Autoimmune liver diseases in older adults: Clinical challenges and management considerations

Table 1 Comparison of elderly vs younger patients across autoimmune liver diseases, n (%)

Ref.	Country	Total patients/elderly (%)	Comorbidities in the elderly	Biochemical profile	Serologic markers	Treatment response	Other characteristics
Autoimmune hepatitis
Czaja and Carpenter[39], 2006	United States	n = 205/47 (23) > 60 years	AT (23%), RA (4%), SS (2%), SLE (2%)	No significant differences	No significant differences	59% vs 61%; less steroid failure (5% vs 24%, P = 0.03)	Cirrhosis more common (33% vs 10%, P = 0.03); HLA-DR4 more frequent (47% vs 13%, P = 0.003)
Miyake et al[40], 2007	Japan	n = 160/34 (21) > 65 years	6 (18): CT, UC, GD, SS	Lower albumin; other labs similar	ANA/ASM 97% vs 94% (P = 0.53)	95% vs 89% (P = 0.41)	Type II HLA: Frequency of DR2-DR4 was similar. Cirrhosis (F3-F4) more common in elderly (53% vs 30%, P = 0.014)
Morii et al[41], 2017	Japan	n = 71/28 (39) > 70 years	SS, RA, CT	Lower albumin and cholesterol	Higher IgG and ANA titers (P = 0.02)	Both groups achieved remission	Fibrosis score similar
Baven-Pronk et al[42], 2018	Netherlands	n = 359/73 (20.3) > 60 years	Higher autoimmune comorbidity (33% vs 20%, P < 0.05): CT, CD, UC, RA, SS, SLE	Lower ALAT (430 vs 670 IU/L, P < 0.001)	No significant differences	81% vs 76% (P = 0.368)	Fewer acute onsets (10%), less jaundice (25%); no difference in cirrhosis
Díaz Ramírez et al[43], 2019	Colombia	n = 214/29 (13.5) > 65 years	HBP (34.5%), dyslipidemia (20.7%), CVD (17.2%)	No significant differences	No significant differences	83.9% vs 100% (P = 0.022)	Cirrhosis more common (55% vs 33%, P = 0.024); 1 elderly transplanted
Sonthalia et al[44], 2020	India	n = 155/73 (20) > 60 years	DM, RA, CT	Higher ALAT and creatinine (P < 0.05)	ASM more common (45.5% vs 25.4%, P < 0.05)	65.6% vs 51.5%	ACLF more frequent (39.4% vs 13.9%, P = 0.0024); cirrhosis more frequent (75.7% vs 56.6%, P = 0.045)
Dalekos et al[45], 2021	Greece	n = 234/25 (10) > 70 years	CVD (72%), DM (32%)	Lower ALAT (P < 0.05)	No significant differences	83.7% vs 88.9% (P = 0.566)	Cirrhosis more common (48% vs 27.3%, P = 0.03); no differences in presentation
Primary biliary cholangitis
Newton et al[46], 2000	United Kingdom	n = 1023/397 (39) > 65 years	Not reported	No significant differences	No significant differences	Not evaluated	Similar clinical features; higher mortality (59% vs 33%, P = 0.001)
Muratori et al[47], 2008	Italy	n = 234/49 (25) > 65 years	Not reported	Lower ALAT/ASAT (P = 0.0024)	No significant differences	Not evaluated	Elderly less symptomatic at diagnosis (26%, P = 0.02); male sex higher (40%, P = 0.002)
Franceschet et al[48], 2016	Italy	n = 376/62 (16) > 65 years	Not reported	Lower ALAT, platelets, albumin	No significant differences	UDCA response similar (56.6% vs 67.7%, P = NS)	Higher mortality (41.9% vs 19.7%, P < 0.001)
Primary sclerosing cholangitis
Hirano et al[49], 2008	Japan	n = 28/10 (25) > 50 years	UC	Not evaluated	Higher IgE in older group	Fewer liver transplants	Less CCA and less liver failure
Tanaka et al[50], 2014	Japan	n = 197 PSC + 43 IgG4SC/98 (49) > 50 years	IBD	No significant differences	IgG and IgG4 similar in elderly vs young; IgG4-SC had higher IgG/IgG4; IgA higher in elderly PSC (P < 0.001)	Similar medical treatment; similar rate of stenting/balloon dilation; similar transplantation rates	Similar symptoms at presentation; 5-year survival 54.7% in elderly
Rupp et al[51], 2018	Germany	n = 215/32 (15) > 50 years	IBD	Lower ALAT/ASAT (P = 0.03/0.05)	No significant differences	6 elderly transplanted	CCA more frequent in elderly (12.5% vs 3.3%, P = 0.02); late onset associated with mortality; poorer transplant-free survival (10.5 years vs 20.8 years)

ACLF: Acute-on-chronic liver failure; ALAT: Alanine aminotransferase; ANA: Antinuclear antibodies; ASAT: Aspartate aminotransferase; ASM: Anti-smooth muscle antibodies; AT: Autoimmune thyroiditis; CCA: Cholangiocarcinoma; CD: Crohn’s disease; CT: Chronic thyroiditis; CVD: Cardiovascular disease; DM: Diabetes mellitus; GD: Graves’ disease; HBP: High blood pressure; IBD: Inflammatory bowel disease; IgG4-SC: Immunoglobulin G4-related sclerosing cholangitis; NS: Not significant; RA: Rheumatoid arthritis; SS: Sjögren’s syndrome; UC: Ulcerative colitis; UDCA: Ursodeoxycholic acid.