| BackgroundAutoimmune Hepatitis(AIH)is an inflammatory liver disease mediated by autoimmune reactions,with variable clinical manifestations and nonspecific laboratory findings.It often coexists with various other liver diseases,and treatment can be complicated by drug side effects,treatment resistance,and relapse after discontinuation.The prevalence of AIH is increasing worldwide.Without timely treatment,AIH can progress to decompensated cirrhosis,liver failure,and other end-stage liver diseases.Acute-on-chronic liver failure(ACLF)occurring on the basis of AIH is relatively common,but the factors contributing to its occurrence and progression are not yet clear.Hepatitis B virus(HBV)infection is prevalent in China,with a 2006 nationwide seroepidemiological survey finding a 7.2%HBsAg positivity rate in the population aged 159 years.The impact of AIH on the course of chronic HBV infection and the effect of chronic HBV infection on the progression of AIH are unclear.ObjectivesTo analyze the clinical characteristics of patients with AIH;to investigate the prevalence of HBV infection among AIH patients;and to identify the risk factors for ACLF and death in patients with AIH.MethodsThe study subjects were patients diagnosed with AIH who were hospitalized at Shandong Public Health Clinical Center between January 2010 and December 2020.Cases were further screened based on inclusion and exclusion criteria.Clinical data including demographic information,clinical manifestations,laboratory and imaging examination results,treatment,and outcomes were collected.The study analyzed the HBV serological markers,HBV DNA quantitative detection results,previous HBV infection and anti-HBV treatment status of AIH patients,as well as the promoting factors and clinical characteristics ofA CLF and the risk factors for in-hospital mortality of AIH patients.Statistical analysis was performed using SPSS version 26.0 software.Quantitative data were described using mean± standard deviation(X ± S)or median and quartile range M(P25,P75)and analyzed using t-test or Mann-Whitney U test.Qualitative data were described using frequency(n)and percentage(%)and analyzed using chi-square test.Logistic regression analysis was used for multivariate analysis.All statistical tests were two-tailed,and P<0.05 indicated statistical significance.ResultsA total of 323 cases that met the inclusion criteria were included in the study,including 24 cases that were HBsAg positive,42 cases that developed ACLF,and 14 cases of in-hospital mortality.The clinical characteristics of AIH,the HBV infection status,the clinical characteristics of ACLF patients,and the risk factors for in-hospital mortality are reported below.1.Clinical features of AIHAmong 323 patients,there were 264 females and 59 males,with a male-to-female ratio of 1:4.5 and a mean age of 55.1 ± 12.1 years.The peak age of onset was between 40 and 59 years.43 cases(13.3%)had concurrent autoimmune diseases outside of the liver,including 8 cases of rheumatoid arthritis,7 cases of Sj?gren’s syndrome,19 cases of autoimmune thyroid disease,4 cases of systemic lupus erythematosus,2 cases of Raynaud’s syndrome,1 case of Behcet’s disease,1 case of adult-onset Still’s disease,and 2 cases of psoriasis.144 cases(44.6%)had liver cirrhosis,42(13.0%)developed ACLF,61(18.9%)had bacterial infections,and 28(8.7%)had viral infections.24 patients(7.4%)had a history of steroid therapy before admission,and 84 patients(26.0%)received immunosuppressive therapy during hospitalization,including 74 cases of steroid monotherapy,8 cases of steroid combined with azathioprine therapy,1 case of steroid combined with mycophenolate mofetil therapy,and 1 case of cyclosporine A monotherapy due to intolerance to steroids and azathioprine.239 cases(74.0%)received supportive treatment such as hepatoprotective drugs.The average age of patients in the immunosuppressive therapy group was younger than that in the nonimmunosuppressive therapy group(51.5±13 vs.56.3±11.5,P=0.002),and the MELD score was higher in the immunosuppressive therapy group than in the nonimmunosuppressive therapy group(13.6±8.2 vs.6.7±7.9,P<0.001).2.Prevalence of HBV infection in AIH patientsAmong 323 AIH patients,24 cases(7.4%)were HBsAg positive,129 cases(39.9%)were HBsAb positive,13 cases(4.0%)were HBeAg positive,43 cases(13.3%)were HBeAb positive,and 118 cases(36.5%)were HBcAb positive.Compared with HBsAgnegative patients,HBsAg-positive patients had no significant differences in mean age(50.9± 10.9 vs.55.± 12.1,P=0.08)and proportion of liver cirrhosis(37.5%vs.45.2%,P=0.53),but had a significantly higher proportion of males(37.5%vs.16.7%,P=0.02)and hepatocellular carcinoma(HCC)(12.5%vs.1.7%,P=0.02).Among the 8 patients who developed HCC,the incidence rates in the HBsAg-positive,HBsAg-positive/HBeAb-positive,HBsAb-positive/-negative/HBcAb-positive,and HBsAb-positive/negative AIH patients were 12.5%,2.8%,3.4%,and 0.1%,respectively.3.Clinical Characteristics and Risk Factors of ACLF in Patients with AIHAmong the 42 ACLF patients,26(61.9%)had bacterial infections,3(7.1%)were HBsAg-positive,2(4.8%)were HBV DNA-positive,and 3(7.1%)had a history of steroid use.Compared to non-ACLF patients,there was no significant difference in the mean age(52.7±13.3 vs.55.4±11.8,P=0.17)or male-to-female ratio(P=1.00).However,ACLF patients had a significantly higher proportion of rural residents(73.8%vs.54.1%,P=0.02),liver cirrhosis(59.5%vs.42.3%,P=0.045),MELD scores(24.1±5.4 vs.6.2±5.4,P<0.001),mortality(28.6%vs.0.7%,P<0.001),bacterial infections(61.9%vs.12.5%,P<0.001),ascites(38.1%vs.11.1%,P<0.001),spontaneous bacterial peritonitis(33.3%vs.7.1%,P<0.001),and hepatic encephalopathy(31.0%vs.1.4%,P<0.001).ACLF patients had significantly elevated levels of ALT,AST,TBIL,IgG,INR,and NEU,and significantly reduced levels of ALB,PLT,GGT,HGB,Na,and CH(P<0.05).Multivariate logistic regression analysis revealed that bacterial infection(OR=6.8,95%CI:1.8-26.2,P=0.005)and MELD score>18(OR=199.8,95%CI:49.5-806.2,P<0.001)were risk factors for ACLF.Among the 42 ACLF patients,12(28.6%)died.The mortality group did not differ significantly from the survival group in terms of age(50.6±13.5 vs.53.6±13.4,P=0.52)or male-to-female ratio(P=0.65).However,the mortality group had significantly higher MELD scores(29.7±3.0 vs.21.9±5.3,P=0.009)and HE rates(83.3%vs.10.0%,P<0.001),and significantly lower Na(130.7±9.8 vs.138.1±13.7,P=0.001)and CH levels[1.9(1.2,2.8)vs.2.6(1.9,3.2),P=0.03].4.Risk Factors for Death in AIH PatientsAmong the 323 AIH patients,14 died,resulting in a mortality rate of 4.3%.Of these,12 died due to ACLF,and 2 died due to septic shock.The mortality group did not differ significantly from the survival group in terms of age(52.2±13.4 vs.55.2±11.9,P=0.36)or male-to-female ratio(P=0.65).However,the death group had a significantly higher proportion of bacterial infections(71.4%vs.16.5%,P<0.001),HE(71.4%vs.2.3%,P<0.001),and ACLF(85.7%vs.0.6%,P<0.001)as well as MELD score(28.4±13.0 vs.7.617.1,P<0.001)than the survival group.The death group also had significantly lower levels of PLT,HGB,Na,and CH than the survival group(P<0.05).Multivariate logistic regression analysis found that compared with the survival group,bacterial infection(OR=6.4,95%CI:11.1-38.2,P=0.04),Na<130mmol/L(OR=61.3,95%CI:7.6-493.7,P<0.001),and MELD score>18 points(OR=22.5,95%CI:3.6-139,P<0.001)were risk factors for death in AIH patients.Conclusions1.AIH is more common in women,with a peak incidence between 40-59 years of age.It usually has a chronic onset,but some patients have an acute onset or develop liver failure.AIH patients are also prone to develop other autoimmune diseases outside the liver.2.In AIH,the HBsAg and HBcAb positive rate are 7.4%and 36.5%,respectively,which are roughly consistent with the results of a national epidemiological survey of hepatitis B in the general population.HB V infection is a risk factor for the development of HCC in AIH patients.3.Bacterial infections and severe liver injury(MELD score>18)are risk factors for ACLF in AIH patients.4.Bacterial infections,hyponatremia(Na<130mmol/L),and severe liver injury(MELD score>18)are risk factors for death in AIH patients. |
