Background|NNP Primary|JJ Sjögren|NNP 's|POS syndrome|NN (|( 1|CD °|NN SS|NNP )|) is|VBZ a|DT systemic|JJ autoimmune|JJ disorder|NN characterized|VBN by|IN dry|JJ eyes|NNS (|( keratoconjunctivitis|NNS sicca|NN )|) ,|, dry|JJ mouth|NN (|( xerostomia|NN )|) as|RB well|RB as|IN involvement|NN of|IN other|JJ exocrine|NN glands|NNS .|. 
While|IN 1|CD °|NN SS|NNP is|VBZ typically|RB considered|VBN an|DT autoimmune|JJ exocrinopathy|NN ,|, the|DT immune|JJ destruction|NN can|MD often|RB extend|VB to|TO affect|VB non-exocrine|JJ organs|NNS .|. 
Around|IN 25|CD %|NN of|IN patients|NNS with|IN 1|CD °|NN SS|NNP can|MD present|VB with|IN involvement|NN of|IN other|JJ organs|NNS such|JJ as|IN the|DT thyroid|NN ,|, central|JJ nervous|JJ system|NN ,|, lungs|NNS ,|, kidney|NN and|CC liver|NN .|. 
The|DT association|NN of|IN liver|NN disease|NN and|CC 1|CD °|NN SS|NNP was|VBD suggested|VBN more|JJR than|IN 40|CD years|NNS ago|RB [|NN 1|CD ]|NN .|. 
While|IN liver|NN involvement|NN in|IN 1|CD °|NN SS|NNP has|VBZ been|VBN considered|VBN "|'' rare|JJ "|'' [|NN 2|CD ]|NN only|RB a|DT few|JJ clinical|JJ studies|NNS specifically|RB address|VBP this|DT complication|NN and|CC evaluate|VB the|DT association|NN of|IN liver|NN function|NN tests|VBZ abnormalities|NNS with|IN the|DT severity|NN of|IN 1|CD °|NN SS|NNP [|NN 3|CD 4|CD 5|CD 6|CD ]|NN .|. 

Liver|NNP diseases|NNS associated|VBN with|IN 1|CD °|NN SS|NNP include|VBP primary|JJ biliary|JJ cirrhosis|NNS (|( PBC|NNP )|) -|: autoimmune|JJ cholangitis|NNS [|NN 8|CD 9|CD 10|CD ]|NN ,|, autoimmune|JJ hepatitis|NN [|NN 5|CD 6|CD ]|NN ,|, viral|JJ hepatitis|NN (|( B|NNP and|CC C|NNP )|) [|NN 11|CD 12|CD 13|CD 14|CD 15|CD 16|CD 17|CD 18|CD 19|CD 20|CD 21|CD ]|NN ,|, sclerosing|VBG cholangitis|NNS [|NN 22|CD ]|NN ,|, and|CC nodular|NN regenerative|JJ hyperplasia|NN [|NN 23|CD ]|NN .|. 
In|IN addition|NN ,|, chronic|JJ lymphocytic|JJ sialadenitis|NNS has|VBZ been|VBN found|VBN in|IN patients|NNS with|IN different|JJ types|NNS of|IN liver|NN cirrhosis|NNS [|NN 16|CD 17|CD 18|CD 19|CD 20|CD 21|CD 22|CD 23|CD 24|CD ]|NN .|. 

We|PRP report|VBP the|DT results|NNS of|IN a|DT review|NN of|IN cases|NNS undertaken|VBN to|TO determine|VB the|DT prevalence|NN of|IN abnormal|JJ liver|NN function|NN tests|NNS (|( LFTs|NNP )|) and|CC liver|NN disease|NN in|IN patients|NNS with|IN 1|CD °|NN SS|NNP referred|VBD to|TO a|DT tertiary|JJ care|NN center|NN and|CC the|DT association|NN of|IN abnormal|JJ LFTs|NNP with|IN other|JJ systemic|JJ features|NNS and|CC autoimmunity|NN markers|NNS of|IN 1|CD °|NN SS|NNP .|. 

Methods|NNP Statistical|NNP analysis|NN The|DT statistical|JJ analysis|NN included|VBD descriptive|JJ measures|NNS (|( means|VBZ ,|, standard|JJ deviations|NNS and|CC ranges|NNS )|) .|. 
Comparison|NNP of|IN results|NNS of|IN patients|NNS with|IN and|CC without|IN liver|NN disease|NN was|VBD done|VBN using|VBG t-tests|JJ of|IN continuous|JJ variables|NNS and|CC Fisher|NNP 's|POS exact|JJ test|NN or|CC x|SYM 2|CD for|IN categoric|JJ measures|NNS .|. 

Results|NNS Of|IN the|DT 115|CD charts|NNS reviewed|VBN ,|, 73|CD cases|NNS (|( 55|CD women|NNS and|CC 18|CD men|NNS ,|, median|JJ age|NN 53|CD )|) fulfilled|VBN EECC|NNP for|IN 1|CD °|NN SS|NNP and|CC were|VBD initially|RB included|VBN for|IN analysis|NN .|. 
Of|IN the|DT 73|CD patients|NNS ,|, a|DT 54|CD %|NN of|IN them|PRP (|( 40|CD patients|NNS )|) have|VBP had|VBD a|DT salivary|JJ gland|NN biopsy|NN performed|VBN .|. 
In|IN all|PDT these|DT patients|NNS ,|, the|DT biopsy|NN confirmed|VBD the|DT diagnosis|NN of|IN Sjögren|NNP 's|POS syndrome|NN .|. 
All|DT patients|NNS studied|VBN had|VBD objective|NN evidence|NN of|IN 1|CD °|NN SS|NNP ,|, including|VBG keratoconjunctivitis|NNS sicca|NN ,|, positive|JJ labial|NN salivary|JJ gland|NN biopsy|NN ,|, autoantibodies|NNS and|CC /|NN or|CC salivary|JJ gland|NN hypofunction|NN .|. 
We|PRP excluded|VBD those|DT patients|NNS without|IN these|DT objective|NN criteria|NNS of|IN 1|CD °|NN SS|NNP and|CC also|RB those|DT who|WP did|VBD not|RB fulfill|VB EECC|NNP criteria|NNS .|. 

The|DT mean|JJ age|NN at|IN time|NN of|IN onset|NN of|IN disease|NN was|VBD 45|CD ±|NN 20.5|CD years|NNS old|JJ and|CC disease|NN duration|NN was|VBD 4.9|CD years|NNS ±|NN 4.5|CD years|NNS (|( mean|VB ±|NN range|NN )|) .|. 
Liver|NNP function|NN tests|NNS had|VBD been|VBN determined|VBN in|IN 59|CD patients|NNS (|( 80.8|CD %|NN )|) and|CC abnormal|JJ liver|NN function|NN tests|NNS were|VBD found|VBN in|IN 29|CD of|IN the|DT 59|CD patients|NNS (|( 49.1|CD %|NN )|) .|. 
Further|RB analysis|NN was|VBD then|RB undertaken|VBN in|IN those|DT patients|NNS in|IN whom|WP LFTs|NNP had|VBD been|VBN measured|VBN .|. 
The|DT clinical|JJ and|CC laboratory|NN characteristics|NNS of|IN these|DT patients|NNS are|VBP shown|VBN in|IN Tables|NNP 2|CD and|CC 3|CD .|. 

For|IN these|DT SS|NNP patients|NNS studied|VBN ,|, abnormal|JJ LFTs|NNP were|VBD more|RBR common|JJ than|IN any|DT other|JJ potential|JJ non-exocrine|JJ features|NNS of|IN SS|NNP .|. 
Clinical|NNP evidence|NN of|IN liver|NN disease|NN ,|, defined|VBN in|IN methods|NNS section|NN ,|, was|VBD found|VBN in|IN 12|CD patients|NNS (|( 20.3|CD %|NN )|) ,|, all|DT of|IN whom|WP had|VBD abnormal|JJ liver|NN function|NN tests|NNS .|. 
Two|CD deaths|NNS occurred|VBD in|IN the|DT population|NN studied|VBD ,|, both|DT attributed|VBD to|TO liver|NN failure|NN .|. 
An|DT additional|JJ patient|NN required|VBD a|DT liver|NN transplant|NN .|. 
In|IN all|DT cases|NNS ,|, the|DT diagnosis|NN of|IN 1|CD °|NN SS|NNP antedated|JJ the|DT onset|NN of|IN liver|NN disease|NN or|CC its|PRP$ diagnosis|NN .|. 
Markers|NNP of|IN viral|JJ hepatitis|NN ,|, sought|VBN in|IN 39|CD patients|NNS ,|, were|VBD found|VBN only|RB in|IN 4|CD .|. Two|CD patients|NNS carried|VBD the|DT surface|NN antigen|NN of|IN hepatitis|NNP B|NNP virus|NN and|CC one|CD had|VBD antibodies|NNS to|TO hepatitis|NNP C|NNP virus|NN .|. 
In|IN a|DT liver|NN biopsy|NN of|IN a|DT patient|NN who|WP lacked|VBD serological|JJ markers|NNS for|IN hepatitis|NN viruses|NNS ,|, hepatitis|NNP B|NNP virus|NN was|VBD detected|VBN by|IN in|IN situ|NN hybridization|NN .|. 

Risk|NN factors|NNS for|IN liver|NN disease|NN were|VBD identified|VBN in|IN 40|CD %|NN of|IN the|DT patients|NNS with|IN abnormal|JJ liver|NN function|NN tests|NNS and|CC are|VBP described|VBN in|IN Table|NNP 4|CD .|. No|DT association|NN with|IN tobacco|NN use|NN was|VBD found|VBN .|. 
Only|RB 5|CD patients|NNS had|VBD documented|VBN evidence|NN of|IN tobacco|NN consumption|NN .|. 
We|PRP found|VBD no|DT significant|JJ differences|NNS in|IN risk|NN factors|NNS for|IN abnormal|JJ liver|NN function|NN tests|NNS among|IN patients|NNS with|IN or|CC without|IN hepatic|JJ involvement|NN .|. 
Therefore|RB ,|, in|IN 60|CD %|NN of|IN the|DT patients|NNS with|IN sub|NN clinical|JJ or|CC clinical|JJ evidence|NN of|IN liver|NN disease|NN ,|, no|DT clear|JJ explanation|NN for|IN the|DT abnormal|JJ LFTs|NNP was|VBD found|VBN ,|, except|IN for|IN the|DT association|NN with|IN 1|CD °|NN SS|NNP .|. 

The|DT pattern|NN of|IN biochemical|JJ liver|NN abnormalities|NNS was|VBD mainly|RB hepatocellular|NN (|( defined|VBN as|IN predominant|NN increase|NN of|IN AST|NNP and|CC /|NN or|CC ALT|NNP in|IN comparison|NN with|IN AP|NNP and|CC /|NN or|CC bilirubins|NNS )|) in|IN 11|CD cases|NNS ;|: cholestatic|JJ (|( defined|VBN as|IN predominant|NN increase|NN in|IN AP|NNP and|CC /|NN or|CC bilirubins|NNS compared|VBN with|IN AST|NNP and|CC /|NN or|CC ALT|NNP )|) in|IN 3|CD and|CC mixed|JJ (|( evidence|NN of|IN both|DT cholestatic|JJ and|CC hepatocellular|NN damage|NN )|) in|IN 8|CD cases|NNS .|. 
Abnormalities|NNP were|VBD persistent|JJ (|( present|JJ on|IN every|DT occasion|NN when|WRB measured|VBN more|RBR than|IN once|RB )|) in|IN 19|CD patients|NNS (|( 65.5|CD %|NN of|IN those|DT with|IN abnormal|JJ LFTs|NNP )|) ,|, intermittent|JJ (|( presence|NN of|IN LFT|NNP abnormalities|NNS was|VBD not|RB found|VBN in|IN all|DT determinations|NNS )|) in|IN 9|CD (|( 31|CD %|NN )|) and|CC in|IN one|CD case|NN (|( 3.5|CD %|NN )|) there|EX was|VBD only|RB one|CD determination|NN of|IN liver|NN function|NN tests|NNS .|. 
The|DT pattern|NN of|IN liver|NN enzyme|NN abnormalities|NNS is|VBZ shown|VBN in|IN Figure|NN 1|CD .|. 
None|NN of|IN the|DT patients|NNS with|IN abnormal|JJ liver|NN function|NN tests|NNS had|VBD clinical|JJ evidence|NN of|IN muscle|NN involvement|NN that|WDT could|MD explain|VB the|DT high|JJ levels|NNS of|IN amino-transferases|JJ .|. 
Activity|NN of|IN CPK|NNP or|CC aldolase|NN was|VBD not|RB elevated|VBD when|WRB measured|VBN in|IN 15|CD of|IN the|DT 29|CD patients|NNS with|IN abnormal|JJ liver|NN function|NN tests|NNS .|. 
Anti-mitochondrial|NNP antibodies|NNS (|( AMA|NNP )|) and|CC anti-smooth|JJ muscle|NN antibodies|NNS (|( ASMA|NNP )|) were|VBD sought|VBN in|IN 5|CD patients|NNS ,|, with|IN positive|JJ ASMA|NNP in|IN 2|CD .|. 

The|DT association|NN of|IN abnormal|JJ liver|NN function|NN tests|NNS with|IN other|JJ non-exocrine|JJ features|NNS of|IN 1|CD °|NN SS|NNP is|VBZ shown|VBN in|IN Figure|NN 2|CD .|. Patients|NNS with|IN abnormal|JJ liver|NN function|NN tests|NNS were|VBD more|RBR likely|JJ to|TO have|VB lung|NN ,|, kidney|NN or|CC hematological|JJ manifestations|NNS ,|, when|WRB compared|VBN to|TO Sjögren|NNP 's|POS patients|NNS without|IN liver|NN disease|NN .|. 
Presence|NNP of|IN other|JJ non-exocrine|JJ features|NNS of|IN 1|CD °|NN SS|NNP was|VBD not|RB influenced|VBN by|IN prevalence|NN of|IN liver|NN diseases|NNS .|. 

Regarding|VBG laboratory|NN test|NN results|NNS ,|, patients|NNS with|IN liver|NN disease|NN were|VBD more|RBR likely|JJ to|TO have|VB an|DT elevated|JJ sedimentation|NN rate|NN at|IN some|DT point|NN during|IN the|DT course|NN of|IN their|PRP$ disease|NN .|. 
A|DT positive|JJ anti-|NN ENA|NNP (|( anti-|NN Ro|NNP ,|, anti-|NN Ro|NNP /|NN La|NNP ,|, and|CC /|NN or|CC anti-|NN RNP|NNP )|) was|VBD also|RB associated|VBN with|IN an|DT increased|JJ prevalence|NN of|IN abnormal|JJ liver|NN function|NN tests|NNS (|( Figure|NN 3|CD )|) .|. 
The|DT sample|NN was|VBD too|RB small|JJ to|TO determine|VB whether|IN a|DT specific|JJ ENA|NNP was|VBD associated|VBN with|IN liver|NN disease|NN .|. 
Other|JJ markers|NNS of|IN systemic|JJ inflammation|NN or|CC autoimmunity|NN did|VBD not|RB correlate|VBP with|IN the|DT presence|NN or|CC absence|NN of|IN LFT|NNP abnormalities|NNS .|. 

Liver|NNP biopsies|NNS ,|, done|VBN in|IN 8|CD patients|NNS ,|, disclosed|VBD post-viral|JJ chronic|JJ active|JJ hepatitis|NN (|( 3|CD )|) ,|, cryptogenic|JJ cirrhosis|NNS (|( 2|CD )|) ,|, and|CC one|CD case|NN each|DT of|IN post-viral|JJ cirrhosis|NNS ,|, alcoholic|JJ hepatitis|NN ,|, and|CC autoimmune|JJ hepatitis|NN .|. 

Discussion|NNP In|IN this|DT group|NN of|IN Sjögren|NNP 's|POS patients|NNS seen|VBN at|IN a|DT tertiary|JJ care|NN center|NN ,|, abnormal|JJ liver|NN function|NN tests|NNS were|VBD found|VBN to|TO be|VB a|DT common|JJ non-exocrine|JJ feature|NN of|IN 1|CD °|NN SS|NNP .|. 
The|DT prevalence|NN of|IN this|DT association|NN was|VBD found|VBN to|TO be|VB higher|JJR in|IN our|PRP$ study|NN than|IN in|IN other|JJ previous|JJ series|NN [|NN 2|CD 3|CD 4|CD 5|CD 6|CD 7|CD ]|NN .|. 
The|DT true|JJ prevalence|NN could|MD be|VB even|RB higher|JJR since|IN liver|NN enzyme|NN profiles|NNS were|VBD not|RB done|VBN in|IN all|DT patients|NNS .|. 
The|DT prevalence|NN suggested|VBD in|IN previous|JJ reports|NNS ranges|NNS from|IN 6|CD to|TO 58|CD %|NN ,|, but|CC the|DT definition|NN of|IN hepatic|JJ disease|NN varies|VBZ from|IN the|DT unspecific|JJ (|( e.g.|NN hepatomegaly|RB )|) to|TO well|RB proven|VBN cases|NNS of|IN liver|NN disease|NN [|NN 1|CD 2|CD 3|CD 4|CD 5|CD 6|CD 7|CD 28|CD ]|NN .|. 
Denko|NNP in|IN 1960|CD reported|VBD that|IN 12|CD %|NN of|IN patients|NNS with|IN SS|NNP had|VBD hepatosplenomegaly|RB [|NN 29|CD ]|NN .|. 
Other|JJ studies|NNS done|VBN in|IN the|DT 1960|CD 's|POS also|RB confirmed|VBD hepatomegaly|RB in|IN 18|CD -|: 20|CD %|NN of|IN patients|NNS with|IN SS|NNP [|NN 30|CD 31|CD ]|NN .|. 
In|IN 1970|CD ,|, Whaley|NNP reported|VBD liver|NN disease|NN in|IN 6|CD %|NN of|IN patients|NNS with|IN SS|NNP and|CC mentioned|VBD an|DT association|NN with|IN anti-mitochondrial|JJ antibodies|NNS [|NN 2|CD ]|NN .|. 
In|IN 1986|CD ,|, Tsianos|NNP and|CC co-workers|NNS described|VBD 22|CD SS|NNP patients|NNS with|IN gastrointestinal|NN complications|NNS ,|, called|VBN from|IN a|DT large|JJ cohort|NN ;|: only|RB two|CD patients|NNS had|VBD liver|NN disease|NN ,|, each|DT with|IN chronic|JJ active|JJ hepatitis|NN [|NN 4|CD ]|NN .|. 
Other|JJ studies|NNS have|VBP reported|VBN variable|JJ prevalence|NN [|NN 3|CD 28|CD ]|NN and|CC different|JJ histopathological|JJ findings|NNS in|IN liver|NN biopsies|NNS ranging|VBG from|IN cholestatic|JJ liver|NN damage|NN (|( stage|NN I|PRP primary|JJ biliary|JJ cirrhosis|NNS )|) to|TO chronic|JJ active|JJ hepatitis|NN due|JJ to|TO hepatitis|NNP C|NNP virus|NN .|. 

In|IN our|PRP$ study|NN ,|, liver|NN disease|NN was|VBD associated|VBN with|IN other|JJ non-exocrine|JJ manifestations|NNS of|IN 1|CD °|NN SS|NNP ,|, specifically|RB those|DT affecting|VBG lung|NN ,|, kidney|NN and|CC blood|NN cells|NNS .|. 
Those|DT patients|NNS with|IN serological|JJ evidence|NN of|IN systemic|JJ inflammation|NN ,|, as|IN shown|VBN by|IN an|DT elevated|JJ sedimentation|NN rate|NN ,|, were|VBD more|RBR likely|JJ to|TO have|VB liver|NN test|NN abnormalities|NNS .|. 
Also|RB ,|, the|DT presence|NN of|IN a|DT positive|JJ anti-|NN ENA|NNP correlated|JJ positively|RB with|IN hepatic|JJ disease|NN .|. 
An|DT association|NN of|IN ENA|NNP response|NN with|IN liver|NN disease|NN has|VBZ been|VBN described|VBN in|IN children|NNS with|IN autoimmune|JJ hepatitis|NN ,|, where|WRB anti-|NN ENA-positive|NNP patients|NNS demonstrated|VBD more|RBR severe|JJ liver|NN test|NN abnormalities|NNS than|IN those|DT who|WP were|VBD anti-|NN ENA-negative|NNP [|NN 32|CD ]|NN .|. 
In|IN another|DT study|NN ,|, a|DT 15|CD %|NN of|IN patients|NNS with|IN various|JJ chronic|JJ liver|NN diseases|NNS were|VBD found|VBN to|TO be|VB anti-|NN RNP|NNP positive|JJ [|NN 33|CD ]|NN .|. 

With|IN etiopathogenesis|NNS of|IN 1|CD °|NN SS|NNP still|RB an|DT open|JJ question|NN [|NN 34|CD ]|NN ,|, a|DT possible|JJ role|NN of|IN hepatitis|NNP C|NNP virus|NN (|( HCV|NNP )|) has|VBZ drawn|VBN attention|NN .|. 
Recent|JJ studies|NNS have|VBP mentioned|VBN HCV|NNP incidence|NN in|IN patients|NNS with|IN 1|CD SS|NNP ranging|VBG from|IN 14|CD -|: 19|CD %|NN [|NN 11|CD 12|CD 16|CD 18|CD 21|CD ]|NN .|. 
Phenotypic|NNP characterization|NN of|IN the|DT minor|JJ salivary|JJ glands|NNS with|IN immunohistochemistry|NN in|IN patients|NNS with|IN hepatitis|NNP C|NNP virus|NN infection|NN and|CC /|NN or|CC 1|CD °|NN SS|NNP has|VBZ given|VBN conflicting|JJ results|NNS [|NN 14|CD 15|CD ]|NN Some|DT reports|NNS mention|VBP that|IN the|DT salivary|JJ gland|NN findings|NNS are|VBP strikingly|RB similar|JJ in|IN patients|NNS with|IN liver|NN disease|NN associated|VBN with|IN HCV|NNP infection|NN than|IN in|IN those|DT with|IN 1|CD °|NN SS|NNP [|NN 12|CD ]|NN ,|, while|IN others|NNS mention|VBP distinctive|JJ differences|NNS between|IN both|DT groups|NNS regarding|VBG focus|NN score|NN ,|, expression|NN of|IN surface|NN markers|NNS in|IN lymphocytes|NNS infiltrating|VBG the|DT salivary|JJ glands|NNS and|CC in|IN epithelial|NN cells|NNS ,|, as|RB well|RB as|IN differences|NNS in|IN the|DT degree|NN of|IN inflammation|NN [|NN 14|CD 15|CD ]|NN .|. 
Transgenic|NNP mice|NNS models|NNS that|WDT carry|VBP the|DT HCV|NNP envelope|NN genes|NNS develop|VBP an|DT exocrinopathy|NN affecting|VBG salivary|JJ and|CC lachrymal|NN glands|NNS [|NN 19|CD ]|NN .|. 
Expression|NNP of|IN autoimmunity|NN markers|NNS also|RB tends|VBZ to|TO differ|VB between|IN HCV-infection|NN and|CC 1|CD °|NN SS|NNP .|. 
Positive|JJ ENAs|NNP are|VBP rarely|RB seen|VBN in|IN HCV-patients|NNP .|. 
Also|RB ,|, in|IN most|JJS cases|NNS sicca|NN symptoms|NNS are|VBP not|RB present|JJ in|IN individuals|NNS with|IN HCV|NNP as|IN compared|VBN with|IN the|DT 1|CD °|NN SS|NNP population|NN .|. 
Although|IN the|DT prevalence|NN of|IN viral|JJ hepatitis|NN markers|NNS in|IN our|PRP$ group|NN of|IN patients|NNS with|IN liver|NN disease|NN was|VBD very|RB low|JJ and|CC did|VBD not|RB account|VB for|IN most|JJS of|IN the|DT cases|NNS with|IN abnormal|JJ liver|NN function|NN tests|NNS ,|, these|DT markers|NNS were|VBD not|RB sought|VBN in|IN a|DT small|JJ percentage|NN of|IN these|DT patients|NNS .|. 
It|PRP is|VBZ important|JJ to|TO note|VB that|IN HCV|NNP appears|VBZ to|TO account|VB for|IN a|DT subgroup|NN of|IN patients|NNS with|IN exocrine|NN complaints|NNS in|IN which|WDT half|PDT the|DT cases|NNS might|MD meet|VB the|DT definition|NN for|IN SS|NNP according|VBG to|TO European|JJ and|CC Manthorpe|NNP criteria|NNS .|. 
However|RB ,|, this|DT subgroup|NN is|VBZ characterized|VBN by|IN the|DT absence|NN of|IN clinical|JJ manifestations|NNS observed|VBD in|IN 1|CD °|NN SS|NNP ,|, and|CC the|DT absence|NN of|IN anti-|NN Ro|NNP and|CC anti-|NN La|NNP [|NN 35|CD ]|NN .|. 

An|DT aberrant|NN interaction|NN between|IN lymphocytes|NNS and|CC different|JJ epithelial|NN tissues|NNS has|VBZ been|VBN proposed|VBN as|IN a|DT mechanism|NN for|IN the|DT damage|NN seen|VBN in|IN different|JJ organs|NNS in|IN 1|CD °|NN SS|NNP [|NN 36|CD ]|NN .|. 
Since|IN it|PRP has|VBZ been|VBN suggested|VBN that|IN the|DT target|NN tissue|NN involved|VBN in|IN the|DT autoimmune|JJ histopathologic|JJ lesions|NNS of|IN 1|CD °|NN SS|NNP might|MD be|VB the|DT epithelium|NN [|NN 37|CD ]|NN ,|, it|PRP is|VBZ interesting|JJ that|IN the|DT findings|NNS in|IN our|PRP$ study|NN point|NN to|TO the|DT association|NN of|IN liver|NN disease|NN with|IN pulmonary|JJ and|CC renal|JJ abnormalities|NNS ,|, all|DT which|WDT are|VBP characterized|VBN by|IN epithelial|NN damage|NN [|NN 38|CD 39|CD ]|NN .|. 
Epithelial|NNP cells|NNS have|VBP been|VBN proposed|VBN to|TO be|VB active|JJ participants|NNS rather|RB than|IN passive|JJ targets|NNS in|IN the|DT chronic|JJ immune|JJ response|NN in|IN 1|CD °|NN SS|NNP but|CC further|JJ studies|NNS are|VBP needed|VBN to|TO establish|VB the|DT role|NN of|IN liver|NN epithelial|NN cells|NNS in|IN the|DT pathogenesis|NNS of|IN hepatic|JJ damage|NN in|IN this|DT disease|NN ,|, including|VBG the|DT analysis|NN of|IN HLA|NNP expression|NN and|CC cytokine|NN secretion|NN pattern|NN in|IN these|DT cells|NNS .|. 

The|DT co-existence|NN of|IN liver|NN disease|NN and|CC the|DT presence|NN of|IN circulating|VBG AMAs|NNP in|IN Sjögren|NNP 's|POS patients|NNS sera|NN has|VBZ been|VBN pointed|VBN as|IN an|DT indicator|NN that|DT liver|NN pathology|NN might|MD be|VB autoimmune|JJ and|CC similar|JJ to|TO that|DT of|IN primary|JJ biliary|JJ cirrhosis|NNS [|NN 4|CD 7|CD 8|CD 10|CD ]|NN .|. 
In|IN previous|JJ studies|NNS ,|, a|DT pericholangial|NN lymphocytic|JJ infiltration|NN similar|JJ to|TO that|DT found|VBD in|IN stage|NN I|PRP of|IN primary|JJ biliary|JJ cirrhosis|NNS ,|, has|VBZ been|VBN reported|VBN in|IN 1|CD °|NN SS|NNP with|IN abnormal|JJ liver|NN function|NN tests|NNS or|CC positivity|NN for|IN AMA|NNP [|NN 4|CD 7|CD ]|NN .|. 
In|IN our|PRP$ review|NN of|IN cases|NNS ,|, we|PRP found|VBD predominance|NN in|IN hepatocellular|NN liver|NN damage|NN rather|RB than|IN cholestatic|JJ disease|NN ,|, which|WDT would|MD argue|VB against|IN a|DT PBC-type|NNP of|IN liver|NN damage|NN .|. 
Other|JJ authors|NNS had|VBD proposed|VBN that|IN SS|NNP associated|VBN with|IN PBC|NNP should|MD be|VB considered|VBN a|DT form|NN of|IN secondary|JJ SS|NNP that|WDT resembles|VBZ more|JJR the|DT "|'' sicca|NN complex|JJ "|'' with|IN exocrine|NN features|NNS seen|VBN in|IN patients|NNS with|IN rheumatoid|NN arthritis|NN [|NN 40|CD 41|CD ]|NN .|. 

Limitations|NNPS of|IN the|DT study|NN come|VB primarily|RB from|IN being|VBG a|DT retrospective|NN analysis|NN .|. 
Since|IN the|DT patients|NNS were|VBD studied|VBN in|IN a|DT tertiary|JJ care|NN referral|NN center|NN ,|, the|DT severity|NN of|IN the|DT disease|NN and|CC the|DT prevalence|NN of|IN the|DT manifestations|NNS might|MD be|VB different|JJ from|IN the|DT general|JJ 1|CD °|NN SS|NNP population|NN .|. 
Furthermore|RB ,|, in|IN many|JJ cases|NNS ,|, Sjögren|NNP 's|POS syndrome|NN diagnosis|NN had|VBD been|VBN sought|VBN because|IN of|IN otherwise|RB unexplained|JJ non-exocrine|JJ features|NNS .|. 
While|IN we|PRP could|MD not|RB find|VB an|DT association|NN between|IN use|NN of|IN NSAIDS|NNP or|CC other|JJ medications|NNS and|CC prevalence|NN of|IN liver|NN function|NN tests|VBZ abnormalities|NNS ,|, the|DT study|NN design|NN did|VBD not|RB allow|VB us|PRP to|TO exclude|VB the|DT possibility|NN of|IN over-the-counter|JJ (|( OTC|NNP )|) medication|NN use|NN that|WDT could|MD have|VB affected|VBN LFT|NNP 's|POS measurement|NN .|. 
Drug|NN toxicity|NN is|VBZ certainly|RB an|DT important|JJ factor|NN to|TO be|VB considered|VBN .|. 
However|RB ,|, given|VBN that|IN most|JJS patients|NNS had|VBD persistent|JJ rather|RB than|IN intermittent|JJ abnormalities|NNS of|IN LFTs|NNP and|CC that|IN the|DT use|NN of|IN hepatotoxic|JJ drugs|NNS was|VBD not|RB elicited|JJ in|IN the|DT majority|NN of|IN patients|NNS with|IN liver|NN abnormalities|NNS ,|, a|DT toxic|JJ effect|NN of|IN medications|NNS could|MD not|RB be|VB established|VBN .|. 

Conclusions|NNP Based|VBN on|IN the|DT results|NNS of|IN this|DT study|NN ,|, we|PRP consider|VBP that|IN an|DT evaluation|NN for|IN clinical|JJ and|CC serological|JJ evidence|NN of|IN liver|NN disease|NN should|MD be|VB done|VBN in|IN every|DT patient|NN with|IN 1|CD °|NN SS|NNP ,|, particularly|RB if|IN there|EX is|VBZ evidence|NN of|IN other|JJ non-exocrine|JJ complications|NNS or|CC serological|JJ evidence|NN of|IN systemic|JJ inflammation|NN .|. 
Although|IN no|DT other|JJ diagnosis|NN explaining|VBG liver|NN disease|NN may|MD be|VB found|VBN ,|, the|DT disorders|NNS for|IN which|WDT treatment|NN might|MD be|VB beneficial|JJ (|( e.g.|NN immunosuppressants|NNS for|IN autoimmune|JJ hepatitis|NN ,|, interferon-alpha|JJ for|IN viral|JJ hepatitis|NN ,|, ursodeoxycolic|JJ acid|NN for|IN primary|JJ biliary|JJ cirrhosis|NNS )|) warrant|NN a|DT diligent|NN search|NN in|IN all|DT cases|NNS of|IN 1|CD °|NN SS|NNP with|IN abnormal|JJ liver|NN function|NN .|. 

Competing|VBG interests|NNS None|NN .|. 
Authors|NNP '|POS contributions|NNS Both|DT authors|NNS contributed|VBD equally|RB to|TO the|DT paper|NN .|. 

