoantibodies involved in AIH diagnosis, apply the diagnostic scoring systems for AIH or address the possibility of AIH features on liver histology and (d) the recent European and American practice guidelines for NAFLD do not mention clearly the importance of IgG determination and liver autoimmune serology according to the AIH guidelines. Patients with NAFLD/AIH coincidence have significantly more frequently hypertension, diabetes, obesity, older age, lower transaminases, bilirubin and simplified score for AIH diagnosis but no female predominance compared to AIH patients only. The true outcome of NAFLD/AIH patients is practically unknown while their management is quite problematic because official clinical practice guidelines for this condition are missing.

      Keywords

      Abbreviations:

      BMI (body mass index), ALT (alanine aminotransferase), ULN (upper limit of normal), NAFLD (non-alcoholic fatty liver disease), AST (aspartate aminotransferase), IgG (immunoglobulin G), ANA (antinuclear antibodies), SMA (smooth muscle antibodies), AIH (autoimmune hepatitis), 1H-MRS (proton magnetic resonance spectroscopy), NAFL (non-alcoholic fatty liver), NASH (non-alcoholic steatohepatitis), HCC (hepatocellular carcinoma), T2DM (type-2 diabetes mellitus), AUD (alcohol use disorder), AASLD (American association for the study of liver diseases), AUDIT (alcohol use disorders inventory test), NFS (NAFLD fibrosis score), FIB-4 (fibrosis-4 index), NOSA (non-organ specific autoantibodies), IAIHG (International AIH Group), EASL (European association for the study of the liver), IgA (immunoglobulin A), IgM (immunoglobulin M), IIF (indirect immunofluorescence), anti-SLA/LP (antibodies against soluble liver antigen or liver pancreas), CYP2D6 (cytochrome P450 2D6)
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