Turkiye Klinikleri Journal of Pediatrics

.: ORIGINAL RESEARCH
Çocuklarda Otoimmün Hepatit: Tek Merkez Deneyimi: Tanımlayıcı Araştırma
Autoimmune Hepatitis in Children: A Single Center Experience: Descriptive Research
Hakan SALMANa, Fatma İSSİ IRLAYICIa, Mustafa AKÇAMa
aSüleyman Demirel Üniversitesi Tıp Fakültesi, Çocuk Gastroenteroloji, Hepatoloji ve Beslenme BD, Isparta, Türkiye
Turkiye Klinikleri J Pediatr. 2023;32(1):1-7
doi: 10.5336/pediatr.2022-92883
Article Language: TR
Full Text
ÖZET
 Amaç: Çocukluk yaş grubunda değişik klinik bulgularla gelebilen otoimmün hepatit, nedeni tam açıklanamayan bazen ciddi seyir göstererek ölümcül olabilen bir durumdur. Bu çalışmada, kliniğimizde takip ettiğimiz otoimmün hepatitli hastaların irdelenmesi amaçlanmıştır. Gereç ve Yöntemler: Ocak 2010-Aralık 2020 tarihleri arasında takipli tanı anında 18 yaş altı otoimmün hepatit (OİH) hastalarının demografik özellikleri, klinik tabloları, laboratuvar ve görüntüleme bulguları, histopatolojik bulguları, tedavi ve seyirleri dosyalarından geriye dönük olarak değerlendirildi. Viral etiyolojiler, Wilson hastalığı ve alkole bağlı olmayan yağlı karaciğer hastalığı gibi kronik karaciğer hastalığı olası nedenleri dışlandı. Tüm hastalara karaciğer biyopsisi yapılarak, uyumlu histopatolojik bulgular ile tanı desteklendi. Bulgular: Değerlendirilen 18 hastanın 11'i (%61,1) kız, tanıda yaş ortalaması 9,75±4,52 yıl idi. En sık görülen klinik bulgu karın ağrısıydı (%66,7). Başlangıçta 10 (%55,6) hasta ikterikti, 7'sinde (%38,9) tanı anında siroz gelişmişti. Otoantikorlara göre 10 (%55,6) hasta Tip 1, 2 (%11,1) hasta Tip 2 ve 6 (%33,3) hasta da seronegatif olarak kabul edildi. En sık görülen histopatolojik bulgu interface hepatitti (%83,3). Takipte 2 (%11,1) hastada varyant sendrom olarak primer sklerozan kolanjit, 4 (%22,2) hastada da ek otoimmün hastalık tespit edildi. Hastaların hepsine steroid ve azatiyoprin, ayrıca kolestatik bulguları olan 15 (%83,3) hastaya ursodeoksikolik asit tedavisi verildi. Tedaviye dirençli 2 (%11,1) hastada tedavi değişikliği yapıldı. İlaç yan etkisi olarak 4 (%22,2) hastada sadece lökopeni, 2 (%11,1) hastada da hem lökopeni hem de osteopeni-osteoporoz gelişti. Sonuç: Pediatrik çağda sıklıkla kızlarda ve 10 yaş civarında görülen OİH değişken klinik bulgularla seyredip, immünsupresif tedaviye sıklıkla yanıt vermektedir. Ancak ideal tedavi için ileri araştırmalara ihtiyaç vardır.

Anahtar Kelimeler: Çocuk; otoimmün hepatit; karaciğer sirozu; transaminazlar
ABSTRACT
 Objective: Autoimmune hepatitis, which may present with different clinical findings in the childhood, is a condition that is not explained clearly, sometimes with a serious course and a mortal course. In this study, it was aimed to examine the patients with autoimmune hepatitis that we followed up in our clinic. Material and Methods: Demographic characteristics, clinical pictures, laboratory and imaging findings, hystopathological findings, treatment and course of patients with autoimmune hepatitis under 18 years of age followed up between January 2010 and December 2020 were evaluated, retrospectively. Possible causes of chronic liver disease such as Wilson's disease, viral etiologies, and non-alcoholic fatty liver disease were excluded. Liver biopsy was performed in all patients and the diagnosis was supported by histopathological findings. Results: Of the 18 patients evaluated, 11 (61.1%) were girls, and the mean age at diagnosis was 9.75±4.52 years. The most common clinical finding was abdominal pain (66.7%). At admission, 10 patients (55.6%) were icteric and 7 (38.9%) had cirrhosis at the time of diagnosis. According to autoantibodies, 10 (55.6%) patients were considered Type 1, 2 patients (11.1%) Type 2 and 6 patients (33.3%) were considered seronegative. The most common histopathological finding was interface hepatitis (83.3%). At followup, primary sclerosing cholangitis was detected as variant syndrome in two patients (11.1%), and additional autoimmune disease was detected in 4 (22.2%) patients. All patients received steroids and azathioprine, as well as ursodeoxycholic acid treatment in 15 (83.3%) patients with cholestatic findings. Treatment changes were made in 2 resistant patients (11.1%). As a side effect of the drug, only leukopenia developed in 4 patients (22.2%) and both leukopenia and ostoepenia-osteoporosis in 2 patients (11.1%). Conclusion: Autoimmune hepatitis, which is frequently seen in girls and around 10 years of age in childhood, has with variable clinical findings and often responds to immunosuppressive therapy. However, further research is needed for the ideal treatment.

Keywords: Child; autoimmune hepatitis; liver cirrhosis; transaminasemias
REFERENCES:
  1. Oettinger R, Brunnberg A, Gerner P, Wintermeyer P, Jenke A, Wirth S. Clinical features and biochemical data of Caucasian children at diagnosis of autoimmune hepatitis. J Autoimmun. 2005;24(1):79-84. [Crossref]  [PubMed] 
  2. Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, et al. Diagnosis and management of autoimmune hepatitis in adults and children: 2019 practice guidance and guidelines from the American Association for the Study of Liver Diseases. Hepatology. 2020;72(2):671-722. [Crossref]  [PubMed] 
  3. Sirbe C, Simu G, Szabo I, Grama A, Pop TL. Pathogenesis of autoimmune hepatitis-cellular and molecular mechanisms. Int J Mol Sci. 2021;22(24):13578. [Crossref]  [PubMed]  [PMC] 
  4. Mackay IR. Historical reflections on autoimmune hepatitis. World J Gastroenterol. 2008;14(21):3292-300. [Crossref]  [PubMed]  [PMC] 
  5. Vergani D, Mieli-Vergani G. Aetiopathogenesis of autoimmune hepatitis. World J Gastroenterol. 2008;14(21):3306-12. [Crossref]  [PubMed]  [PMC] 
  6. Garrido I, Lopes S, Simões MS, Liberal R, Lopes J, Carneiro F, et al. Autoimmune hepatitis after COVID-19 vaccine - more than a coincidence. J Autoimmun. 2021;125:102741. [Crossref]  [PubMed]  [PMC] 
  7. Avci E, Abasiyanik F. Autoimmune hepatitis after SARS-CoV-2 vaccine: New-onset or flare-up? J Autoimmun. 2021;125:102745. [Crossref]  [PubMed]  [PMC] 
  8. Czaja AJ, Doherty DG, Donaldson PT. Genetic bases of autoimmune hepatitis. Dig Dis Sci. 2002;47(10):2139-50. [Crossref]  [PubMed] 
  9. Zachou K, Rigopoulou E, Dalekos GN. Autoantibodies and autoantigens in autoimmune hepatitis: important tools in clinical practice and to study pathogenesis of the disease. J Autoimmune Dis. 2004;1(1):2. [Crossref]  [PubMed]  [PMC] 
  10. Bellomo-Brandão MA, Costa-Pinto EA, De Tommaso AM, Hessel G. Clinical and biochemical features of autoimmune hepatitis in 36 pediatric patients. Arq Gastroenterol. 2006;43(1):45-9. [Crossref]  [PubMed] 
  11. Gregorio GV, Portmann B, Reid F, Donaldson PT, Doherty DG, McCartney M, et al. Autoimmune hepatitis in childhood: a 20-year experience. Hepatology. 1997;25(3):541-7. [Crossref]  [PubMed] 
  12. Ozen H, Koçak N, Saltik IN, Yüce A, Gürakan F. Autoimmune hepatitis. Indian J Pediatr. 2001;68(8):725-8. [Crossref]  [PubMed] 
  13. Rafeey M, Kianrad M, Hasani A. Autoimmune hepatitis in Iranian children. Indian J Gastroenterol. 2007;26(1):11-3. [PubMed] 
  14. Choudhuri G, Somani SK, Baba CS, Alexander G. Autoimmune hepatitis in India: profile of an uncommon disease. BMC Gastroenterol. 2005;5:27. [Crossref]  [PubMed]  [PMC] 
  15. Porta G, Miura IK, Cardoso RA, Bittencout PL, Vianna R, Pugliese RPS, et al. Clinical and laboratory features of Brazilian children with autoimmune hepatitis types 1 and 2. J Pediatr Gastroenterol Nutr. 2000; 31(supplement 2): 4-19. [Link] 
  16. Peng M, Li Y, Zhang M, Jiang Y, Xu Y, Tian Y, et al. Clinical features in different age groups of patients with autoimmune hepatitis. Exp Ther Med. 2014;7(1):145-8. [Crossref]  [PubMed]  [PMC] 
  17. Sütçüoğlu O, Gök Sargın Z, Alizadeh Haghighi N, Demirbaş Yüceldi S, Karataş A, Önal İK, et al. Otoimmün hepatit hastalarında tek merkez tedavi deneyimi [A single center treatment experience in autoimmune hepatitis patients]. Gazi Medical Journal. 2017;28:174-8. [Link] 
  18. Zachou K, Gatselis NK, Arvaniti P, Gabeta S, Rigopoulou EI, Koukoulis GK, et al. A real-world study focused on the long-term efficacy of mycophenolate mofetil as first-line treatment of autoimmune hepatitis. Aliment Pharmacol Ther. 2016;43(10):1035-47. [Crossref]  [PubMed] 
  19. Najafi M, Kianifar HR, Mir-Nasseri SMM, Mohammad S, Khodadad A. Autoimmune hepatitis in children, clinical features and biochemical of Iranian children. Govaresh. 2005;10(2):103-7. [Link] 
  20. Khedr MA, Salem TA, Boghdadi GM, Elharoun AS, El-Shahaway AA, Atallah HR, et al. Seronegative autoimmune hepatitis in children: A real diagnostic challenge. Wien Klin Wochenschr. 2022;134(5-6):195-201. [Crossref]  [PubMed] 
  21. Khedr MA, Adawy NM, Salim TA, Salem ME, Ghazy RM, Elharoun AS, et al. Kupffer Cell hyaline globules in children with autoimmune hepatitis. J Clin Exp Hepatol. 2022;12(1):20-8. [Crossref]  [PubMed]  [PMC] 
  22. Özsoylu S, Yüce A, Koçak N. Çocuklarda kronik aktif hepatit (47 vakanın analizi) [Chronic active hepatitis in children: analysis of 47 cases]. Turk J Gastroenterohepatol. 1993;4(2):133-36. [Link] 
  23. Maggiore G, Veber F, Bernard O, Hadchouel M, Homberg JC, Alvarez F, et al. Autoimmune hepatitis associated with anti-actin antibodies in children and adolescents. J Pediatr Gastroenterol Nutr. 1993;17(4):376-81. [Crossref]  [PubMed] 
  24. Mogahed E, El-Karaksy H, Zaki H, Abdullatif H. Autoimmune hepatitis in Egyptian children: A single center experience. Int J Immunopathol Pharmacol. 2022;36:20587384211073265. [Crossref]  [PubMed]  [PMC] 
  25. Kaya MN, Yıldız A, Kırık A, İçli MC, Toprak Ö. Otoimmün hepatit hastalarında karaciğer fibrozisi ile ortalama trombosit hacmi arasındaki korelasyon [Correlation between liver fibrosis and mean platelet volume in autoimmune hepatitis patients]. Sakarya Medical Journal. 2020;10(4):615-22. [Crossref] 
  26. Heneghan MA, McFarlane IG. Current and novel immunosuppressive therapy for autoimmune hepatitis. Hepatology. 2002;35(1):7-13. [Crossref]  [PubMed] 
  27. Alvarez F, Ciocca M, Ca-ero-Velasco C, Ramonet M, de Davila MT, Cuarterolo M, et al. Short-term cyclosporine induces a remission of autoimmune hepatitis in children. J Hepatol. 1999;30(2):222-7. [Crossref]  [PubMed] 
  28. Aksoy B, Baran M, Cagan Appak Y, Sag E, Cakir M, Guven B, et al. Efficiency of azathioprine monotherapy for maintenance treatment of autoimmune hepatitis in children. Eur J Gastroenterol Hepatol. 2022;34(1):92-7. [Crossref]  [PubMed] 
  29. Di Giorgio A, Tulone A, Nicastro E, Norsa L, Sonzogni A, D'Antiga L. Use of oral vancomycin in children with autoimmune liver disease: A single centre experience. World J Hepatol. 2021;13(12):2113-27. [Crossref]  [PubMed]  [PMC] 
  30. Shin E, Schwarz KB, Jones-Brando LV, Florea LD, Sabunciyan S, Wood LD, et al. Expression of HLA and autoimmune pathway genes in liver biopsies of young subjects with autoimmune hepatitis type 1. J Pediatr Gastroenterol Nutr. 2022;75(3):269-75. [Crossref]  [PubMed]  [PMC] 

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