Management of Difficult Cases of Autoimmune Hepatitis

  • Craig Lammert
  • Veronica M. Loy
  • Kiyoko Oshima
  • Samer GawriehEmail author
Liver (S Cotler and E Kallwitz, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Liver


Autoimmune hepatitis (AIH) is a complex autoimmune disease characterized by immune-mediated destruction of hepatic parenchyma which can result in cirrhosis, liver failure, and death. Current American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of Liver (EASL) guidelines recommend corticosteroids alone or in combination with azathioprine as first-line treatment strategies. However, a significant proportion of patients may not be able to tolerate or achieve complete biochemical response with these options. In this article, we discuss approaches to these patients and other challenging AIH patient groups such as the asymptomatic, pregnant, elderly, and liver transplant recipients.


Autoimmune hepatitis Pregnancy Cirrhosis Nonstandard treatment Liver transplantation Refractory 



Autoimmune hepatitis


American Association for the Study of Liver Diseases


European Association for the Study of Liver




Aspartate aminotransferase


Alanine aminotransferase


Immunoglobulin G




Mycophenolate mofetil


Primary sclerosing cholangitis


Primary biliary cholangitis


6-Thioguanine nucleotide


6-Methyl mercaptopurine


Mammalian target of rapamycin


International normalized ratio


Model for end-stage liver disease


Recurrent autoimmune hepatitis


Human leukocyte antigen


Compliance with Ethical Standards

Conflict of Interest

Craig Lammert reports grants from NIH, during the conduct of the study; Veronica M. Loy, Kiyoko Oshima, and Samer Gawrieh declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

With regard to the authors’ research cited in this paper, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. In addition, all applicable international, national, and/or institutional guidelines for the care and use of animals were followed.

Grant Support

This publication was made possible with support provided to Craig Lammert from Grant Numbers KL2TR001106 and UL1TR001108 (A. Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.••
    European Association for the Study of the Liver. EASL clinical practice guidelines: autoimmune hepatitis. J Hepatol. 2015;63(4):971–1004. Electronic address: Most up to date, recently released national society AIH consensus statement aimed at providing diagnostic and therapeutic guidance for clinicians. Includes a wide collection of small observational AIH studies, few randomized controlled trails, and a large degree of expert opinion.CrossRefGoogle Scholar
  2. 2.
    Heneghan MA, Yeoman AD, Verma S, Smith AD, Longhi MS. Autoimmune hepatitis. Lancet. 2013;382(9902):1433–44.CrossRefPubMedGoogle Scholar
  3. 3.
    Waldenstrom J. Liver, blood proteins and nutritive protein. Dtsch Z Für Verdau- Stoffwechselkrankheiten. 1953;9:113–9.Google Scholar
  4. 4.
    de Vries AB, Janse M, Blokzijl H, Weersma RK. Distinctive inflammatory bowel disease phenotype in primary sclerosing cholangitis. World J Gastroenterol. 2015;21(6):1956–71.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Carbone M, Mells GF, Pells G, Dawwas MF, Newton JL, Heneghan MA, et al. Sex and age are determinants of the clinical phenotype of primary biliary cirrhosis and response to ursodeoxycholic acid. Gastroenterology. 2013;144(3):560–9.e7. quiz e13–4.CrossRefPubMedGoogle Scholar
  6. 6.
    Verma S, Torbenson M, Thuluvath PJ. The impact of ethnicity on the natural history of autoimmune hepatitis. Hepatology. 2007;46(6):1828–35.CrossRefPubMedGoogle Scholar
  7. 7.•
    Ngu JH, Gearry RB, Frampton CM, Stedman CAM. Predictors of poor outcome in patients with autoimmune hepatitis: a population-based study. Hepatology. 2013;57(6):2399–406. A large population based evaluation of 133 AIH patients and predictors of outcome with median follow-up of 9 years. Model indicated that early normalization of liver tests are associated with improved outcomes, yet cirrhosis, was not a poor predictor.CrossRefPubMedGoogle Scholar
  8. 8.•
    Kirstein MM, Metzler F, Geiger E, Heinrich E, Hallensleben M, Manns MP, et al. Prediction of short- and long-term outcome in patients with autoimmune hepatitis. Hepatology. 2015;62(5):1524–35. A large European single center outcome experience with 354 AIH patients. Early diagnosis (<18 years) and + anti-SLA/LP antibodies were significant risk factors for worse outcomes.CrossRefPubMedGoogle Scholar
  9. 9.
    Feld JJ, Dinh H, Arenovich T, Marcus VA, Wanless IR, Heathcote EJ. Autoimmune hepatitis: effect of symptoms and cirrhosis on natural history and outcome. Hepatology. 2005;42(1):53–62.CrossRefPubMedGoogle Scholar
  10. 10.
    Cook GC, Mulligan R, Sherlock S. Controlled prospective trial of corticosteroid therapy in active chronic hepatitis. Q J Med. 1971;40(158):159–85.CrossRefPubMedGoogle Scholar
  11. 11.••
    Grønbæk L, Vilstrup H, Jepsen P. Autoimmune hepatitis in Denmark: incidence, prevalence, prognosis, and causes of death. A nationwide registry-based cohort study. J Hepatol. 2014;60(3):612–7. A Danish nationwide assessment of over 1700 AIH patients indicating that AIH incidence doubled during the study period (1994–2012). During the first year of AIH diagnosis, mortality was 6 times higher than that of the general population, and 2 times higher thereafter.CrossRefPubMedGoogle Scholar
  12. 12.
    Manns MP, Czaja AJ, Gorham JD, Krawitt EL, Mieli-Vergani G, Vergani D, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51(6):2193–213.CrossRefPubMedGoogle Scholar
  13. 13.•
    Hübener S, Oo YH, Than NN, Hübener P, Weiler-Normann C, Lohse AW, et al. Efficacy of 6-Mercaptopurine as second-line treatment for patients with autoimmune hepatitis and azathioprine intolerance. Clin Gastroenterol Hepatol. 2015. doi: 10.1016/j.cgh.2015.09.037. Largest assessment of 6-MP in AIH patients that are intolerant to AZA therapy. 75% (15) of patients tolerated 6-MP well even after significant (mostly gastrointestinal) side effects of AZA.PubMedGoogle Scholar
  14. 14.
    Montano-Loza AJ, Carpenter HA, Czaja AJ. Features associated with treatment failure in type 1 autoimmune hepatitis and predictive value of the model of end-stage liver disease. Hepatology. 2007;46(4):1138–45.CrossRefPubMedGoogle Scholar
  15. 15.
    Werner M, Wallerstedt S, Lindgren S, Almer S, Björnsson E, Bergquist A, et al. Characteristics and long-term outcome of patients with autoimmune hepatitis related to the initial treatment response. Scand J Gastroenterol. 2010;45(4):457–67.CrossRefPubMedGoogle Scholar
  16. 16.
    Lüth S, Herkel J, Kanzler S, Frenzel C, Galle PR, Dienes HP, et al. Serologic markers compared with liver biopsy for monitoring disease activity in autoimmune hepatitis. J Clin Gastroenterol. 2008;42(8):926–30.CrossRefPubMedGoogle Scholar
  17. 17.
    Hennes EM, Oo YH, Schramm C, Denzer U, Buggisch P, Wiegard C, et al. Mycophenolate mofetil as second line therapy in autoimmune hepatitis? Am J Gastroenterol. 2008;103(12):3063–70.CrossRefPubMedGoogle Scholar
  18. 18.•
    Jothimani D, Cramp ME, Cross TJS. Role of mycophenolate mofetil for the treatment of autoimmune hepatitis—an observational study. J Clin Exp Hepatol. 2014;4(3):221–5. MMF is well tolerated in 74% of AIH patients with AZA intolerance. In a small subgroup, it is unlikely to provide liver test normalization in AZA treatment failure.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Lees CW, Maan AK, Hansoti B, Satsangi J, Arnott IDR. Tolerability and safety of mercaptopurine in azathioprine-intolerant patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2008;27(3):220–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Hindorf U, Johansson M, Eriksson A, Kvifors E, Almer SHC. Mercaptopurine treatment should be considered in azathioprine intolerant patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2009;29(6):654–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Czaja AJ. Drug choices in autoimmune hepatitis: part a—steroids. Expert Rev Gastroenterol Hepatol. 2012;6(5):603–15.CrossRefPubMedGoogle Scholar
  22. 22.
    Soloway RD, Summerskill WH, Baggenstoss AH, Geall MG, Gitnićk GL, Elveback IR, et al. Clinical, biochemical, and histological remission of severe chronic active liver disease: a controlled study of treatments and early prognosis. Gastroenterology. 1972;63(5):820–33.PubMedGoogle Scholar
  23. 23.
    Manns MP, Woynarowski M, Kreisel W, Lurie Y, Rust C, Zuckerman E, et al. Budesonide induces remission more effectively than prednisone in a controlled trial of patients with autoimmune hepatitis. Gastroenterology. 2010;139(4):1198–206.CrossRefPubMedGoogle Scholar
  24. 24.
    Miyake Y, Iwasaki Y, Terada R, Okamaoto R, Ikeda H, Makino Y, et al. Persistent elevation of serum alanine aminotransferase levels leads to poor survival and hepatocellular carcinoma development in type 1 autoimmune hepatitis. Aliment Pharmacol Ther. 2006;24(8):1197–205.CrossRefPubMedGoogle Scholar
  25. 25.
    Verma S, Gunuwan B, Mendler M, Govindrajan S, Redeker A. Factors predicting relapse and poor outcome in type I autoimmune hepatitis: role of cirrhosis development, patterns of transaminases during remission and plasma cell activity in the liver biopsy. Am J Gastroenterol. 2004;99(8):1510–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Muratori L, Muratori P, Lanzoni G, Ferri S, Lenzi M. Application of the 2010 American Association for the study of liver diseases criteria of remission to a cohort of Italian patients with autoimmune hepatitis. Hepatology. 2010;52(5):1857.CrossRefPubMedGoogle Scholar
  27. 27.
    Kanzler S, Löhr H, Gerken G, Galle PR, Lohse AW. Long-term management and prognosis of autoimmune hepatitis (AIH): a single center experience. Z Für Gastroenterol. 2001;39(5):339–48.CrossRefGoogle Scholar
  28. 28.•
    Dhaliwal HK, Hoeroldt BS, Dube AK, McFarlane E, Underwood JCE, Karajeh MA, et al. Long-term prognostic significance of persisting histological activity despite biochemical remission in autoimmune hepatitis. Am J Gastroenterol. 2015;110(7):993–9. A small paired liver biopsy study revealing that only young age at diagnosis and continued disease activity on biopsy (despite normal liver tests) are associated with reduced transplant-free survival.CrossRefPubMedGoogle Scholar
  29. 29.•
    van Gerven NMF, Verwer BJ, Witte BI, van Erpecum KJ, van Buuren HR, Maijers I, et al. Epidemiology and clinical characteristics of autoimmune hepatitis in the Netherlands. Scand J Gastroenterol. 2014;49(10):1245–54. This large Scandinavian AIH epidemiology study revealed AIH prevalence is 18.3 per 100,000 and concurrent autoimmune diseases were found in a quarter of those with AIH.CrossRefPubMedGoogle Scholar
  30. 30.
    Sockalingam S, Blank D, Abdelhamid N, Abbey SE, Hirschfield GM. Identifying opportunities to improve management of autoimmune hepatitis: evaluation of drug adherence and psychosocial factors. J Hepatol. 2012;57(6):1299–304.CrossRefPubMedGoogle Scholar
  31. 31.
    Dhaliwal HK, Anderson R, Thornhill EL, Schneider S, McFarlane E, Gleeson D, et al. Clinical significance of azathioprine metabolites for the maintenance of remission in autoimmune hepatitis. Hepatology. 2012;56(4):1401–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Ansari A, Elliott T, Baburajan B, Mayhead P, O’Donohue J, Chocair P, et al. Long-term outcome of using allopurinol co-therapy as a strategy for overcoming thiopurine hepatotoxicity in treating inflammatory bowel disease. Aliment Pharmacol Ther. 2008;28(6):734–41.CrossRefPubMedGoogle Scholar
  33. 33.
    Al-Shamma S, Eross B, Mclaughlin S. Use of a xanthine oxidase inhibitor in autoimmune hepatitis. Hepatology. 2013;57(3):1281–2.CrossRefPubMedGoogle Scholar
  34. 34.
    Sharzehi K, Huang MA, Schreibman IR, Brown KA. Mycophenolate mofetil for the treatment of autoimmune hepatitis in patients refractory or intolerant to conventional therapy. Can J Gastroenterol. 2010;24(10):588–92.PubMedCentralPubMedGoogle Scholar
  35. 35.
    Zachou K, Gatselis N, Papadamou G, Rigopoulou EI, Dalekos GN. Mycophenolate for the treatment of autoimmune hepatitis: prospective assessment of its efficacy and safety for induction and maintenance of remission in a large cohort of treatment-naïve patients. J Hepatol. 2011;55(3):636–46.CrossRefPubMedGoogle Scholar
  36. 36.
    Hoeltzenbein M, Elefant E, Vial T, Finkel-Pekarsky V, Stephens S, Clementi M, et al. Teratogenicity of mycophenolate confirmed in a prospective study of the European Network of Teratology Information Services. Am J Med Genet A. 2012;158A(3):588–96.CrossRefPubMedGoogle Scholar
  37. 37.
    Kerkar N, Dugan C, Rumbo C, Morotti RA, Gondolesi G, Shneider BL, et al. Rapamycin successfully treats post-transplant autoimmune hepatitis. Am J Transplant. 2005;5(5):1085–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Chatrath H, Allen L, Boyer TD. Use of sirolimus in the treatment of refractory autoimmune hepatitis. Am J Med. 2014;127(11):1128–31.CrossRefPubMedGoogle Scholar
  39. 39.
    Ytting H, Larsen FS. Everolimus treatment for patients with autoimmune hepatitis and poor response to standard therapy and drug alternatives in use. Scand J Gastroenterol. 2015;50(8):1025–31.CrossRefPubMedGoogle Scholar
  40. 40.
    Porcelli L, Quatrale AE, Mantuano P, Silvestris N, Rolland JF, Biancolillo L, et al. Synergistic antiproliferative and antiangiogenic effects of EGFR and mTOR inhibitors. Curr Pharm Des. 2013;19(5):918–26.CrossRefPubMedGoogle Scholar
  41. 41.
    Czaja AJ. Review article: the management of autoimmune hepatitis beyond consensus guidelines. Aliment Pharmacol Ther. 2013;38(4):343–64.CrossRefPubMedGoogle Scholar
  42. 42.
    Fernandes NF, Redeker AG, Vierling JM, Villamil FG, Fong TL. Cyclosporine therapy in patients with steroid resistant autoimmune hepatitis. Am J Gastroenterol. 1999;94(1):241–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Tannous MM, Cheng J, Muniyappa K, Farooq I, Bharara A, Kappus M, et al. Use of tacrolimus in the treatment of autoimmune hepatitis: a single centre experience. Aliment Pharmacol Ther. 2011;34(3):405–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Ichai P, Duclos-Vallée J-C, Guettier C, Hamida SB, Antonini T, Delvart V, et al. Usefulness of corticosteroids for the treatment of severe and fulminant forms of autoimmune hepatitis. Liver Transpl. 2007;13(7):996–1003.CrossRefPubMedGoogle Scholar
  45. 45.
    Miyake Y, Iwasaki Y, Terada R, Onishi T, Okamoto R, Sakai N, et al. Clinical characteristics of fulminant-type autoimmune hepatitis: an analysis of eleven cases. Aliment Pharmacol Ther. 2006;23(9):1347–53.CrossRefPubMedGoogle Scholar
  46. 46.•
    Yeoman AD, Westbrook RH, Zen Y, Bernal W, Al-Chalabi T, Wendon JA, et al. Prognosis of acute severe autoimmune hepatitis (AS-AIH): the role of corticosteroids in modifying outcome. J Hepatol. 2014;61(4):876–82. Well phenotyped, acute severe hepatitis carries a high risk of progression to transplant or death. Treatment with high-dose corticosteroids did not increase risk for poor outcomes. Approximately half of patients treated with steroids recovered, yet there was no difference in MELD scores for responders versus nonresponders in this group.CrossRefPubMedGoogle Scholar
  47. 47.
    De Martin E, Coilly A, Ichai P, Samuel D, Duclos-Vallée J-C. The role of corticosteroids in acute-severe autoimmune hepatitis is still highly debatable. J Hepatol. 2015;63(4):1041–2.CrossRefPubMedGoogle Scholar
  48. 48.••
    Mendizabal M, Marciano S, Videla MG, Anders M, Zerega A, Balderramo DC, et al. Fulminant presentation of autoimmune hepatitis: clinical features and early predictors of corticosteroid treatment failure. Eur J Gastroenterol Hepatol. 2015;27(6):644–8. Approximately half of fulminant AIH patients are rescued from transplant with corticosteroids. Advanced hepatic encephalopathy and a higher MELD (>27) score seemed to be associated with corticosteroid failure.PubMedGoogle Scholar
  49. 49.
    Westbrook RH, Yeoman AD, Kriese S, Heneghan MA. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun. 2012;38(2–3):J239–44.CrossRefPubMedGoogle Scholar
  50. 50.
    Werner M, Björnsson E, Prytz H, Lindgren S, Almer S, Broomé U, et al. Autoimmune hepatitis among fertile women: strategies during pregnancy and breastfeeding? Scand J Gastroenterol. 2007;42(8):986–91.CrossRefPubMedGoogle Scholar
  51. 51.
    Heneghan MA, Norris SM, O’Grady JG, Harrison PM, McFarlane IG. Management and outcome of pregnancy in autoimmune hepatitis. Gut. 2001;48(1):97–102.PubMedCentralCrossRefPubMedGoogle Scholar
  52. 52.
    Schramm C, Herkel J, Beuers U, Kanzler S, Galle PR, Lohse AW. Pregnancy in autoimmune hepatitis: outcome and risk factors. Am J Gastroenterol. 2006;101(3):556–60.CrossRefPubMedGoogle Scholar
  53. 53.
    Francella A, Dyan A, Bodian C, Rubin P, Chapman M, Present DH. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Gastroenterology. 2003;124(1):9–17.CrossRefPubMedGoogle Scholar
  54. 54.
    Christopher V, Al-Chalabi T, Richardson PD, Muiesan P, Rela M, Heaton ND, et al. Pregnancy outcome after liver transplantation: a single-center experience of 71 pregnancies in 45 recipients. Liver Transpl. 2006;12(7):1138–43.CrossRefPubMedGoogle Scholar
  55. 55.
    Whitacre CC, Reingold SC, O’Looney PA. A gender gap in autoimmunity. Science. 1999;283(5406):1277–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Kim M, Rostas S, Gabardi S. Mycophenolate fetal toxicity and risk evaluation and mitigation strategies. Am J Transplant. 2013;13(6):1383–9.CrossRefPubMedGoogle Scholar
  57. 57.
    Kogan J, Safadi R, Ashur Y, Shouval D, Ilan Y. Prognosis of symptomatic versus asymptomatic autoimmune hepatitis: a study of 68 patients. J Clin Gastroenterol. 2002;35(1):75–81.CrossRefPubMedGoogle Scholar
  58. 58.
    Schvarcz R, Glaumann H, Weiland O. Survival and histological resolution of fibrosis in patients with autoimmune chronic active hepatitis. J Hepatol. 1993;18(1):15–23.CrossRefPubMedGoogle Scholar
  59. 59.
    Czaja AJ, Carpenter HA. Decreased fibrosis during corticosteroid therapy of autoimmune hepatitis. J Hepatol. 2004;40(4):646–52.CrossRefPubMedGoogle Scholar
  60. 60.
    Czaja AJ. Features and consequences of untreated type 1 autoimmune hepatitis. Liver Int. 2009;29(6):816–23.CrossRefPubMedGoogle Scholar
  61. 61.
    Chen J, Eslick GD, Weltman M. Systematic review with meta-analysis: clinical manifestations and management of autoimmune hepatitis in the elderly. Aliment Pharmacol Ther. 2014;39(2):117–24.CrossRefPubMedGoogle Scholar
  62. 62.
    Roberts SK, Therneau TM, Czaja AJ. Prognosis of histological cirrhosis in type 1 autoimmune hepatitis. Gastroenterology. 1996;110(3):848–57.CrossRefPubMedGoogle Scholar
  63. 63.
    Uribe M, Go VL, Kluge D. Prednisone for chronic active hepatitis: pharmacokinetics and serum binding in patients with chronic active hepatitis and steroid major side effects. J Clin Gastroenterol. 1984;6(4):331–5.PubMedGoogle Scholar
  64. 64.
    Czaja AJ. Diagnosis, pathogenesis, and treatment of autoimmune hepatitis after liver transplantation. Dig Dis Sci. 2012;57(9):2248–66.CrossRefPubMedGoogle Scholar
  65. 65.
    Czaja AJ. Autoimmune hepatitis after liver transplantation and other lessons of self-intolerance. Liver Transpl. 2002;8(6):505–13.CrossRefPubMedGoogle Scholar
  66. 66.
    González-Koch A, Czaja AJ, Carpenter HA, Roberts SK, Charlton MR, Porayko MK, et al. Recurrent autoimmune hepatitis after orthotopic liver transplantation. Liver Transpl. 2001;7(4):302–10.CrossRefPubMedGoogle Scholar
  67. 67.
    Ayata G, Gordon FD, Lewis WD, Pomfret E, Pomposelli JJ, Jenkins RL, et al. Liver transplantation for autoimmune hepatitis: a long-term pathologic study. Hepatology. 2000;32(2):185–92.CrossRefPubMedGoogle Scholar
  68. 68.
    Montano-Loza AJ, Mason AL, Ma M, Bastiampillai RJ, Bain VG, Tandon P. Risk factors for recurrence of autoimmune hepatitis after liver transplantation. Liver Transpl. 2009;15(10):1254–61.CrossRefPubMedGoogle Scholar
  69. 69.
    Duclos-Vallee J-C, Sebagh M. Recurrence of autoimmune disease, primary sclerosing cholangitis, primary biliary cirrhosis, and autoimmune hepatitis after liver transplantation. Liver Transpl. 2009;15 Suppl 2:S25–34.CrossRefPubMedGoogle Scholar
  70. 70.
    Tencate V, Komorowski R, Cronin D, Hong J, Gawrieh S. A case study: refractory recurrent autoimmune hepatitis following liver transplantation in two male patients. Transplant Proc. 2014;46(1):298–300.CrossRefPubMedGoogle Scholar
  71. 71.•
    Lammert C, Comerford M, Love J, Bailey JR. Investigation gone viral: application of the social mediasphere in research. Gastroenterology. 2015;149(4):839–43. The rarity of AIH and challenge of geographic barriers represent major limitations to development of large observational and prospective studies. Social media overcomes these limitations, and provides patient access to support and disease engagement.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Craig Lammert
    • 1
  • Veronica M. Loy
    • 2
  • Kiyoko Oshima
    • 3
  • Samer Gawrieh
    • 1
    Email author
  1. 1.Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisUSA
  2. 2.Division of HepatologyLoyola UniversityMaywoodUSA
  3. 3.Department of PathologyMedical College of WisconsinMilwaukeeUSA

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