Real-World Management of Patients with Primary Biliary Cholangitis—A Retrospective Study from a Tertiary Medical Center in Israel

Abstract

Background: Primary biliary cholangitis (PBC) is a rare autoimmune liver disease with variation in prevalence, phenotype and prognosis across different geographical regions. Little is known about PBC in Israel. Our aim was to characterize the demography, clinical presentation, treatment patterns and prognosis in a cohort of PBC patients followed in a referral center in central Israel. Methods: Clinical, demographic and laboratory data were collected from the medical records of PBC patients followed at Tel Aviv Medical Center in the years 2003–2020. Results: We have identified 189 patients with a confirmed diagnosis of PBC; 92.6% were female and the mean age at diagnosis was 54.7 years. Thirty-nine percent were diagnosed with another autoimmune disease and 5.9% were diagnosed with a PBC-AIH (autoimmune hepatitis) variant syndrome. Ninety-six percent were treated with ursodeoxycholic acid (UDCA) at a mean dose of 13.3 mg/kg. A total of 28.1% were found with inadequate response to UDCA according to the Toronto criteria, and 53% of the UDCA non-responders were treated with bezafibrate. Younger age at diagnosis, higher baseline levels of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT), AIH-PBC variant and positive anti-smooth muscle antibodies (ASMA) were associated with an inadequate UDCA response. In a multivariable analysis, higher ALP at diagnosis (OR = 1.92 CI 1.11–3.20 per 50-unit change, p = 0.018) and ASMA (OR = 27.6 CI 2.58–295, p = 0.006) independently predicted inadequate UDCA response. Higher alanine transaminase (ALT), ALP and GGT, lower albumin, younger age at diagnosis and pruritus conferred an increased risk for disease progression. Conclusions: Disease characteristics, treatment patterns, response to therapy and prognosis of a PBC patient cohort in a tertiary center in central Israel were revealed. The results highlight the importance of risk stratification in PBC, specifically in younger patients, those presenting with a high level of liver enzymes and in ASMA-positive patients with an assumed diagnosis of the AIH-PBC variant.

The treatment of primary biliary cholangitis: from shadow to light

“…Logically, patients who respond to registered PBC treatment can expect a better prognosis than patients who do not respond. In recent years, several studies have been published looking at the prognosis of PBC patients treated with UDCA, evaluating standard laboratory parameters prior to the initiation of PBC treatment 28 , 34 – 37 Chinese authors found that a low albumin level and a higher IgG level as well as all liver tests (alanine aminotransferase (ALT), AST, GGT, and ALP) before starting UDCA treatment predicted a lack of response to UDCA. 36 High ALP prior to UDCA treatment is associated with an incomplete response to treatment.…”

“… 35 High ALP prior to UDCA treatment correlated with an inadequate response to treatment in multivariate analysis, while young age at diagnosis of PBC, presence of pruritus prior to treatment, low albumin prior to treatment, and high ALT, GGT, and ALP predicted disease progression. 37 Low AST and ALT levels prior to UDCA treatment correlate with the achievement of a biochemical response. 34 …”