Background: Rheumatoid arthritis (RA) can be associated to extra-articular manifestations and comorbidities, including hepatic disturbances. It can be related to an underlying viral, metabolic or immune disease, or to a medical treatment toxicity [1].

Objectives: We aim to study liver involvement in a group of RA patients.

Methods: We performed a cross sectional study in 249 RA patients responding to the ACR/EULAR 2010 criteria for RA diagnosis. Hepatic enzymes, B and C hepatitis viruses screening tests, abdominal ultrasonography, biliary tract MRIs, fibrotests and fibroscans if available were collected and analysed.

Results: Two hundred and forty-nine patients were included with 83.8% of women. The mean age was 59±11.67 years. The mean age at diagnosis was 47±14.9 years with a mean disease evolution of 11±8.83 years.

The mean disease activity (DAS28) was 4,66 with levels ranging from 0.12 to 7.78.

Liver abnormalities were found in 68 patients (27.3%).

Viral disease represented 32.3% of liver abnormalities and was found in 8.8% of the total number of patients. Positive anti-HBc antibodies with negative HBs antigen were found in 8.4% of the patients, no viral reactivation with conventional or biological disease-modifying anti-rheumatic drugs was noted.

Besides, 4 of the 249 patients had positive HCV antibodies tests; one of them had a reactivation of a hepatitis C infection after treatment with leflunomide, one had a chronic C hepatitis with chronic liver disease, one had an old B and C hepatitis infection and the last one had an associated liver nodule for which an exploration was triggered. One patient had post hepatitis C cirrhosis associated with a hepatocellular carcinoma treated with surgery and an association of ledipasvir and sofosbuvir with a negative serology.

Medical treatment toxicity was responsible for 25% of liver abnormalities. Paracetamol caused both hepatic cholestasis and cytolysis in 5 patients, and isolated cholestasis in 2 patients. NSAIDs caused both hepatic cholestasis and cytolysis in 2 patients, and isolated cholestasis in one patient. Methotrexate was responsible for isolated cholestasis in 2 patients, isolated hepatic cytolysis in one patient and both cholestasis and cytolysis in one patient. An interaction between methotrexate and fluconazole caused one case of hepatic cholestasis and cytolysis. Treatment of a latent tuberculosis with isoniazid and rifampicin was responsible for cholestasis in one patient.

Immune hepatic disease was present in 3 patients: 2 patients had a primary biliary cholangitis that manifested with a cholestasis and one patient had an auto-immune hepatitis that manifested with cytolysis and cholestasis.

The prevalence of hepatic steatosis was of 4.8%, assessed with ultrasonography or microscopic examination of a liver biopsy. Hepatic enzymes test was normal in 2%, showed isolated cholestasis in 2% and both cholestasis and hepatic cytolysis in 0.8% of the patients.

One patient had a secondary hemochromatosis to multiple transfusions for sickle cell anaemia, causing cholestasis and cytolysis.

No aetiology was found for hepatic cholestasis and/or cytolysis in 7.2% of patients.

Conclusion: Liver involvement in RA is common and has different aspects. A careful monitoring of liver enzymes tests is crucial to detect hepatic disease and prevent its evolution to a chronic liver disease and cirrhosis. On the other hand, screening for viral hepatitis B and C is necessary to prevent an aggravation of a chronic infection and a reactivation of a latent one [2].

REFERENCES:

[1]Sellami M, Saidane O, Mahmoud I, Tekaya AB, Tekaya R, Abdelmoula L. Etiological Features of Liver Involvement in Rheumatoid Arthritis. Curr Rheumatol Rev. 2020;16(4):332-6.

[2]Karadağ Ö, Kaşifoğlu T, Özer B, Kaymakoğlu S, Kuş Y, İnanç M, et al. Viral hepatitis screening guideline before biological drug use in rheumatic patients. Eur J Rheumatol. mars 2016;3(1):25-8.

Disclosure of Interests: None declared