American Society for Microbiology, American Society for Clinical Laboratory Science and American Society for Clinical Pathology

View all recommendations from this society

Released November 7, 2022

Do not prescribe immune suppressive agents for suspected autoimmune hepatitis (AIH) without first excluding hepatotropic virus infections (e.g., viral hepatitis A, B, and C). Viral hepatitis may mimic AIH, both serologically and histologically, features that may resolve with direct-acting antiviral (DAA) treatment.

Viral hepatitis, including that caused by hepatitis A, B, and C, can lead to development of autoantibodies (e.g., antinuclear, anti-smooth muscle actin (SMA)/F-actin, liver–kidney microsomal type 1 (LKM-1), soluble liver antigen (SLA), and immunoglobulin G (IgG)) in approximately 50% of cases. The autoantibody profile in patients with chronic HCV may cause clinical suspicion of concurrent AIH and may prompt unnecessary liver biopsies and/or immune suppressive treatments. HAV, HBV, and HCV, may have similar histologic and clinical features including frequent plasma cells, elevated transaminases and may lead to cirrhosis. However, treatment is markedly different. Treatment of HCV is with interferon (IFN)-free or DAA therapy, achieving sustained viral responses (SVR) in most cases and has been shown to eliminate both clinical and histologic features of AIH. Therefore, patients with chronic hepatitis C who have serum markers and/or histologic features of AIH should first be treated with DAA in most cases.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1–2) The American Society for Microbiology’s (ASM) list was developed under the leadership of the ASM’s Clinical and Public Health Microbiology Committee. The subject matter experts who identified the list and formulated the recommendations are laboratory directors at academic, commercial and public health laboratories and test utilization experts across the fields of microbiology and laboratory medicine. They worked together to identify a list of diagnostic and management decisions that have resulted in misuse of laboratory studies and resources.

In this submission, two statements were written to address the most common clinical microbiology laboratory test misconceptions. They consist of diagnostic tests or treatments that are commonly ordered, expensive and have no evidence to illustrate its value and in some cases, may be potentially harmful to the patient. The recommendations, if instituted, would result in higher quality care, lower costs, and more effective use of our laboratory resources and personnel. The experts involved in the new 2022 recommendations are James Dunn, Laura Filkins, Omai Garner, Elizabeth Palavecino and Preeti Pancholi.How This List Was Created

(3–4) These ASCLS recommendations were developed under the leadership of ASCLS’s Choosing Wisely Committee and the ASCLS Board of Directors. The Committee examined numerous options based on evidence available. Subject matter experts from the ASCLS Scientific Assemblies reviewed, edited, and recommended approval of these recommendations, which were subsequently reviewed and approved by the ASCLS Board of Directors.How This List Was Created

(5) The American Society for Clinical Pathology (ASCP) recommendation was developed under the leadership of the ASCP Effective Test Utilization Steering Committee. This committee is chaired by an ASCP Past President and is comprised of subject matter and test utilization experts across the fields of pathology and laboratory medicine. The committee considered a list of possible recommendations compiled as the result of a survey administered to Society members serving on ASCP’s many commissions, committees and councils. In addition, an announcement was made to ASCP’s Advisory Board seeking suggestions for possible recommendations to promote member involvement. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is harmful; use of the test is costly and it does not provide higher quality care; and eliminating it or changing to another test is within the control of the clinician. Implementation of these recommendations will result in higher quality care, lower costs and a more effective use of our laboratory resources and personnel.

Sources

Simoes CC, Saldarriaga OA, Utay NS, Stueck AE, Merwat SK, Merwat SN, Schiano TD, Fiel MI, Stevenson HL. Direct-acting antiviral treatment of patients with hepatitis C resolves serologic and histopathologic features of autoimmune hepatitis. Hepatol Commun. 2019; 3:1113–23. doi: 10.1002/hep4.1388. PMID: 31388631; PMCID: PMC6671831.

Himoto T, Masaki T. Extrahepatic manifestations and autoantibodies in patients with hepatitis C virus infection. Clin Dev Immunol 2012; 2012:871401.

Cassani F, Cataleta M, Valentini P, Muratori P, Giostra F, Francesconi R, et al. Serum autoantibodies in chronic hepatitis C: comparison with autoimmune hepatitis and impact on the disease profile. Hepatology 1997; 26:561-566.

Pavic S, Simonovic J, Boricic I, Svirtlih N. Autoantibodies characteristic for autoimmune hepatitis found in chronic hepatitis C. [In Serbian] Srp Arh Celok Lek 2003; 131:437-442.

Clifford BD, Donahue D, Smith L, Cable E, Luttig B, Manns M, et al. High prevalence of serological markers of autoimmunity in patients with chronic hepatitis C. Hepatology 1995;21:613-619.

Sugiura A, Wada S, Mori H, Kimura T, Matsuda Y, Tanaka N, et al. Successful treatment for chronic hepatitis C-autoimmune hepatitis overlap syndrome due to daclatasvir and asunaprevir. Case Rep Gastroenterol 2017; 11:305-311.