GASTROENTEROLOGY 2001;120:239 –249
Autoantibodies in Liver Disease
ALBERT J. CZAJA* and HENRY A. HOMBURGER‡
*Division of Gastroenterology and Hepatology and ‡Department of Laboratory Medicine and Pathology, Mayo Clinic and Mayo Foundation,
Rochester, Minnesota
utoantibodies are immunoglobulins that react
A against normal host proteins and may be natural or
pathologic.1 Natural autoantibodies are germline re-
sponses that develop from genetically programmed
clones of B cells and are typically present in low serum
titers as isotypes of immunoglobulin M.2–5 Natural au-
toantibodies do not fix complement and usually have
weak antigen-binding affinities, multiple reactivities,
and no disease associations.6,7 They occur more com-
monly in women than in men,8 the repertoires remain
stable with aging,9,10 and they may bind products of
natural cell death or foreign antigens that resemble self-
antigens.11,12 In this fashion, natural autoantibodies may
prevent the emergence of autoreactive immunocytes and
have a protective function.2,4,6,11,12
Pathologic autoantibodies are produced by antigen-
specific B-cell activation and subsequent clonal expan-
sion of dedicated plasma cells.1,2 These autoantibodies
typically are present in high serum titers as isotypes of
immunoglobulin G. Pathologic autoantibodies fix com-
plement, have high antigen-binding affinities, inhibit
autoantigen activity in vitro, and have disease associa-
tions.2,6 They are rarely pathogenic, but their presence in
serum does imply the existence of an antigen-driven
immunopathic process. This process may be crucial for
disease expression, a consequence of other cytodestructive
mechanisms, or coincidental with the main disorder.
Natural and pathologic autoantibodies can be distin-
guished from each other by class-specific attributes (Ta-
ble 1). The presence of low-titer autoantibodies in the
absence of hypergammaglobulinemia or a compatible
clinical liver disease usually indicates the presence of
natural autoantibodies.
Any component of the liver cell can trigger the pro-
duction of pathologic autoantibodies, and reactivities
have been described against nuclear, microsomal, cyto-
solic, and mitochondrial proteins.13 Expression of the
antigen on the surface of professional antigen-presenting
cells is the principal mechanism for activation of B cells,
and antigen presentation to CD4 T-helper cells is re-
stricted by the class II molecules of the major histocom-
patibility complex.14 –16 Intracellular antigens can be ex-
pressed on the surface of the liver cell membrane, and the
hepatocyte can present autoantigens that generate auto-
antibodies.17,18
Mechanisms for pathologic autoantibody production
include the discovery of self-antigens that had been
poorly recognized or sequestered during ontogeny (cryp-
tic or sequestered epitopes) or the generation of new
antigens by the degradation of viruses, xenobiotics, and
chemicals within the hepatocyte (neoepitopes).19,20 Self-
antigens can be targeted by an exuberant immune re-
sponse to an infectious agent (superantigen effect), and
nonspecific mediators of inflammation, including cyto-
kines, chemotactic substances, macrophages, and natural
killer cells, can extend the immune response (bystander
effects). Epitopes within the same antigen or between
different antigens can become involved (epitope spread);
autologous antigens can combine with infectious or en-
vironmental agents (adjuvant effects); or foreign antigens
can mimic self-antigens (molecular mimicry).19,20
Autoantibodies may lack disease specificity or patho-
genic importance, and bystander effects, adjuvant effects,
and molecular mimicry may explain in part the occur-
rence of autoantibodies in nonautoimmune diseases. Im-
portantly, autoantibodies are not found in all forms of
hepatocellular injury and are not simply the trappings of
liver cell destruction. Autoantibody titers do not corre-
late closely with the severity of liver cell damage, and
changes in autoantibody expression do not reflect disease
behavior.21
Abbreviations used in this paper: AIH, autoimmune hepatitis; AMA,
antimitochondrial antibody; ANA, antinuclear antibody; anti-ASGPR,
antibody to asialoglycoprotein receptor; anti-dsDNA, antibody to dou-
ble-stranded DNA; anti-LC1, antibodies to liver cytosol type 1; anti-
LKM1, antibody to liver/kidney microsome type 1; anti-LP, antibody to
liver–pancreas; anti–PDH-E2, antibody to pyruvate dehydrogenase
complex E2; anti-SLA, antibody to soluble liver antigen; anti-SLA/LP,
antibody to soluble liver antigen/liver-pancreas; HLA, human leuko-
cyte antigen; pANCA, perinuclear antineutrophil cytoplasmic antibody;
PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis;
SMA, smooth muscle antibody.
© 2001 by the American Gastroenterological Association
0016-5085/01/$10.00
doi:10.1053/gast.2001.20223
240 CZAJA AND HOMBURGER GASTROENTEROLOGY Vol. 120, No. 1

Table 1. Distinguishing Features of Pathologic and Natural diagnosis of autoimmune hepatitis (AIH) requires the
Autoantibodies presence of autoantibodies, including antinuclear anti-
Pathologic autoantibodies Natural autoantibodies body (ANA), SMA, or antibody to liver/kidney micro-
Autoantigen-driven Germline response some type 1 (anti-LKM1),36 and the diagnosis of primary
Reflective of immunopathic process Unassociated with disease biliary cirrhosis (PBC) is made by detection of antimi-
Probes of target autoantigen Putative preservers of self-
tolerance
tochondrial antibody (AMA) in patients with cholestatic
Associated with indices of disease Associated with normal features (Table 2).37 Perinuclear antineutrophil cytoplas-
activity laboratory tests mic antibody (pANCA) is present in most patients with
IgG type IgM type primary sclerosing cholangitis (PSC)38 – 40 or AIH40 – 43
Strong autoantigen affinity Weak autoantigen affinity
Inhibit autoantigen in vitro Reactivities to multiple and is useful in reclassifying patients with cryptogenic
epitopes chronic hepatitis (Table 2).43,44 Other diagnostic auto-
Fix complement No complement fixation antibodies are not generally available, but they promise
Relatively independent of age and Common in women ⱖ 60 yr
sex
to extend the diagnosis of AIH to patients with seroneg-
High titer Low titer ative or cryptogenic disease. Antibody to soluble liver
antigen (anti-SLA)45 and antibody to liver-pancreas
(anti-LP)46 have identical reactivities and may character-
The genetic predisposition of the host may be a de-
ize some of these patients.45– 49
terminant of autoantibody production and may explain
Autoantibodies may also have prognostic value (Table
in part the sporadic occurrence of autoantibodies and the
2). This attribute has not been established among the
various types encountered in different liver diseases.22–27
standard or investigational autoantibodies. Nevertheless,
The female gender predisposes to their production, as do
the likelihood that some autoantibodies have greater
the human leukocyte antigens (HLA) -DR3 and
disease pertinence than others justifies continuing efforts
-DR4.22,23,25,28 Indeed, the HLA phenotype may affect
to define this feature. Antibodies to actin have high
the type of autoantibody produced. Smooth muscle anti-
specificity for AIH and characterize young patients in
body (SMA) and antibody to double-stranded DNA
whom conventional corticosteroid therapy commonly
(anti-dsDNA) have been associated with HLA-DR4,22,29
fails (Table 2).30,50 Anti-dsDNA in ANA-positive pa-
and mixed cryoglobulinemia and antibody to actin (anti-
tients with AIH is associated with a poor immediate
actin) have been associated with HLA-DR3.27,30 A host-
response to corticosteroids,29 and antibody to asialogly-
dependent phenotype characterized by female sex and
coprotein receptor (anti-ASGPR) is associated with his-
HLA status may promote the expression of pathologic
tologic activity and a propensity for relapse after corti-
autoantibodies in various liver diseases.28
costeroid withdrawal (Table 2).51–53 Similarly, antibody
The relationship between autoantibody production,
to liver cytosol type 1 (anti-LC1) may connote aggressive
disease activity, and genetic predisposition can be ob-
disease in young patients54,55 and recurrent disease in
scure, and multiple factors may interact at different
times in the course of the disease.31–35 In some patients
with chronic hepatitis C, autoantibodies associated with
Table 2. Potential Applications of Autoantibody Assays
histologic changes of cirrhosis and marked biochemical
and histologic activity may be consequences of hepato- Potential applications Pertinent autoantibodies

cellular inflammation.33–35 In other patients with chronic Diagnosis of chronic liver disease ANA
SMA
hepatitis C or the same patient at a different time,
Anti-LKM1
autoantibodies associated with histologic changes of in- AMA
terface hepatitis, panacinar hepatitis, and lymphoplasma- pANCA
cytic portal inflammation may reflect immune-mediated Antibody to histones
Anti–PDH-E2 complex
pathogenic pathways.24,35 The inability to distinguish Anti-SLA/LP
autoantibodies reflective of primary pathogenic mecha- Estimation of treatment outcome Anti-dsDNA
nisms from those secondary to liver cell injury compli- Antiactin
Anti-ASGPR
cates efforts to define clinical relevance. Anti-LC1
Identification of autoantigen Antibody to P450 IID6
Role of Autoantibody Testing in the Antibody to UDP
glucuronosyltransferase
Evaluation of Liver Disease pANCA
Autoantibodies are assessed in liver disease mainly Anti-LC1
Anti-SLA/LP
to diagnose autoimmune conditions (Table 2). A definite
January 2001 AUTOANTIBODIES IN LIVER DISEASE 241

others.56 This antibody also varies in concentration ac- Table 3. Standard Autoantibody Repertoire
cording to disease activity and in contrast to the serum Autoantibody
titers of anti-LKM1.56 Consequently, anti-LC1 may re- type Proposed target(s) Clinical use(s)
flect treatment response and the pertinent pathogenic Nucleus Centromere Diagnosis of type 1 AIH
mechanisms of the disease. pANCA has been associated Ribonucleoproteins
Ribonucleoprotein
with intrahepatic and extrahepatic bile duct disease in complexes
PSC,40 and AMA of increasing titers has been associated dsDNA dsDNA Diagnosis of type 1 AIH
with advancing histologic stage in PBC (Table 2).57 The Smooth Actin Diagnosis of type 1 AIH
muscle Tubulin
use of autoantibodies as barometers of disease activity or Vimentin
predictors of outcome is feasible, but prospective studies Desmin
are needed to corroborate this application and clarify Skeletin
discrepant experiences. Studies that have failed to asso- LKM1 P450 IID6 Diagnosis of type 2 AIH
(CYP2D6)
ciate anti-LC1 with prognosis58,59 or AMA titers with Mitochondria PDH-E2 Diagnosis of PBC
disease progression60,61 must be confirmed or abrogated pANCA Granulocyte-specific Diagnosis of PSC and
in this fashion. antigens in the CUC
nuclear lamina Diagnosis of type 1 AIH
Finally, autoantibodies can be used as biologic probes Actin Reclassification of
to identify disease-associated autoantigens (Table 2).62– 65 cryptogenic hepatitis
These autoantigens are the presumed basis of a cell-
CUC, chronic ulcerative colitis.
mediated immune response that causes the disease. Their
recognition, sequencing, and cloning can improve diag-
nostic and prognostic tests as well as facilitate the de- those for ANA, have been adapted to an enzyme immu-
velopment of animal models essential for clarifying im- noassay format using microtiter plates with adsorbed
munomodulatory mechanisms and designing site-specific recombinant or highly purified antigens. The analytic
therapies. Identification of the cytochrome mono-oxyge- sensitivity for ANA detection is approximately the same
nase P450 IID6 (CYP2D6) as the autoantigen of type 2 as that for established indirect immunofluorescence tech-
AIH63 and uridine diphosphate glucuronosyl transferase niques, but patterns of reactivity are not reported. Indi-
as the target of antibody to liver/kidney microsome type vidual specificities of ANA can be determined by further
3 in chronic hepatitis D64 resulted from these character- testing by enzyme immunoassay.77
izations. Other autoantibody targets—such as actin for ANA reacts against diverse recombinant nuclear anti-
pANCA66; glutathione S-transferases67 or a 50-kilodal- gens, including centromere, ribonucleoproteins, and ri-
ton cytosolic enzyme of uncertain function for anti- bonucleoprotein complexes, and none of the subspecies
SLA49; and formiminotransferase cyclodeaminase68 and defined by nuclear reactivity has had diagnostic specific-
argininosuccinate lyase69 for anti-LC1— have emerged ity or prognostic importance in type 1 AIH (Table
from similar screening strategies, and their relevance is 3).76,78 Because multiple nuclear antigens are targeted by
being assessed. ANA, the autoantibodies may simply be expressions of
heightened immunoreactivity and consequences of liver
cell injury. Alternatively, a single pathogenic immuno-
Repertoire of Standard
reaction may be hidden among the diverse responses76 or
Autoantibodies in the Evaluation the multiple reactivities may be directed against a com-
of Liver Disease plex, as yet unidentified subcellular immunogen.73
ANA is the principal serologic marker of AIH; ANA is the most nonspecific marker of AIH in the
together with SMA, the presence of ANA defines a standard diagnostic repertoire and can be found in PBC,
subgroup designated type 1 AIH (Table 3).70 Nuclear PSC, chronic viral hepatitis, drug-related hepatitis, non-
reactivity can be assessed by indirect immunofluores- alcoholic steatohepatitis, and alcoholic liver dis-
cence on Hep-2 cell lines, and patterns are commonly ease.25,28,32–34,79,80 Furthermore, expression of ANA can
homogeneous (Figure 1A) or speckled (Figure 1B).71–75 vary in the same patient. The autoantibodies can disap-
The speckled pattern is commonly found in young pa- pear and reappear in an unpredictable fashion or be
tients and is associated with higher serum aspartate replaced by SMA.21
aminotransferase levels than the homogeneous pattern.76 Diagnostic specificity may be enhanced if antibodies
However, particular patterns of indirect immunofluores- to histones (antihistones) are sought.81– 84 Histones are
cence have not correlated with treatment outcome.75,76 small basic nuclear proteins that are complexed with
Recently, a number of tests for autoantibodies, including DNA in all eukaryotic cells and are subunits of the
242 CZAJA AND HOMBURGER GASTROENTEROLOGY Vol. 120, No. 1

Figure 1. (A ) ANA (homogeneous pattern) by indirect immunofluorescence on HEp-2 cells (original magnification 125⫻). (B) ANA (speckled
pattern) by indirect immunofluorescence on HEp-2 cells (original magnification 125⫻).

Figure 2. SMA by indirect immunofluorescence on murine stomach
and kidney. The immunofluorescence involves smooth muscle fibers
within blood vessels and muscularis mucosa (original magnification
125⫻).
Figure 3. Anti-LKM1 reacts to the proximal tubules of the murine
kidney (lower portion). The absence of reactivity against the distal
tubules of the murine kidney and gastric parietal cells (upper portion)
distinguishes these antibodies from AMA (original magnification
125⫻).

Figure 4. AMA reacts to the distal tubules of the murine kidney (left)
and the parietal cells of the murine stomach (right) by indirect immu- Figure 5. pANCA by indirect immunofluorescence of human neutro-
nofluorescence (original magnification 125⫻). phils (original magnification 125⫻).
January 2001
nucleosome.85 Histones are probably important in the
binding of DNA to the cell nucleus; theoretically, anti-
bodies against histones could destabilize the nucleus and
impair its function. The predominant antibody against
histones in AIH is the immunoglobulin G antibody to
the H3 histone; preliminary studies suggested that this
antibody occurs mainly in younger patients with higher
serum aspartate aminotransferase levels and greater fre-
quency of HLA-DR4 than seronegative patients.84 There
is still uncertainty whether these determinations, includ-
ing those for class-specific antibodies, offer a diagnostic
and/or prognostic advantage.
Anti-dsDNA is common in ANA-positive patients
with type 1 AIH and may have prognostic value.29,86
However, recognition of these autoantibodies is assay
dependent, and the results of an enzyme immunosorbent
assay have not correlated with those of an indirect im-
munofluorescence assay using Crithidia luciliae as sub-
strate.29
SMA is directed against actin and nonactin compo-
nents, including tubulin, vimentin, desmin, and skel-
etin, and is also a standard marker of type 1 AIH (Table
3).87–92 Using cultured fibroblasts treated with vinblas-
tine, 3 types of SMA have been described and have been
designated as antibodies to actin, tubulin, and interme-
diate filaments.90,91 SMA is present in a variety of liver
and nonliver diseases, and its utility as a diagnostic
marker depends on the clinical syndrome.88,90,91 Like
ANA, SMA has variable expression in individual pa-
tients, and the autoantibody profile rarely “breeds true”
throughout the illness.21 Typically, the antibody is dem-
onstrated in the clinical laboratory by indirect immuno-
fluorescence on murine stomach and kidney (Figure 2).30
Antiactin, especially the polymerized F-actin, has
greater specificity for type 1 AIH than SMA,89,90,93,94 but
the method of detection has not been standardized.95–98
A thermolabile F-actin depolymerizing factor has been
described in serum, and its effect on assay performance
remains unclear.98 Consequently, determinations of anti-
actin have not been incorporated into conventional di-
agnostic algorithms. Preliminary studies using multiple
assays for antiactin have indicated its occurrence in pa-
tients who more commonly have HLA-DR3, early age of
disease onset, and a poorer response to therapy than
patients without antiactin.30 The autoantibodies are less
sensitive for type 1 AIH than SMA, and testing for
antiactin is unlikely to replace testing for SMA as a
screening measure.30,92
Anti-LKM1 typically occurs in the absence of SMA
and ANA and is the serologic marker of type 2 AIH
(Table 3).99 Seropositivity requires reactivity against the
AUTOANTIBODIES IN LIVER DISEASE 243
proximal tubules of the murine kidney and the hepato-
cytes of the murine liver by indirect immunofluorescence
(Figure 3). This pattern can be confused with that of
AMA (Figure 4), and misclassification is possible in 27%
of instances.100 In the United States, only 4% of adult
patients with AIH have anti-LKM1.100 In Europe, espe-
cially among pediatric patients, seropositivity for anti-
LKM1 is more frequent.63,99,101
Anti-LKM1 reacts with high specificity to a short
linear sequence of the recombinant antigen cytochrome
mono-oxygenase P450 IID6 (CYP2D6)63,102–104 and also
inhibits cytochrome P450 IID6 activity in vitro.105
These findings, in concert with evidence that liver-infil-
trating lymphocytes have specific reactivity to P450
IID6,106 have justified designation of this cytochrome as
the target antigen of type 2 AIH.
Homologies exist between P450 IID6 and the ge-
nomes of the hepatitis C virus and herpes simplex type 1
virus.63 Consequently, anti-LKM1 can be found in these
infections.107–111 Reactivities associated with chronic
hepatitis C infection are usually against diverse epitopes,
and epitope screening can distinguish the antibody sub-
types.102,110,112,113 Furthermore, seropositivity for anti-
LKM1 in chronic hepatitis C is extremely unusual in the
United States and Britain, possibly because of environ-
mental factors, genetic predisposition of the host, and/or
genomic variations in the virus.114,115
AMA is the diagnostic hallmark of PBC and is de-
tected by indirect immunofluorescence of the distal tu-
bules of the murine kidney and the parietal cells of the
murine stomach (Table 3; Figure 4).116 Specificity for
PBC can be enhanced by determination of the M2 anti-
bodies that react against the trypsin-sensitive antigens of
the inner mitochondrial membrane.117 The M2 antibod-
ies can be further subclassified according to their reac-
tivities against the 2-oxo acid dehydrogenase complexes
within mitochondria. Antibody reacting against the di-
hydrolipoamide acyltransferase E2 subunits of the pyru-
vate dehydrogenase enzyme complex (anti–PDH-E2) has
the greatest specificity for PBC.37,118 Testing for anti–
PDH-E2 is rarely necessary, and in most clinical situa-
tions, the indirect immunofluorescence assay for AMA is
sufficient for diagnosis.60
pANCA is the newest addition to the standard diag-
nostic repertoire for autoimmune liver disease (Table 3;
Figure 5). Its inclusion has been justified by the fre-
quency of pANCA in PSC and AIH,38 – 44 the putative
association of pANCA with extensive biliary tract disease
in patients with PSC,40 the ability of these pANCA to
distinguish type 1 from type 2 AIH,43 and the potential
of pANCA to reclassify individuals with cryptogenic
244 CZAJA AND HOMBURGER
chronic hepatitis.44 The target antigen is unknown, but
myeloperoxidase, proteinase 3, and elastase have been
eliminated as candidates.42 Furthermore, the nomination
of actin as the target autoantigen has been challenged.66
The reactivity of atypical pANCA in inflammatory bowel
disease and hepatobiliary disorders is against granulo-
cyte-specific antigens in the nuclear lamina, and the
search for target antigens for pANCA is probably best
directed at this site.119
Patients with type 1 AIH and those with ulcerative
colitis commonly express the immunoglobulin (Ig) G1
isotype of pANCA, whereas most patients with PSC
express the IgG1 and IgG3 isotypes.42 Furthermore, the
pANCA in type 1 AIH reacts with neutrophils and
monocytes, whereas the pANCA in PSC reacts only with
neutrophils.42 These observations suggest that the target
autoantigens of pANCA are disease specific. Other stud-
ies have not found similar distinctions, and additional
investigations in well-defined patient populations are
needed to resolve these issues.40
Repertoire of Investigational
Autoantibodies in the Evaluation
of Liver Disease
Anti-ASGPR can coexist with ANA, SMA, and
anti-LKM1 (Table 4).52 This antibody is directed against
a transmembrane glycoprotein on the hepatocyte surface
that can capture, internalize, and display potential anti-
gens to immunocytes.120 –122 Anti-human anti-ASGPR
occurs in 88% of patients with AIH, compared with 7%
of patients with chronic hepatitis B, 8% of patients with
alcoholic liver disease, and 14% of patients with
PBC.52,123 Its presence correlates with inflammatory ac-
tivity; its disappearance connotes effective corticosteroid
treatment; and its persistence after corticosteroid with-
Table 4. Investigational Autoantibody Repertoire
Autoantibody type Proposed target(s)
Asialoglycoprotein receptor Transmembrane hepatocytic glycoprotein
(lectin)
Actin Polymerized F-actin
SLA (identical to LP) 50-kilodalton cytosolic protein
Glutathione S-transferases
LP (identical to SLA) Same as SLA
Liver cytosol type 1 Formiminotransferase cyclodeaminase
Argininosuccinate lyase
Nuclear protein envelope 210-kilodalton transmembrane protein of
nuclear core complex
Histones Nucleosomes
H3 molecule
GASTROENTEROLOGY Vol. 120, No. 1
drawal heralds relapse.51–53 Anti-ASGPR may be a ge-
neric marker of AIH, biologic probes of an important
autoantigen, and/or important indices of treatment re-
sponse. Unfortunately, the assay is difficult to establish,
and a commercial kit is not available.
Anti-SLA has been promulgated as a marker of a type
3 AIH (Table 4).45 Patients with anti-SLA typically lack
ANA and anti-LKM1, but they commonly have SMA
and AMA.45 Furthermore, 11% of patients with type 1
AIH have anti-SLA, and these patients are indistinguish-
able from their counterparts who lack anti-SLA.47,48 Glu-
tathione S-transferases have been proposed as the target
antigens of anti-SLA,67 but this proposal has been dis-
puted,124 and a 50-kilodalton cytosolic protein is now
considered a more likely candidate.49 Characterization of
the target antigen and collaborative studies among the
laboratories that initially described the reactivities have
demonstrated the identity of anti-SLA and anti-LP. Con-
sequently, they are now designated as anti-SLA/LP.49,124
Anti-SLA/LPs have specificity for AIH but are doubtful
markers of a valid subgroup. Their major clinical role
may be in the evaluation and reclassification of crypto-
genic chronic hepatitis.47,48
Anti-LP was initially described independent of anti-
SLA,46 and only recently has its identity to anti-SLA
been recognized.49,124 Consequently, anti-LP can be ex-
pected to have the same clinical utility as anti-SLA, and
the designation anti-SLA/LP replaces the previous terms
anti-LP and anti-SLA.
Anti-LC1 is specific for AIH (Table 4), and formim-
inotransferase cyclodeaminase68 and argininosuccinate
lyase69 have been proposed as the antigenic targets. Anti-
LC1 is rare in patients older than 40 years, and its
prevalence increases in populations younger than 20
years.54,55 Thirty-two percent of patients with anti-LC1
have anti-LKM1, and early studies indicated that anti-
Investigational use(s)
Generic marker of AIH
Barometer of disease activity
Predictor of relapse
Diagnosis of type 1 AIH
Predictor of poorer outcome
Diagnosis of type 3 AIH
Marker of autoimmunity
Reclassification of cryptogenic hepatitis
Same as anti-SLA
Barometer of disease activity
Prognostic index
PBC specific
Evaluation of AMA-negative autoimmune cholangitis
Specific for type 1 AIH
January 2001
LC1 is associated with type 2 AIH, frequent concurrent
immunologic diseases, marked hepatocellular inflamma-
tion, absence of infection with hepatitis C virus, and
rapid progression to cirrhosis.54,55 These observations
have not been fully corroborated, and anti-LC1 has been
absent in children with fulminant AIH, coexistent with
SMA and ANA in type 1 AIH and PSC, and present in
chronic hepatitis C.58 Serum levels fluctuate with disease
activity, in contrast to anti-LKM1, and anti-LC1 may
prove useful as a marker of residual hepatocellular in-
flammation in type 2 AIH or as a probe of an autoantigen
associated with disease severity.56
Antibody to nuclear protein envelope antigens has
been shown to have diagnostic specificity for PBC (Table
4).125,126 The major autoantigen is a 210-kilodalton
transmembrane protein of the nuclear pore complex and
the predominant epitope of antibodies against this pro-
tein is a 15–amino acid sequence in the cytoplasmic,
carboxy-terminal domain.126 Antibody to nuclear enve-
lope protein has distinguished patients with different
clinical features127 and may be present in the absence of
AMA.126 This autoantibody may have value in under-
standing the pathogenesis of PBC and in securing the
diagnosis of atypical forms.
Diagnostic and Treatment
Algorithms
Tests for ANA, SMA, AMA, and anti-LKM1
should be performed in all patients with liver disease
of unknown cause, regardless of duration (Figure 6).
AIH commonly has an acute presentation, and the
onset can be fulminant.128,129 Seropositivity is more
important than autoantibody titer, and a diagnosis of
autoimmune liver disease should never be discarded on
Figure 6. Diagnostic applications of autoantibody
tests. ANA, SMA, AMA, and anti-LKM1 must be
sought first in the evaluation of liver disease of
unknown cause. Seropositivity for one or more of
these autoantibodies in conjunction with the appro-
priate clinical syndrome allows designation of the
disease as type 1 AIH, type 2 AIH, or PBC. Seroneg-
ativity for the entire battery justifies additional diag-
nostic tests, including determinations of pANCA and
repeat assessments of ANA, SMA, AMA, and anti-
LKM1. Investigational antibodies, such as anti-SLA,
or antibodies with high disease specificity, such as
anti–PDH-E2, can also be useful at this time. Pa-
tients who are seronegative at presentation may
subsequently be classified as having AIH, PSC, PBC,
cryptogenic chronic hepatitis, or autoimmune
cholangitis (AIC) by repeat or extended testing.
AUTOANTIBODIES IN LIVER DISEASE 245
the basis of low-level immunoreactivity.21 Immunose-
rologic findings must be balanced against all features
of the clinical syndrome, and the correct diagnosis
must reflect the net result of this comprehensive anal-
ysis. Autoantibodies are neither pathogenic or patho-
gnomonic.
Seropositivity will facilitate classification of the disease
as type 1 AIH, type 2 AIH, or PBC (Figure 6). Seroneg-
ativity by initial screening justifies additional studies to
discriminate AIH, PSC, PBC, cryptogenic chronic hep-
atitis, and autoimmune cholangitis. pANCA may sug-
gest the diagnosis of AIH or PSC, and its detection
justifies cholangiography. Patients with AIH may be
seronegative at presentation, and repeat testing for con-
ventional autoantibodies may allow their recognition.
The availability of investigational assays for anti-SLA/LP
may also facilitate this classification. Repeat testing for
AMA by indirect immunofluorescence or for anti–PDH-
E2 by immunoassay may support the diagnosis of PBC,
whereas persistent seronegativity justifies the diagnosis
of cryptogenic chronic hepatitis130 or, in rare cases, au-
toimmune cholangitis.131 Theoretically, patients with
cryptogenic chronic hepatitis could have autoimmune
liver disease that has escaped detection by the currently
available assays. Alternatively, they may have a disease in
transition, variant syndrome, viral infection, or toxic
etiology, and they must be monitored and evaluated as
indicated with liver biopsy examination and cholangiog-
raphy.130 –132
The success of treatment must be measured by the
clinical, biochemical, and histologic responses. Standard
autoantibodies are not useful parameters of disease activ-
ity or treatment outcome.21 Consequently, they need not
be monitored longitudinally or used as endpoints of
246 CZAJA AND HOMBURGER
therapy in patients with established diagnoses. Autoan-
tibody titers can fluctuate, and new autoantibody species
can appear during the period of observation.21 Investi-
gational autoantibodies have not been validated as diag-
nostic or prognostic indices, and their measurement has
not been standardized (Table 4). They should be mea-
sured only in an investigational context.
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Received November 4, 1999. Accepted July 19, 2000.
Address requests for reprints to: Albert J. Czaja, M.D., Mayo Clinic,
200 First Street S.W., Rochester, Minnesota 55905. Fax: (507) 284-
0538; e-mail: czaja.albert@mayo.edu.
The authors thank Linda Grande for secretarial support.