Sjogren’s patients are at increased risk of liver disease.
Up to half of Sjogren’s patients have abnormal liver tests (214, p. 335). Mild elevations of liver enzymes are common and usually do not indicate serious liver disease (201). Although it does not appear that Sjogren’s is a direct cause of liver disease, it is an important comorbidity.
Every Sjogren’s patient should be screened for liver disease because early detection enables treatment at a time when damage is more likely to be reversible.
Liver disease symptoms
Early liver disease is usually asymptomatic (214, p. 335). That is why screening is so important. When symptoms do occur, they may resemble common Sjogren’s symptoms such as increased fatigue, decreased appetite, nausea, or itchy skin.
Multiple types of liver disease can impact Sjogren’s patients.
Finding the underlying cause(s) of liver disease is key to proper management.
The most common causes of liver disease in Sjogren's are:
Non-alcoholic fatty liver disease (related to metabolic syndrome)
Infections (e.g., hepatitis B, hepatitis C, HIV, possibly SARS-CoV-2)
Medications (e.g., methotrexate, azathioprine)
Overuse of acetaminophen (more than 4000 mg/ day)
Toxins (especially alcohol). Dietary supplements, herbs, and even turmeric in large doses can damage the liver. A rising number of liver failure cases are being reported as a result of using these products.
Less often, liver disease is caused by the following comorbid autoimmune diseases:
Primary Biliary cholangitis (PBC) - 2-5% (242)
Autoimmune hepatitis (AIH) - 1-4% (214, p. 364)
Sclerosing cholangitis (rare)
The only way to detect liver disease early is through annual blood tests that screen for liver disease. Tests may need to be done more often than once a year in patients with risk factors such as methotrexate use.
"Basic lab tests that evaluate liver health and function should be checked at least yearly in Sjogren’s patients." ~ Dr. Chad Johr (214, p. 366)
Standard screening blood tests for liver disease
*ALT, with or without **AST These are liver enzymes that damage liver cells and are usually ordered once a year, more often if risk factors exist or if levels were previously elevated. The ALT is more specific to the liver. Both ALT and AST are usually elevated in liver disease.
*Alanine aminotransferase (ALT) **Asparagine aminotransferase (AST)
"Mild, asymptomatic elevations of alanine transaminase (ALT) and aspartate transaminase (AST) levels, defined as less than five times the upper limit of normal, are common in primary care. The prevalence of elevated transaminase levels is estimated to be approximately 10%, although less than 5% of these patients have a serious liver disease."
HIV screening "All people between the ages of 13 and 64 should be tested for HIV at least once as part of routine health care, and those at ongoing risk should be tested more frequently."
~ Center for Disease Control (CDC)
Hepatitis C Virus (HCV) antibody tests
Hepatitis C antibody tests should be checked at least once because 1 in 50 U.S. adults have chronic hepatitis C, which is curable.
HIV and Hepatitis C screening should be ruled out as part of an initial Sjogren’s evaluation. Both diseases can mimic Sjogren’s symptoms, including sicca.
More specialized blood tests (when indicated)
Alkaline phosphatase and bilirubin - levels may be high when there is damage to liver duct cells
Antimitochondrial antibodies (AMA) - usually positive in Primary Biliary Cholangitis (PBC)
Anti-smooth muscle antibody (ASMA) and other autoantibodies associated with autoimmune hepatitis (AIH) (242)
Hepatitis B screening panel
If there are indicators of liver disease, additional diagnostic tests may be performed, typically in collaboration with a hepatologist.
This may include more blood tests, ultrasounds, CT scans, and rarely, a liver biopsy (214, p. 364-365).
More Resources
Sjogren’s Foundation Patient Education Sheet, GI Tips For more information, I recommend these two excellent presentations from the 2022 Sjogren’s Foundation National Patient Conference: 1. The Kidney, Liver, and Pancreas in Sjogren’s by Dr. Chadwick Johr, MD 2. Gastrointestinal Issues in Sjogren’s by Dr. Lucinda Harris, MD
