Clinic Rev Allerg Immunol DOI 10.1007/s12016-014-8427-x

Extrahepatic Autoimmune Conditions Associated with Primary Biliary Cirrhosis Annarosa Floreani & Irene Franceschet & Nora Cazzagon & Alice Spinazzè & Alessandra Buja & Patrizia Furlan & Vincenzo Baldo & M. Eric Gershwin

# Springer Science+Business Media New York 2014

Abstract There is a paucity of information on extrahepatic autoimmune (EHA) conditions associated with primary biliary cirrhosis (PBC) and on the impact of EHA conditions on PBC patients’ survival. Our goal was to assess the association between PBC and other autoimmune diseases and the impact of EHA conditions on the natural history of PBC. We took advantage of 361 consecutive PBC patients enrolled between 1975 and 2012 (22 males, 339 females; mean follow-up 8± 6.9 years). Any associated EHA conditions, PBC histological stage at diagnosis, biochemical data, physiological history, and extrahepatic malignancies developing during the followup were recorded. Survival was analyzed by means of KaplanMeier curves. Importantly, 221 patients (61.2 %) had at least one EHA conditions: 45 patients (20.4 %) had Hashimoto thyroiditis; 7 (3.2 %) had Graves’ thyroiditis; 65 (29.4 %) had Raynaud’s phenomenon; 124 (56.1 %) had Sjogren’s syndrome; 8 (3.6 %) had systemic lupus erythematosus; 22 (9.9 %) had scleroderma; 22 (9.9 %) had rheumatoid arthritis; 18 (8.1 %) had cutaneous autoimmune diseases; 8 (3.6 %) had vasculitis; 5 (1.4 %) had celiac disease; and 25 (13.1 %) had other EHA conditions. The proportion of patients with associated EHA conditions enrolled during representative periods (1975–1980, 1981–1990, 1991–2000, 2001–2010, 2011– 2012) remained stable. No differences emerged between A. Floreani (*) : I. Franceschet : N. Cazzagon : A. Spinazzè Department of Surgery, Oncology and Gastroenterology—DiSCOG, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy e-mail: [email protected] A. Buja : P. Furlan : V. Baldo Department of Hygiene and Public Health, University of Padova, Padova, Italy M. E. Gershwin Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, USA

patients with versus without EHA conditions in terms of mean age at PBC diagnosis, antimitochondrial antibody (AMA), or antinuclear antibody (ANA) positivity, histological stage at diagnosis, smoking habits, alcohol consumption, or BMI >25. Multiple logistic regression analysis showed that only female gender was significantly associated with positivity for EHA conditions (OR 4.8; 95 % CI 1.6–13.7, p=0.004). The mean survival after the diagnosis of PBC was much the same in patients with and without EHA conditions. In conclusion, EHA conditions are often associated with PBC, especially in female patients, but they do not reduce patient survival. Keywords PBC . Autoimmune diseases . Scleroderma . Sjogren’s syndrome

Introduction Primary biliary cirrhosis (PBC) is a chronic liver disease mainly affecting women, characterized by destruction of the bile ducts and eventually leading to cirrhosis [1]. Several autoimmune diseases have often been found in association with PBC due to a shared autoimmune mechanism [2]. The most studied are the associations with other autoimmune liver disorders, or “overlaps” between PBC and autoimmune hepatitis [3]. For liver disorders, the term “overlap syndrome” is used to define the coexistence of autoimmune hepatitis (AIH) with another hepatic autoimmune condition, namely, PBC or primary sclerosing cholangitis (PSC) [3, 4]. The association between PBC and other extrahepatic autoimmune (EHA) conditions has been only partially studied, focusing mainly on rheumatologic disorders [5]. Although there have been extensive studies of animal models of PBC and considerable data on the immunological mechanisms that underlie the effector pathways that drive biliary obstruction [6–17], there still remains a major void in our understanding of the

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geoepidemiology of PBC and, in particular, the impact of extrahepatic pathology on the survival of patients with PBC. The aim of the present study was to shed light on the association between PBC and other EHA conditions and on the impact of the latter on the natural history of PBC patients’ liver disease.

Methods All PBC patients were prospectively seen and included in a database (1975–2012); a detailed description of our recruitment methods and our diagnostic and follow-up criteria is available elsewhere [18]. In the present study, we included all consecutive PBC patients collected between 1975 and 2012 who had at least 1 year of follow-up. PBC was diagnosed on the basis of an antimitochondrial antibody (AMA) positivity higher than 1:40, abnormal alkaline phosphatase levels (at least 1.5 times the normal value), and/or a compatible liver histology. The AMA-negative variant was diagnosed in cases with abnormal alkaline phosphatase levels (at least 1.5 times the normal value), an antinuclear antibody (ANA) positivity of at least 1:40, and a liver histology compatible with PBC. In AMA-negative patients, biliary tree patency was assessed by ultrasound and nuclear magnetic resonance imaging with cholangiography. Histological staging was done according to Scheuer’s classification [19]. Cases of EHA were defined as patients with at least one of the following conditions: Sjogren’s syndrome; rheumatoid arthritis (RA); Raynaud’s phenomenon; scleroderma (SS); vitiligo; CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, teleangectasia); celiac disease (CD); lichen planus; autoimmune thyroid dysfunction; systemic lupus erythematosus (SLE); dermatomyositis; antiphospholipid syndrome; or polymyositis. A diagnosis of RA was established according to the revised American College of Rheumatology classification criteria [20]. SS was diagnosed according to the Le Roy classification criteria [21]. SLE was diagnosed according to the 2009 Systemic Lupus International Collaborating Clinic revision of the ACR classification criteria for SLE [22]. A diagnosis of polymyositis (PM) or dermatomyositis (DM) was based on the criteria reported by Bohan and Peter [23]. Patient Follow-up and Event Assessment All patients were assessed at 4–6-month intervals at the outpatient clinic by the same dedicated staff, who recorded the following: (a) clinical signs and symptoms of liver disease and EHA and (b) laboratory parameters including the following: aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), bilirubin, prothrombin time, alkaline phosphatase, serum albumin, IgG,

IgA, IgM, total cholesterol, platelets and leukocyte count, hemoglobin, and alpha-fetoprotein. Liver ultrasound was performed annually in patients in the pre-cirrhotic stage, and every 6 months in cases of histological stage IV. From 1987 onwards, all patients were treated with ursodeoxycholic acid (UDCA) at a dose of 15 mg/kg/day. Only eight patients with SLE or RA were treated with prednisolone or prednisone, tapered to a maintenance dose of 7.5 mg/day. Patients with hepatitis B or hepatitis C infection were excluded for the purposes of this study. The Mayo Risk Score, based on a combination of five variables (bilirubin, age, albumin, prothrombin time, and severity of edema) was calculated for all patients when their PBC was diagnosed [24]. The mean follow-up was 8.0±6.9 years. The onset of major complications during the follow-up was classified as follows: HCC was diagnosed by US, CT, or NMRI, as appropriate; ascites was identified by US of the abdomen; gastrointestinal bleeding due to portal hypertension was confirmed by endoscopy in cases of esophageal or gastric varices or hypertensive gastropathy; portal-systemic encephalopathy was established from clinical parameters according to the West Haven criteria [25]. The study was approved by the local ethical committee, and all participants gave their informed consent to the study. Statistical Analyses Standard descriptive statistics were used to describe sample characteristics. The chi-squared or Fisher’s exact tests were used, as appropriate, to test for differences in categorical variables between two independent groups; Student’s t test was used for differences in continuous variables between two independent groups. Logistic regression analysis (with 95 % confidence intervals) was applied, using EHA as an independent variable. Survival was analyzed with Kaplan-Meier curves, and Cox’s proportional model was applied, when appropriate. The statistical analysis was completed using SPSS software (Chicago, IL, USA).

Results The study involved 361 patients with PBC (339 females, 22 males; mean age 53.1±12.4 years): there were 111 cases (30.7 %) in histological stage I, 65 (18 %) in stage II, 95 (26.3 %) in stage III, and 28 (7.8 %) in stage IV. Liver biopsy was not performed in 62 patients (17.2 %). Of the 361 patients, 295 (81.7 %) had a classical AMA-positive PBC, and the other 66 (18.3 %) had the AMA-negative variant. At presentation, 221 patients (61.2 %) had at least one EHA condition, 123 had only one disease (34.1 %), 70 (19.4 %) had two, 23 (6.4 %) had three, and 5 (1.4 %) had four or five

Clinic Rev Allerg Immunol Table 1 Autoimmune diseases associated with PBC patients No. of PBC patients (%) (tot. 361) Hashimoto’s thyroiditis Graves’s thyroiditis Raynaud’s syndrome Sjogren’s syndrome Systemic lupus erythematosus Scleroderma/CREST Rheumatoid arthritis Cutaneous autoimmune diseases Celiac disease Vasculitis Other EAI

45 (12.5) 7 (1.9) 65 (18.0) 124 (34.3) 8 (2.2) 22 (6.1) 22 (6.1) 18 (5.0) 5 (1.4) 8 (2.2) 25 (6.9)

associated autoimmune conditions. The PBC patients’ associated EHA conditions are listed in Table 1. The proportion of PBC patients with associated EHA conditions remained unchanged over the years (comparing representative intervals, i.e., 1973–1980, 1981–1990, 1991–2000, 2001–2010, 2011–2012). As expected, there was a significantly higher proportion of females among the PBC patients who had associated EHA conditions (97.3 vs 88.6 % of those who did not, p=0.0017) (Table 2). On the other hand, these two groups of patients were comparable in terms of nonorgan-specific autoantibody (AMA, ANA, SMA, LKM) positivity, histological stage, smoking habits, alcohol intake, BMI, mean age at diagnosis, and length of follow-up (Table 2).

Logistic regression analysis confirmed that only female gender was significantly associated with the presence of EHA conditions (OR 4.8; 95 % CI 1.6–13.7; p=0.004). The major events recorded during the follow-up are listed in Table 3. The presence of at least one EHA condition did not increase the risk of hepatic or extrahepatic neoplastic disease or the onset of complications of liver cirrhosis (ascites, variceal bleeding, spontaneous bacterial peritonitis, or hepatic encephalopathy). The Kaplan-Meier survival curves were also much the same for patients with and without EHA conditions (Fig. 1). Patients with scleroderma did not have a survival significantly different from PBC patients without this condition (log rank test p=0.92).

Discussion This study focuses on EHA conditions associated with PBC using a single-center database of patients with a long-term follow-up. EHA conditions were found associated with PBC in 61.2 % of our sample. Female gender was more prevalent in the group who had EHA conditions, but patients who had EHA diseases had much the same biochemical, histological, and immunological profile as those who did not. Having one or more EHA conditions did not influence the incidence of end-stage liver disease complications during the follow-up nor did it correlate with the onset of hepatic or extrahepatic malignancies. Survival was also much the same for patients

Table 2 Comparison between PBC patients with (n=221) and without (n=140) associated EHA conditions

Female AMA positivity ANA positivity SMA positivity LKM positivity ENA positivitya Histological stage I II III IV ND Smoking habits Alcohol intake BMI >25 Mean age at diagnosis (years) Mean follow-up (years) a

Data available in only 52 patients

All patients

Patients with PBC alone (n=140)

Patients with PBC+EAI (n=221)

p value

339 (93.1 %) 295 (81.7 %) 167 (46.3 %) 22 (6.1 %) 2(0.6 %) 22 (42.3 %)

124 (88.6 %) 117 (83.6 %) 61 (43.6 %) 5 (3.6 %) 1 (0.7 %) 4 (26.7 %)

215 (97.3 %) 178 (80.5 %) 106 (47.9 %) 17 (7.7 %) 1 (0.5 %) 18 (48.65)

0.0017 0.49 0.45 0.12 0.74 0.15

111 (30.7 %) 65 (18.0 %) 95 (26.3 %) 28 (7.8 %) 62 (17.2 %) 71 (20.7 %) 67 (19.5 %) 111 (35.6 %) 53.1±12.4 8.0±6.9

39 (27.9 %) 24 (17.1 %) 36 (25.7 %) 13 (9.3 %) 28 (20.0 %) 33 (23.6 %) 25 (17.9 %) 41 (29.3 %) 52.9±13.2 7.9±6.7

72 (32.6 %) 41 (18.5 %) 59 (26.7 %) 15 (6.8 %) 34 (15.4 %) 38 (17.2 %) 42 (19.0 %) 69 (31.2 %) 53.2±11.84 8.6±6.96

0.64

0.1772 0.8932 0.7856 0.8172 0.3037

Clinic Rev Allerg Immunol Table 3 Clinical events occurred during the follow-up in PBC patients with (n=221) and without (n=140) associated EHA conditions Patients with PBC alone (%) n=140

Patients with PBC+EAI (%) n=221

Long rank test p value

H.R.a

95 % CI

p value

Death Extrahepatic malignancies Variceal bleeding HCC

32 (22.9 %) 11 (7.9 %) 8 (5.7 %) 6 (4.3 %)

48 (21.7 %) 24 (10.9 %) 9 (4.1 %) 5 (2.3 %)

0.69 0.49 0.57 0.24

1.05 2.22 0.91

0.58–1.92 0.91–5.37 0.70–1.18

0.85 0.07 0.49

Ascites

14 (10.0 %)

18 (8.1 %)

0.46

a

Adjusted for sex, age, age at diagnosis, histological stadium, smoke alcohol, BMI >25, and Mayo score

with and without EHA conditions. These results prompt several considerations. First of all, a 61.2 % rate of comorbidity for EHA conditions and their stable prevalence over the years in patients being diagnosed with PBC suggest that most PBC patients might be identified as a result of their EHA condition rather than any symptoms related to their liver disease. This raises the question of how strictly we can define patients with PBC as being symptomatic or asymptomatic. For many years, hepatologists have defined asymptomatic PBC patients as individuals who have no symptoms attributable to their liver disease at the time of its diagnosis. In this setting, pruritus and fatigue are considered symptoms of liver disease in almost all studies, but no mention is usually made of any extrahepatic symptoms of autoimmunity. A complete clinical work-up should include assessing all organs, and a routine examination should rule out the following in all patients with PBC: sicca syndrome, rheumatological disorders, celiac, and thyroid diseases. As expected, the most common association seen in our sample was Sjogren’s syndrome (in 34.3 % of cases), a rate confirming other reports in the literature, in which the

Fig. 1 Kaplan-Meier survival curves for PBC patients with and without EHA conditions

proportion of cases of Sjogren’s syndrome ranges from 33 % to nearly 100 % of cases [5, 26–29]. The clinical symptoms include ocular and oral dryness persisting for more than 3 months or the use of artificial tears more than 3 times a day or the need to drink in order to swallow food. Schirmer’s test is highly specific for the diagnosis of Sjogren’s syndrome [30], and all PBC patients should undergo this easy test at the outpatients clinic. The association between SS and PBC has been interpreted as paradigmatic for a shared immunopathogenesis [31]. In both conditions, environmental triggers (putatively infectious agents and xenobiotics) induce salivary or biliary epithelial cell apoptosis, contributing to the breakdown of the individual’s tolerance of self-antigens exposed to the apoptotic blebs (SSA or SSB) and not protected by posttranslational modifications. When we analyzed cases of SS separately, we found no survival advantage for PBC patients with than for those without SS, so we could not confirm the report from the Royal Free Hospital of PBC patients with associated SS having a slower disease progression than matched patients with PBC alone [32]. The English study had a shorter median follow-up

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than ours, which amounted to 3.16 years for the patients who had both PBC and SS and 4.8 years for those with PBC alone, matched by bilirubin levels. We found a lower prevalence of CD (1.4 %) than in a previous study (3.4 %) published in 2002 [33], and the same picture was seen in the UK, where Lawson et al. also found a lower prevalence of CD in PBC than they had previously reported [34]. The most important point emerging from our study is that any associated EHA conditions were not related with the onset of major events during the follow-up (complications of endstage liver disease, HCC, or extrahepatic cancer), and they did not affect patient survival. The interest of the association between PBC and some rheumatological diseases (and RA in particular) regards the two conditions’ management with immunosuppressants and, more recently, with tumor necrosis alpha (TNFα) antagonists. Nowadays, treatments with biological agents are generating new opportunities for the management of several autoimmune conditions, and they will also enable us to shed light on the cytokine and signaling pathways regulating disease activity; they will probably also improve the quality of life of many patients with EHA conditions. Encouraging results have recently been reported on the use of biological agents in two patients with PBC and associated RA [35, 36]. Importantly, EHA conditions are often associated with PBC, especially in female patients, but these associated conditions do not reduce PBC patient survival and should be taken into account in the clinical management of autoimmune biliary diseases [37].

Declaration of Funding Source This work was partially supported by a grant from the University of Padova.

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