Me again-AIH Biopsy

Posted by Dianne on July 02, 1999 at 10:14:36
I had a repeat biopsy after 4 years and wondered if you can comment The general architecture of the liver is distorted by the presence of pseudolobular formations, nodular fragmentation and expansions of the portal areas with chronic inflamation (inflammation).  Focal areas show irregularity of the limiting plate and a moderate inflamatory infiltrate in the portal areas consisting mainly of lymphocytes.  Focal area of bile duct proliferation is seen.  No malignanat changes are seen.  Trichrome stain-- periportal fibrous tissues and the presence of fibrous bands with pseudolobular formations are noted.  Some of the pseudolobules are small and other large.  Reticulan stain-- increase in reticular fibers in the fibrous septa.  Nothing on iron or other stains.  Comparison with 1995- slightly increase fibrosis.  Inflammatory activity not changed significantly-Diagnosis-- fibrosis with regenerative microndules consistent with micronodular cirrhosis.
In reading your comments on other biopsies, I could not detect some of those magic words such as bridging.  I was also told that at this point it was likely that I had some permanent damage.  I would like to know what micronodular cirrhosis is.  I got the impression from my visit that I was moving forward in a slow progression and that the progression would or could at some point progress to end stage liver disease.  I would also like to know better what that entails.  I was given a guestamate of 10 years when I prodded.  We also discussed the fact that I am not taking prednisone per my request, only immuran.  My levels have never returned to normal, but run about the same as they did on the prednison.  I had to weigh, the long term consequences of taking it, and what it was doing to may ability to get things done in the present.  My doc was wonderful in understanding this, but did say that now that I am moving another doctor may not be so willing to allow me that option.  He could not say whether it would have made the difference or not.  Anyway, I have some mixed feelings about all this, but most of all would like to understand better.  The terminology is different in comparing the reports I have.  Thank you for any info you can provide, and your opinion on the prednisone issue would be greatly appreciated.  Dianne

Posted by HFHSM.D.-D.M. on July 11, 1999 at 15:45:54
Dear Dianne;
I really appreciated hearing from you and hearing about your recent biopsy.  I would like to make a few comments.
First of all, cirrhosis is an advanced form of scarring and fibrosis.  It is considered more advanced that bridging fibrosis and actually is considered a stage 4 out of 4 and most grading systems for fibrosis.  However, we do know that patients with autoimmune hepatitis who have cirrhosis can respond well to treatment and remain stable for long periods of time without developing signs of a failing liver.  
Decisions on immunosuppression and prednisone are very complicated.  As you yourself have pointed out there are trade-offs and decisions have to be made by patients to weigh the side effects of medication versus the underlying disease.  Sometimes, in some of our patients with autoimmune hepatitis we try to compromise by using imuran with relatively low doses of prednisone.  We feel the low doses of prednisone will work well with imuran to help retard disease progression and that we can control the side effects of low doses of prednisone, especially with newer drugs that help prevent prednisone associated osteoporosis (bone thinning).
As always, I enjoy your letters.  If you have additional questions or more information, feel free to post the material back to MEDHELP.   The direct number to the Liver Clinic at Henry Ford is [phone].
This response is being provided for general informational purposes only and should not be considered medical advice or consultation. Always check with your personal physician when you have a question pertaining to your health.
Posted by Dianne on July 11, 1999 at 21:23:53
Thank you for your comments.  I appreciate your straightforwardness.  Could you explain to me what prednisone does that immuran doesn't?  I understand, I think, that prednisone is an anti-imflammatory, while immuran is an immune suppressant, so I would guess that one reduces imflamation directly and the other does so by suppressing the attack from the immune system? Is that why the combo is recommended?  I am willing to do what is best for me, but I just don't know what that is.  On 10mg a day of prednisone, the body aches and moodiness were the most troublesome, along with the weight gain, which I feel can still be in my realm of control if I were to take it again.  It's hard to explain, but I got so frustrated with feeling like I was always on the verge of getting the flu.  Can a smaller dosage be effective?  Also, I have not been told about any medication for bone loss.  What would that be?  I do also dislike the idea of having to take one pill to treat the effects of another pill.  Lastly, I know that there is no way of knowing the speed of progression, etc.  How do I say this?  I can live with the idea of things getting worse, but what I am struggling with is my ability to do my work well.  I will have 6 years until tenure, and I can't be satisified with just getting by.  I have worked hard for many years to do nothing but the best I can do.  It is hard for me to even think that I will have to settle for anything less.  This is a giant fear for me, that I won't be productive.  Silly, I know.  I'm am an over-achieving summa *** laude sort.  What advice to you give your patients in terms of finding a balance in all this?  I desparately want to feel that I have some control here.  Thanks again.  Sorry for the length.  

Posted by sunney on August 25, 1999 at 00:01:14
i cannot believe that i have finally found someone out there that has the same thoughts on the Prednisone vs immuran and the questions as to why both are recommended jointly. I have been on a dosage of 30mg Prednisone and 100 mg Imuran daily for some time now. I cannot make it through a full day of work due to the feeling that I want to run away from my own body. I've been on as low as 10mg pred which was i could manage but my liver counts seem to go crazy periodically for what they call "no reason" and the dosage roller coaster starts again. Can the imuran produce the desired affect alone?

Posted by HFHSM.D.-D.M. on September 05, 1999 at 20:51:22
Dear Diane and sunney:
First I regret the delay in answering the MedHelp questions in the last month but the delay was due to factors outside my control.  Let me try to address some of your most recent questions.  
You both are interested in the differences and specific roles of prednisone and imuran.  First of all prednisone has both anti-inflammatory and immunosuppressive properties.  It is one of the most effective drugs known for autoimmune hepatitis and is the mainstay of therapy.  Unfortunately it has a lot of side effects especially when used over many years.  Imuran is called an anti-metabolite and has more specific immunosuppressive property especially against T cells.  While it typically has fewer side effects than prednisone, it is generally less potent.  In autoimmune hepatitis, we use it to allow us to taper and hopefully eliminate prednisone.  Up to a third of patients with autoimmune hepatitis can eventually be taken off prednisone and left on imuran alone.  
Diane asked if doses of less than 10 mg of prednisone would be effective for her.   Its difficult for me to answer that.  Again, we typically taper the prednisone to the lowest dose that still results in normal liver enzymes.  A variety of medications are used to prevent bone loss and they include calcium, diphosphate (fosomax) drugs, calcitonin  and vitamin D.  The best drugs depend upon the individual, their specific disease and their unique concerns.
I hope this information is helpful to you. Good luck to both of you.  Feel free to let me know if you have additional questions or information by posting them to MedHelp.  The direct number to our Liver Clinic at Henry Ford at [phone]. We have an active group of liver specialists with experience with autoimmune hepatitis.
This response is being provided for general informational purposes only and should not be considered medical advice or consultation.  Always check with your personal physician when you have a question pertaining to your health.