Editorial: The Role of Liver Biopsy in ANA Positive Subjects

An interesting study from Germany on the role of liver biopsy in patients with elevated antinuclear antibody (ANA) is presented [1]. As the authors point out, according to international guidelines, liver biopsy is recommended in patients with a clinical suspicion of AIH. However, the specific criteria of a ‘clinical suspicion’ are poorly defined. Although liver biopsy results are a part of the new simplified autoimmune hepatitis score [2] and in some guidelines [3], the necessity to perform a liver biopsy in patients with typical laboratory features of AIH has been challenged [4]. This is based on the results that histological findings do rarely change management in these patients, as shown in a study from the Mayo Clinic [5] and recently reproduced in a Turkish study [6]. In the current German study, a similar rate of possible AIH was observed in patients with and without pos ANA, 20% versus 15% [1]. Overall, 61% of the cohort undergoing a biopsy were ANA positive, 22% of the ANA positive had compatible AIH histology, whereas this occurred in around 16% in the ANA negative group. Interestingly, in the subgroup with ALT < 101 U/L, only 9% of patients had liver histology features compatible with AIH [1]. Not surprisingly, the prevalence of AIH (likely or possible) increased with rising ALT levels, from 9% in patients with ALT < 101 U/L to 50% in those with ALT > 1000 U/L. Only three of the patients with mild ALT (< 101 U/L) elevation were ultimately diagnosed with AIH and started on long-term immunosuppression. Two of them had cirrhosis and elevated liver stiffness measurements, in line with previous studies showing that patients with cirrhosis or advanced fibrosis can present with mild or moderate liver test elevations [7]. Other interesting results of the current study in patients with ALT > 1000 U/L were the substantial number of patients with histologically ‘unlikely’ AIH (n = 13) who nonetheless were treated with corticosteroids (n = 7) with a biochemical response in all of them (n = 7) and to the initiation of long-term immunosuppression in 29% (n = 2). This agrees with the study from the Mayo Clinic that demonstrated that although the histological features were considered ‘atypical’, most of these patients also received immunosuppression [5]. There are several take home messages from this retrospective study on the role of liver biopsies in patients with positive ANA. Firstly, in patients with low ALT and concomitant ANA, liver biopsy is rarely helpful. Secondly, if these patients turn out to have possible or likely AIH, they most often have advanced fibrosis or cirrhosis. Thirdly, the proportion with likely AIH diagnosis increased with higher enzyme elevations and in those with positive ANA and ALT > 1000 U/L, 50% had likely AIH. Also, among these with these high ALT levels (ALT > 1000 U/L), a significant number received corticosteroids and long-term immunosuppression despite having ‘unlikely’ histological findings. Thus, the current study provides helpful data in decision making of patients with elevated liver tests and ANA positivity. Einar S. Björnsson: conceptualization, investigation, methodology. The author has nothing to report. The author declares no conflicts of interest. This article is linked to Niazi et al. papers. To view this article, visit https://doi.org/10.1111/apt.70665. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.