Chapter 4.4
Autoimmune hepatitis and viral hepatitis and nutrition
Natasha A. Vidas1 and Catherine McAnenny2
1King’s College Hospital NHS Foundation Trust, London, UK
2Royal Infirmary of Edinburgh, Edinburgh, UK
4.4.1 Autoimmune hepatitis
Autoimmune hepatitis (AIH) is a rare chronic progressive inflammatory liver disease of unknown aetiology. AIH is classified as type 1 or type 2 according to serum autoantibody profiles [1].
Nutritional consequences
Symptoms of AIH include anorexia, nausea, abdominal pain, fatigue and arthralgia, of which the latter two can be incapacitating [2]. These symptoms may affect appetite, oral intake and nutritional status [3,4]. Further nutritional consequences of AIH stem predominantly from medication side-effects and co-existing autoimmune diseases.
Autoimmune hepatitis is frequently treated with long-term corticosteroids. Nutritional side-effects include increased appetite, weight gain, fluid retention and mood changes in the short term. Longer term side-effects include weight gain, central obesity, peptic ulcers, onset of steroid-induced diabetes and/or hypertension, deterioration in the control of pre-existing diabetes and/or hypertension, increased risk of fractures secondary to osteopenia, osteoporosis and avascular bone necrosis, pancreatitis and psychosis [1,2]. Osteoporosis with vertebral compression and brittle diabetes has been found in 27% and 20% of patients with AIH respectively. Patients most at risk of these drug-related side-effects include postmenopausal women, individuals with pre-existing osteoporosis, brittle diabetes, emotional instability or obesity. Treatment risk benefit is thus important to consider before corticosteroid initiation [1,2].
Azathioprine, frequently used in combination with corticosteroids in AIH, particularly for treatment periods over 6 months, has several side-effects which may have nutritional consequences including nausea, vomiting, pancreatitis and, more rarely, a diarrhoeal syndrome associated with small intestinal villous atrophy and malabsorption. Side-effects develop in 10% of patients but improve when azathioprine is reduced or stopped [2].
The incidence of coeliac disease is 4% in type 1 AIH and 8% in type 2. Screening for coeliac disease before and during treatment in patients with AIH has been suggested [5]. Sixteen percent of patients with AIH have ulcerative colitis (UC) [6]. Both these diseases have nutritional consequences and need to be taken into account in the nutritional management of these patients.
Dietary management
The symptoms of AIH, side-effects of azathioprine, existence of coeliac disease and UC, and the potential progression to cirrhosis in patients with AIH should all be considered in nutritional assessment and intervention.
Manns et al. (2010) suggest that corticosteroid treatment and related bone disease should direct lifestyle and dietary advice and treatment including weight-bearing exercise, vitamin D and calcium supplementation [2]. The use of bisphosphonates should be considered in individuals with osteopenia and osteoporosis. Dual-energy X-ray absorptiometry (DEXA) scans are recommended annually for patients on long-term corticosteroids [2]. The development or worsening of diabetes and hypertension with corticosteroid use should be managed with dietary and medical intervention as appropriate.
Future developments
It is suggested that insulin resistance is involved in the pathogenesis of AIH [7]. Salmon et al. found steatosis related to age and diabetes in 25% of patients with AIH [8]. It seems reasonable to suggest that a well-balanced diet and regular exercise may prove beneficial but further studies to demonstrate this are required.
4.4.2 Viral hepatitis
Viral hepatitis is inflammation of the liver due to a viral infection and it affects over 700,000 people in the UK. It can present as a recent infection with a rapid onset or it can take a chronic form. The most common causes of viral hepatitis are five unrelated hepatotrophic viruses: hepatitis A, B, C, D and E.
Hepatitis A, B and C are the most common hepatic viruses but B and C can cause long-term liver damage and liver cancer. Hepatitis D, also known as a delta virus, can only exist in the body in the presence of hepatitis B. It is seen mostly in central Africa, the Middle East and central South America. Infection rates are low in most of Europe and the USA. The treatment for hepatitis D is the same as the treatment for hepatitis B. Hepatitis E is most common in South Asia, Africa and Central America, areas that are known for poor sanitation. There is no specific dietary advice for patients infected with hepatitis D and hepatitis E. For hepatitis E, there is no specific treatment and most people go on to make a full recovery.
Hepatitis A
Hepatitis A is a virus that is transmitted by the faecal–oral route, often through the ingestion of contaminated food and drink. The virus passes out in the stool of the infected person. It is common in areas where the water supplies and sewage disposal are of a poor standard. Fruit, vegetables and uncooked foods washed in contaminated water can cause the infection as can shellfish if it is sourced from contaminated waters. Incubation time averages 28 days and most people fully recover within 2 months. Infection is not common in the UK but a vaccine is available that can offer protection for up to 10 years. Most people recover from hepatitis A with no lasting damage to the liver [9].
Hepatitis B
The hepatitis B virus (HBV) is classified by the World Health Organization as the world’s second greatest carcinogen after tobacco. HBV is 50–100 times more infectious than HIV. In the UK, HBV has a low prevalence but there is significant variation across the country. Transmission of HBV is by parenteral exposure to infected blood or body fluids. HBV is not spread by casual contact such as touching hands and kissing, or sharing towels and eating utensils. A vaccine is available that will prevent infection from HBV for life.
The goal of therapy for HBV is to improve the quality of life and prevent progression to end-stage liver disease, hepatocellular carcinoma (HCC) and death [10]. Two major groups of antiviral therapies are used in the treatment of HBV: interferon and an oral nucleoside. HBV infection cannot be totally cleared so therapy is aimed at reducing HBV DNA to as low as possible [10]. The most common side-effect is an initial flu-like illness; other common side-effects include fatigue, anorexia and weight loss. Generally speaking, the treatment for HBV appears to be well tolerated and patients do not have the same tolerance issues that can arise with hepatitis C treatment. However, other co-morbidities, including alcohol abuse and being overweight, can affect the natural course of HBV as well as the efficacy of the antiviral strategies [10].
Hepatitis C
Hepatitis C virus (HCV) is the main cause of chronic liver disease worldwide [11]. It is estimated that over 200 million people, i.e. 3% of the world population have HCV. Prior to the 1990s, the main routes of transmission of HCV were through blood transfusions, unsafe injection procedures and intravenous drug use [12]. Currently new HCV infections are due mostly to intravenous or nasal drug use and to a lesser extent unsafe medical or surgical practices. The risk of perinatal and heterosexual transmission is low; recent data indicate that promiscuous male homosexual activity is related to HCV infection [13].
In some cases the HCV infection resolves spontaneously but as acute HCV is often asymptomatic, detection and diagnosis are usually difficult. The primary goal of HCV therapy is to eradicate the circulating virus by achieving a sustained virological response (SVR) and preventing the complications of HCV-related liver disease.
Dietary effects of HCV or its management
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