Case ReportA collaborative integrative and Ayurvedic approach to cirrhosis in the setting of autoantibody negative autoimmune hepatitis: a case report
Introduction
Autoimmune hepatitis (AIH) is a chronic and progressive inflammatory process of the liver of unknown etiology. There are 3 main subtypes of autoimmune hepatitis, type 1 and type 2 have auto-antibodies found on serology, including anti-smooth muscle antibodies, anti-mitochondrial antibodies, anti-microsomal antibodies, antinuclear antibodies, and/or anti-soluble liver antigen antibodies [1]. In the third subtype, the patient does not have demonstrable autoantibodies, but responds to treatments similar to those used for types 1 and 2, indicating a similar underlying disease process [1]. AIH can present at any age and at similar rates in all ethnic groups; it is more common in women [1].
The clinical presentation is varied and can range from asymptomatic incidental findings in lab work or imaging to acute fulminant liver failure, sometimes with long periods of subclinical disease prior to presentation. It generally has a poor prognosis without treatment, but outcomes are greatly improved through the use of immunosuppressive medications. Randomized clinical trials have established prednisone and azathioprine as first-line treatment options [2], [3], [4].
Remission rates with this treatment are generally good, with approximately 65% and 80% of patients achieving remission at 18 and 36 months, respectively [5]. Of those who achieve remission, however, 50–90% will relapse within 12 months after stopping treatment, though 80% of those patients will again achieve remission with retreatment [5], [6]. Up to 30% of adults with autoimmune hepatitis will have cirrhosis at the time of diagnosis, and cirrhosis develops in another 30–50% of patients during follow up [5], [6].
Many other treatment options have been evaluated for patients who do not respond to prednisone and azathioprine. For those who fail to respond to all pharmacological interventions, liver transplantation is often the only alternative [7].
A potential source of additional treatment options, however, can be found in the field of integrative medicine. According to the National Institutes of Health, integrative health care brings evidence based conventional and complementary approaches together in a coordinated way to emphasize a holistic, patient-focused approach to health care and wellness [8]. Ayurvedic Medicine, one of the healing traditions that is incorporated within integrative medicine, is a natural system of medicine which originated in India more than 3000 years ago, and encourages lifestyle interventions as well as natural therapies to regain a balance between the body, mind, spirit and the environment [9]. While there are many Integrative and Ayurvedic treatment options that have been shown to be helpful for other liver disorders, no studies have been performed to evaluate these therapies in AIH with cirrhosis [10].
Our case report details the care of a 55-year-old female AIH and cirrhosis who presented to The University of Arizona Center for Integrative Medicine Clinic to seek other treatments while awaiting a liver transplant. The patient was treated with a regimen of evidence-based supplements and lifestyle modifications and experienced a significant improvement in her liver function. To our knowledge this is the first such case report detailing an integrative and Ayurvedic approach to AIH with cirrhosis that has shown such a notable improvement in disease severity.
Section snippets
Case overview
A 55-year-old female with no known significant past medical history developed symptoms of fatigue and generalized swelling approximately 8 months prior to initial presentation to her primary care physician. She had abnormal liver function tests and was referred to a gastroenterologist, who obtained imaging that demonstrated signs of cirrhosis and cholelithiasis. She was admitted to the hospital, where lab testing was negative for antinuclear antibodies, anti-microsomal antibodies, anti-smooth
Outcome and follow-up
Four months later, the patient followed up with her primary care clinician and was noted to have continued improvement to her disabling edema and muscle cramps. Of particular importance, her MELD score further decreased to 10 and her Child Pugh’s score was 7, placing her in class B, improved from category of class C (see summary in Fig. 1 and Table 2). The patient continues to be on the liver transplant list, but may be removed from the transplant list if her MELD and Child Pugh scores continue
Discussion
The Integrative approach to this patient centered on a regimen of dietary supplements prescribed, as mentioned previously, with the express intent of improving her intrahepatic glutathione stores, given that glutathione deficiency has been deemed a pathophysiological hallmark of chronic liver disease, and repleting glutathione is a promising strategy to recover oxidative stress-induced liver damages [12], [13]. The roles of each of the agents the patient received are discussed below.
Glutathione
Conclusion/summary points
The patient described in this case report who had AIH with cirrhosis experienced significant improvement in MELD score (from 25 to 10) as well as subjective improvements in quality of life while undergoing treatment with allopathic, integrative, and Ayurvedic therapies over a course of approximately 7 months. It is unclear to what extent the patient’s immunosuppressive medications, supplements, spiritual approaches, and/or antibiotic treatments contributed to her improvement over time, based on
CRediT authorship contribution statement
George Schatz: Conceptualization, Writing – original draft, Writing – review & editing. Erica Kumala: Conceptualization, Writing – original draft, Writing – review & editing. Amita Nathwani: Conceptualization, Writing – original draft, Writing – review & editing.
Conflict of interest
The authors have no conflicts of interest to disclose.
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