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Update of the simplified criteria for autoimmune hepatitis: Evaluation of the methodology for immunoserological testing

  • Author Footnotes
    † Equally contributing authors.
    Johanna Galaski
    Footnotes
    † Equally contributing authors.
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Author Footnotes
    † Equally contributing authors.
    Christina Weiler-Normann
    Footnotes
    † Equally contributing authors.
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
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  • Miriam Schakat
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Kalliopi Zachou
    Affiliations
    Institute of Internal Medicine and Hepatology, Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
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  • Paolo Muratori
    Affiliations
    Department for Life Quality Studies, Alma Mater Studiorum, University of Bologna, Bologna, Italy

    European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
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  • Sibylle Lampalzer
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Friedrich Haag
    Affiliations
    Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Christoph Schramm
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
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  • Marco Lenzi
    Affiliations
    Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy

    European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
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  • George N. Dalekos
    Affiliations
    Institute of Internal Medicine and Hepatology, Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
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  • Ansgar W. Lohse
    Correspondence
    Corresponding author. Address: I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. Tel.: +49 (0)40 741053910, fax: +49 (0)40 741058531.
    Affiliations
    I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
    Search for articles by this author
  • Author Footnotes
    † Equally contributing authors.

      Highlights

      • IFT on HEp-2 cells is a valid alternative for the diagnosis of AIH when cut-off titers are increased.
      • ANA ELISA and F-actin ELISA represent potential alternatives to IFT for the diagnosis of AIH.
      • ANA ELISA kits should include HEp-2 nuclear extracts to account for unrecognized autoantigens.
      • ELISA cut-offs need to be validated locally to be predictive in diagnosing AIH.

      Background & Aims

      The simplified criteria for the diagnosis of autoimmune hepatitis (AIH) include immunofluorescence testing (IFT) of antinuclear and smooth muscle autoantibodies (ANA and SMA) on rodent tissue sections. We aimed to establish scoring criteria for the implementation of ANA IFT on human epithelioma-2 (HEp-2) cells and ELISA-based testing.

      Methods

      ANA and SMA reactivity of 61 AIH sera and 72 non-alcoholic fatty liver disease controls were separately assessed on tissue sections and HEp-2 cells to compare the diagnostic value at increasing titers. A total of 113 patients with AIH at diagnosis and 202 controls from 3 European centers were assessed by IFT as well as 3 different commercially available ANA ELISA and 1 anti-F-actin ELISA.

      Results

      ANA assessment by IFT on liver sections had 83.6% sensitivity and 69.4% specificity for AIH at a titer of 1:40. On HEp-2 cells, sensitivity and specificity were 75.4% and 73.6%, respectively, at an adjusted titer of 1:160. Area under the curve (AUC) values of ANA ELISA ranged from 0.70–0.87, with ELISA coated with HEp-2 extracts in addition to selected antigens performing significantly better. SMA assessment by IFT had the highest specificity for the SMA-VG/T pattern and anti-microfilament reactivity on HEp-2 cells. ELISA-based anti-F-actin evaluation was a strong predictor of AIH (AUC 0.88) and performed better than SMA assessment by IFT (AUC 0.77–0.87).

      Conclusion

      At adjusted cut-offs, both ANA IFT using HEp-2 cells and ELISA-based autoantibody evaluation for ANA and SMA are potential alternatives to tissue-based IFT for the diagnosis of AIH.

      Lay summary

      Autoantibodies are a hallmark of autoimmune hepatitis and are traditionally tested for by immunofluorescence assays on rodent tissue sections. Herein, we demonstrate that human epithelioma cells can be used as a reliable substrate for immunofluorescence testing. ELISA-based testing is also a potentially reliable alternative for autoantibody assessment in autoimmune hepatitis. We propose the implementation of these testing methods into the simplified criteria for the diagnosis of autoimmune hepatitis.

      Graphical abstract

      Keywords

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