Autoimmune liver disease and the Canadian First Nations Aboriginal Communities of British Columbia’s Pacific Northwest

attack.In PBC, it is the microscopic intra-hepatic bile duct that is the immunologic target, whereas in PSC, both intra-and extra-hepatic bile ducts are involved and in AIH, the antigenic target is located on the hepatocyte.Aside from the fact that all three diseases will result in end-stage cirrhosis, resulting in morbidity and premature mortality unless rescued by an increasingly scarce liver transplant, there are similarities between all these three liver diseases.Overlap syndrome, in which a patient may have features of both PBC and AIH [1] or PSC and AIH [2] , is well recognized to occur and is often seen by clinicians.Occasionally, patients have been reported to have overlap with PBC and PSC as well as all three [3] .Furthermore, it is well recognized that patients with PBC and AIH can have many associated extra-hepatic autoimmune disease, especially rheumatologic conditions [4,5] .PSC, although classically occurring in the context of ulcerative colitis, is also reported to be associated with an increased likelihood of co-existent extra-intestinal, extra-hepatic autoimmune diseases compared to those with ulcerative colitis alone [6] .Recently, we have reported evidence that suggests that the Aboriginal population of British Columbia (BC), Canada (i.e.part of Canada's First Nations) has a significant burden of PBC [7][8][9] and possibly AIH [10,11] .It is commonly accepted by the gastroenterology community of BC that inflammatory bowel disease is extremely rare amongst its First Nations peoples, a fact that most likely explains the rarity of PSC in the First Nations population.The finding of an increased rate of PBC and AIH in BC's First Nations community has clinical, epidemiologic, anthropologic as well as socio-political implications.First Nations of Canada, also referred to as American Indians or Native Americans in the United States, are the original inhabitants of the continent and pre-date, by millennia, the subsequent European colonizers.In Canada, the First Nations peoples constitute about 4% of the population.In British Columbia, with a total population of close to 4 million people, about 170 000 are First Nations in demographic background.Often plagued by socioeconomic injustice, it is well recognized in recent years that the global health of Canada's First Nations communities is disproportionately worse than the rest of Canadian society.Chronic health problems, including diabetes mellitus, obesity, coronary artery disease, etc, are over-represented in our First Nations communities [12,13] .Excessive alcohol consumption remains a problem amongst some within the First Nations communities [14] , however, the stereotypic generalization that all chronic liver diseases amongst First Nations are a result of alcoholic liver disease more likely

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