Cited by 1,482Liver Diseases and ImmunityPediatric Hepatobiliary Diseases and TreatmentsIgG4-Related and Inflammatory Diseases

EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis.

Open access
Hirschfield, Gideon M., Beuers, Ulrich, Corpechot, Christophe, Invernizzi, Pietro, Jones, David, Marzioni, Marco, Schramm, Christoph·2017·Journal of Hepatology

Abstract

Clinical practice guidelines summarising diagnosis, risk stratification, and management of PBC including ursodeoxycholic acid, obeticholic acid, and off-label therapies.

Integrity signals

Registry

Crossref · 10.1016/j.jhep.2017.03.022

Cites

278 of 278 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

18 of 48 cited sources checked · 7 supported · 0 flagged · accuracy not yet measured

  • Background
    § Standard serum liver tests

    Serum bilirubin has been recognized since the 1970s as a major predictor of poor PBC outcome.

    “Serum bilirubin has been recognised since the 1970s as a major predictor of poor outcome in PBC [72,7].”
    Quote in the paperNot yet classified2 of 2 sources checked
    • cites [72] 72. Shapiro JM, Smith H, Schaffner F. Serum bilirubin: a prognostic factor in primary biliary cirrhosis. Gut 1979;20:137-140. source
    • cites [7] 7. Lammers WJ, van Buuren HR, Hirschfield GM, Janssen HL, Invernizzi P, Mason AL, et al. Levels of alkaline phosphatase and bilirubin are surrogate end points of outcomes of patients with primary biliary cirrhosis: an international follow-up study. Gastroenterology 2014;147:1338-1349. source
  • Background
    § Demographics

    Male sex is linked to later diagnosis, more advanced disease at presentation, poorer biochemical response to UDCA, and higher HCC risk.

    “Male sex is associated with later diagnosis, more advanced disease at presentation, poorer biochemical response to UDCA therapy, and higher risk of developing hepatocellular carcinoma (HCC) [6,8,65].”
    Quote in the paperNot yet classified1 of 3 sources checked
    • cites [6] 6. 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;144:560-569. source

      The Results and Discussion (page not provided) report that men with PBC presented at an older age, had signs suggesting more advanced disease and delayed diagnosis, and were less likely to meet UDCA response criteria. The passages found do not address whether men have a higher risk of developing HCC, so this source does not support that part of the sentence. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [8] 8. Trivedi PJ, Lammers WJ, van Buuren HR, Pares A, Floreani A, Janssen HL, et al. Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicentre international study. Gut 2016;65:321-329. source
    • cites [65] 65. Cheung A, Lammers WJ, Hirschfield GM, Invernizzi P, Mason A, Ponsioen CY, et al. Age, bilirubin and albumin, regardless of sex, are the strongest independent predictors of biochemical response and transplantation-free survival in patients with primary biliary cirrhosis. J Hepatol 2015;62: S798-S799. source
  • Background
    § Demographics

    Patients diagnosed younger than 45 are often symptomatic and less likely to respond well to standard UDCA treatment.

    “Patients who present at a younger age (\45 years) are often symptomatic and less likely to respond well to standard treatment with UDCA [6].”
    Quote in the paperNot yet classified1 of 1 sources checked
    • cites [6] 6. 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;144:560-569. source
  • Background
    § Introduction

    PBC is chronic and often progressive, leading to end-stage liver disease and related complications.

    “The disease is chronic and often progressive, resulting in end-stage liver disease and its associated complications [6][7][8].”
    Quote in the paperNot yet classified2 of 3 sources checked
    • cites [6] 6. 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;144:560-569. source

      The Additional information section defines PBC-related failure to include liver transplantation or death from liver failure, supporting the possibility of severe outcomes. But the Discussion describes a potentially aggressive course particularly in younger patients, while characterizing the typical patient's course as relatively benign; it does not establish that PBC is often progressive to end-stage disease. Page numbers were not available in our copy. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [7] 7. Lammers WJ, van Buuren HR, Hirschfield GM, Janssen HL, Invernizzi P, Mason AL, et al. Levels of alkaline phosphatase and bilirubin are surrogate end points of outcomes of patients with primary biliary cirrhosis: an international follow-up study. Gastroenterology 2014;147:1338-1349. source
    • cites [8] 8. Trivedi PJ, Lammers WJ, van Buuren HR, Pares A, Floreani A, Janssen HL, et al. Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicentre international study. Gut 2016;65:321-329. source
  • Finding
    § Liver transplantation

    Recurrent PBC after liver transplantation has been reported in about 20% of patients on average, with histological recurrence likely higher.

    “PBC recurrence has been reported in 20% of patients on average [253,258] but the rate of histological recurrence is likely higher [259].”
    Quote in the paperNot yet classified1 of 2 sources checked
    • cites [253] 253. Carbone M, Neuberger JM. Autoimmune liver disease, autoimmunity and liver transplantation. J Hepatol 2014;60:210-223. source

      In the section on recurrence after liver transplantation (page unavailable), the paper reports recurrent PBC prevalence of 0–35% and 10-year incidence of 21–37%, but does not give a 20% average. It says recurrence can occur with normal liver tests and that biopsy practices affect reported rates, supporting the possibility of missed histological recurrence without quantifying how much higher its rate is. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [258] 258. Silveira MG, Talwalkar JA, Lindor KD, Wiesner RH. Recurrent primary biliary cirrhosis after liver transplantation. Am J Transplant 2010;10:720-726. source

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • A diagnosis of primary biliary cholangitis is made if patients meet at least two of the following criteria: have biochemical evidence of chronic cholestasis, positive anti-mitochondrial antibodies in sera, and histological features compatible with primary biliary cholangitis.

    “A diagnosis of primary biliary cholangitis is made if patients meet at least two of the following criteria: have biochemical evidence of chronic cholestasis, positive anti-mitochondrial antibodies in sera, and histological features compatible with primary biliary cholangitis.[3][4][5]”

    From Primary biliary cholangitis. (2024) · cites this paper as [3]

    The guideline’s diagnostic recommendations support diagnosing PBC in adults with cholestasis and positive AMA, and its Histology section discusses biopsy when PBC-specific antibodies are absent. They do not state a general rule that any two of the three listed findings suffice; the Immunological markers section says AMA must be interpreted with abnormal liver tests, and the recommendations limit when biopsy is used. (LLM, conf=0.86)

    Experimental — accuracy not yet measured
  • Treatment response to ursodeoxycholic acid is incomplete in about 20-40% of patients with primary biliary cholangitis after 1 year, as judged by various biochemical criteria.

    “the treatment response to ursodeoxycholic acid was incomplete in about 20-40% of patients with primary biliary cholangitis after 1 year, as judged by various biochemical criteria, either binary or continuously.3”

    From Primary biliary cholangitis. (2024) · cites this paper as [3]

    The “Qualitative binary definitions” section says inadequate biochemical response occurs in 25–50% of patients in most cohorts, depending on the definition used, and that most definitions were validated at 12 months. The “Defining inadequate response to treatment” section describes both binary criteria and continuous scoring systems. The cited guideline therefore supports the general point, but not the stated 20–40% range. (LLM, conf=0.87)

    Experimental — accuracy not yet measured
  • Clinically, primary biliary cholangitis is characterised by persistent elevation of cholestatic liver enzymes, including alkaline phosphatase and GGT, and detection of antimitochondrial antibodies or PBC-specific anti-nuclear antibodies (anti-sp100 or anti-gp210).

    “Clinically, primary biliary cholangitis is characterised by persistent elevation of cholestatic liver enzymes, including alkaline phosphatase and gammaglutamyl transpeptidase (GGT), and detection of antimitochondrial antibodies or primary biliary cholangitis-specific anti-nuclear antibodies (anti-sp100 or anti-gp210).[3][4][5]”

    From Primary biliary cholangitis. (2024) · cites this paper as [3]

  • Non-invasive liver stiffness measurement (LSM) has proven useful as an alternative to invasive liver biopsy for the evaluation of liver fibrosis, and LSM using transient elastography is recommended at the time of diagnosis of primary biliary cholangitis.

    “Non-invasive liver stiffness measurement (LSM) has proven useful as an alternative to invasive liver biopsy for the evaluation of liver fibrosis, and LSM using transient elastography is recommended at the time of diagnosis.3,4,55”

    From Primary biliary cholangitis. (2024) · cites this paper as [3]

  • Clinical practice guidelines from EASL, AASLD, and APASL recommend ursodeoxycholic acid treatment (13-15 mg/kg per day) for all patients with primary biliary cholangitis and elevated cholestatic enzymes.

    “Clinical practice guidelines from the European Association for the Study of the Liver, the American Association for the Study of Liver Diseases (AASLD), and the Asian-Pacific Association for the Study of the Liver recommend ursodeoxycholic acid treatment (13-15 mg/kg per day) for all patients with primary biliary cholangitis and elevated cholestatic enzymes.[3][4][5]”

    From Primary biliary cholangitis. (2024) · cites this paper as [3]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Transplant-assessment bilirubin threshold has conflicting units

    Minor

    The recommendation pairs a bilirubin threshold of 50 mmol/L with 3 mg/dl, while the transplantation discussion pairs a threshold of 50-85 lmol/L with 3-5 mg/dl. The two passages give incompatible units for the same approximate threshold.

  • LDL is described as both elevated and not elevated

    Minor

    The hyperlipidaemia section reports elevated LDL in early disease and says it may rise further, but later states that LDL cholesterol is not elevated.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Corpechot, 2016, Relationships between biochemical response to UDCA and progression of liver stiffness as determined by Fibroscan in patients with PBC, Hepatology, 64, 194A

Cited by

Sorted by citations

Authors
Hirschfield, G. M., Beuers, U., Corpechot, C., Invernizzi, P., Jones, D., Marzioni, M., & Schramm, C.
Affiliations
European Association for the Study of the Liver (CH)
Venue
Journal of Hepatology
Publisher
Elsevier BV
Published
2017-07
Volume
67
Issue
1
Pages
145-172
ISSN
0168-8278 (ISSN-L)
OpenAlex
W2605729742
Cited by
1,480
References
274
Citations by year
2026: 166 · 2025: 207 · 2024: 205 · 2023: 178 · 2022: 175 · 2021: 140 · 2020: 136 · 2019: 131 · 2018: 111 · 2017: 30 · 2012: 1
FWCI
68.84
Type
journal article
Language
en
Open access
Locations
  • Journal of Hepatology (publishedVersion)
  • PubMed (publishedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion, cc-by-nc-nd)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • BOA (University of Milano-Bicocca) (submittedVersion)
  • Università Politecnica delle Marche (Università Politecnica delle Marche) (submittedVersion)
  • Pure Amsterdam UMC (submittedVersion)
Funders
  • European Association for the Study of the Liver
  • DFG
  • Helmut and Hannelore Greve Foundation
  • YAEL-Foundation
  • NIHR
  • Birmingham Liver Biomedical Research Centre
  • EU Marie Curie scheme
  • Newcastle Biomedical Research Centre
  • Medical Research Council
Topics
  • Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
  • Health Sciences › Medicine › Surgery › Pediatric Hepatobiliary Diseases and Treatments
  • Health Sciences › Medicine › Rheumatology › IgG4-Related and Inflammatory Diseases
Keywords
primary biliary cirrhosis, autoimmune cholestatic liver disease, antimitochondrial antibodies, cholestatic hepatitis, risk stratification, ursodeoxycholic acid, obeticholic acid, fibrates, budesonide, off-label therapy, individualized care, diagnosis, management
MeSH terms
Cholangitis, Female, Humans, Male, Prognosis, Ursodeoxycholic Acid, Liver Transplantation, Practice Guidelines as Topic

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