Autoimmune Hepatitis

Autoimmune hepatitis is a special inflammatory disorder of the liver where the liver shows chronic active inflammation. The presence of autoimmune antibodies and high-level gamma globulin in the serum and piecemeal necrosis of liver cells are its characteristic histological features.

There are three types of autoimmune hepatitis: Type I, classic AH, is mostly present in females. The serum ANA (+) and ASM (+) are its characteristic markers. Type II is mostly seen in children and exhibits anti-liver and anti-kidney micro-some antibodies. Type III shows anti-liver soluble antigen antibodies as its major characteristic.

The prognosis of AH is related to the genetic features of the patients and also the activities of the inflammation. For severe cases, if left untreated, the mortality rate is around 90% within ten years. For genetic marker MLADR3 positive patients, the onset age is younger, the inflammation is more serious and liver failure is more common without treatment.

The onset of the disease is usually a subtle and gradual process. During the beginning stage, there may be some joint pain, low grad fever, fatigue, skin rashes, and amenorrhea (pauses in menstruation). The systematic extra-liver manifestations of the disease may mislead diagnosis. It is often misdiagnosed as rheumatoid arthritis, connective diseases disorder, or menstruation disorders. The disease is usually correctly diagnosed when jaundice occurs. About 20 to 30% of patients will have an onset of acute viral hepatitis and the diagnosis should be distinguished from chronic active hepatitis B and C. It does not have serum titles of the anti-viral antibodies and instead show multiple autoimmune antibodies in the serum. Alcohol and drug related hepatitis should also be excluded from the diagnosis. The standard for a definite diagnosis of this disease is a liver biopsy.

Conventional medical treatments mainly use immune suppressive therapies. These methods can improve the symptoms but do not change the disease course. The immune suppressive treatments are often hard on the liver and can cause adverse reactions that make long-term treatment unavailable. MCM has developed many liver protective and immune regulatory herbal treatments that can alter the course of the disease and can also be safely used for the long-term.

Epidemiology

This disease is more often seen in females than males, the ratio is around 4 ~ 6 :1. Incidence peaks around the childhood period. For females, the post-menopausal period may become another peak period of incidence. This disease has obvious racial and genetic tendencies. The Northern European, English, Irish, and Jewish populations have a higher incidence rate compared to other racial groups.

Extra-liver manifestations are the characteristics of AH

1. Symmetrical recurrent vacillate arthritis: it usually affects major joints, causes pain, stiffness, but without deformation. This can often be misdiagnosed as rheumatic or rheumatoid arthritis.
2. Low grad fever, skin rashes, inflammation of skin and blood vessels, and subcutaneous bleeding.
3. Endocrine system dysfunction: Round moon-like face, acne, hair overgrowth, amenorrhea in females, breast development in males, Hashimoto disease, hyperthyroidism, and diabetes.
4. Glomerulonephritis, acid tubal nephropathy, and immuno-globulin deposit in the kidney.
5. Inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) and Sjogren’s syndrome in about half of the patients.
6. Hematologically, light anemia, low WBC and platelet counts. The mal-functioning of the spleen and the effects of autoimmune anti-WBC and Anti-platelet antibodies cause Low WBC and platelet counts.
7. Interstitial lung inflammation, lung fibrosis, and hypertension in the lung artery.

Laboratory tests for AH diagnosis

1. The LFTs: Persistent ALT and AST elevation, usually is three to five times higher than the normal range. ALT > AST in the early stage and AST>ALT during the later stages. GGT and AKP are usually elevated, albumin is usually normal and gamma-globulin is dramatically elevated. The elevation of IgG is greater than IgM and IgA. bilirubin total and direct are greatly elevated.
2. Multiple autoimmune serum factors are the characteristic features of this disease:
1. ANA positive in about 60 to 80% of the patients;
2. Anti-smooth-muscle antibodies positive in about 30% of the patients.
3. Anti-mitochondrial antibodies positive in about 30% of the patient.
4. Liver cell membrane antibodies, LSP and LMA antibodies positive. 

Treatments for AH

1. For general treatment during the active liver inflammation period, bed rest is advisable. Physical activities should be limited. Abstain from alcohol and maintain a well-balanced diet. Any chronic infections such as gum diseases, sinusitis, bronchitis etc, should also be treated.
2. Immune suppressive therapies.

In conventional medicine, the main medications used are steroids such as prednisone; it might improve the symptoms will not prevent cirrhosis from occurring. If the blood counts are within normal range, prednisone plus Azathioprine (AZP) could be used. After biochemical parameters have improved, treatment should last for one year. AZP should be used until prednisone use has completely stopped. About 65% of patients can enter remission within three years of treatment. When the treatment has stopped, about 50% patients may relapse within six months. The same treatment can be repeated and will still be effective, but the likelihood of relapse will also increase. For a patient with one relapse, a small maintenance dose is necessary. For those who did not respond to the treatment, increasing the dosage might increase the response rate. Other therapies include Cyclosporin, FK-506. The problem for conventional treatment is that the drugs themselves are toxic to the liver. AZP is toxic to the liver and can cause bile retention and necrosis of the liver cells. In severe cases, it even can cause liver failure. With AH, the liver function of the patient is already compromised so this type of treatment may cause further damage to the liver. Other side effects include hair loss, gastrointestinal dysfunctions, mouth and skin inflammation, fever and pancreatitis. Long-term use can weaken the immune system and render the patient vulnerable to opportunistic infections.

3. Modern Chinese Medicine immune regulatory treatments:

Based on the pathogenesis of AH, suppressing the production of auto-antibodies is the main goal of treatment. We use immune regulatory herbs to reduce auto-antibody production and reduce the gamma-globulin level. A circulation promoting formula used to promote phagocytosis of macrophages and removal of immune complex. Herbs with anti-inflammatory effects are used to help reduce inflammation in the liver. Controlling the inflammation is the primary measure in stopping the progression of liver fibrosis.

4. MCM liver protective treatments:

Using anti-fibrosis herbs to control liver cell inflammation and necrosis, and reduce the level of ALT and AST.  

5. Bile retention releasing treatments:
   For elevated GGT, Bilirubin AKP, and jaundice, herbs can be used for facilitating bile secretion to bring down bilirubin levels and eliminate itching of the skin.  
6. Peripheral treatments can be combined with symptomatic treatments. Herbal sleep aids can help improve sleep and infections can be treated with the anti-microbial formulas, fatigue with energy enhancing herbs, etc.