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The field of autoimmune hepatitis has been quite active since the last update on the topic at
the Day of Hepatology of Beaujon Hospital in 2002. A simplified diagnostic score, better
knowledge of some unusual forms, more solid criteria for remission and relapse, better
understanding of prognostic factors, and especially improved therapeutic options are now
available. The purpose of this chapter is to discuss these advances. The overlapping forms of
autoimmune hepatitis with other liver or biliary diseases will not be discussed here.
The autoimmune hepatitis is characterized by three elements: (a) a particular lesion, interface
hepatitis, (b) the absence of other causes of this lesion (viral hepatitis, drug-induced hepatitis,
Wilson’s disease or alpha-1 antitrypsin deficiency); and (c) signs of autoimmunity
(autoantibodies or other autoimmune diseases).
Table 1. Simplified diagnostic criteria of autoimmune hepatitis
Probable AIH > 6 Definite AIH > 7
A complex international score was established by the International Autoimmune Hepatitis
Group (IAHG), in an essentially academic aim (1). Recently, simplified criteria, more easily
used clinically have been developed in a group of 443 patients with or without AIH, and
validated in an independent sample of 393 patients with or without AIH (2). These criteria are
presented in Table 1. Excellent specificity of these simplified criteria were confirmed in a
more recent study (3), however the sensitivity remains lower than the old criteria of IAHG
particularly because neither other autoimmune diseases nor the HLA DR3 group were taken
into consideration (3). In other words, a low simplified score implies the use of the more
ATYPICAL CLINICAL AND HISTOLOGICAL FORMS
The autoimmune hepatitis is not exclusive to the young white woman, although it has long
been considered the typical background. In addition, particular histological forms have been
characterized, in which interface hepatitis is not the most significant lesion.
The age of 40 years seems to distinguish 2 forms of autoimmune hepatitis corresponding to
two incidence peaks: one around the age of 30 years, and the other towards the age of 55
years. The form of the older subjects is more frequent, always type 1; more frequently
associated with HLA-DR4 group; characterized by a less acute presentation; more frequently
associated with cirrhosis at the onset or during evolution; and less often associated with
relapse. However, whatever the age group, the incidence of response to immunosuppressive
treatment and serious side effects of treatment are equivalent (4-6).
The autoimmune hepatitis occurring in the subjects of black race is generally more serious,
particularly as they are male. Cirrhosis is more frequent at diagnosis, progression to fibrosis is
faster, and the terminal stage of cirrhosis is reached more frequently (7, 8).
Men are clearly less exposed to autoimmune hepatitis, but they are not spared. There is no
special semiology or progression of autoimmune hepatitis affecting men (9).
An individualized from where the initial lesions are located in the centrilobular region
(necrosis with mononuclear inflammatory infiltrate, without steatohepatitis), while interface
hepatitis is absent or minimal. As a rule, typical lesions of the periportal region appear
secondarily. This form has a good response to immunosuppressive therapy (10-12). The
differential diagnosis of this form with acute drug-induced immunoallergic hepatitis is
Form with giant cells
Multinucleated hepatocytes, cholestasis, and a mononuclear inflammatory or eosinophilic
infiltrate constitute the group of lesions which are referred to as giant cell hepatitis. The
mechanisms of formation of multinucleated hepatocytes are not clarified. This syndrome is
more common in infants than in adults. In adults, this syndrome is associated with a viral
infection (EBV, CMV, HHV6, paramyxovirus, HCV, HEV) or drug toxicity in about half of
the cases. In the other cases, it is often associated with autoimmune manifestations, can
progress rapidly to cirrhosis or liver failure, and is sensitive to immunosuppressive therapy
Forms with antimitochondrial antibodies
Antimitochondrial autoantibodies type M2 may be present (and sometimes isolated) in the
absence of cholestasis (alkaline phosphatase <1.5 N) and histological signs of lymphocytic
cholangitis. These forms do not exhibit an overlap with primary biliary cirrhosis and do not
predict its subsequent development (17, 18).
TREATMENT AND PROGNOSIS
Definition of response criteria
Although the reference remains the disappearance of necrotic and inflammatory lobular and
portal lesions, a consensus seems to be acquired on a purely biochemical definition. Although
a certain degree of heterogeneity persists, a growing consensus is emerging around the
- Complete (biochemical) remission: Persistently normal transaminases.
- Partial remission: Transaminases <2 times the upper limit of normal (x ULN).
- Relapse: Increase of transaminases to a value above the normal values after their
- Failure of treatment: Stability or increase of transaminases.
These definitions are based on the very good relationship between the lesions of necrosis or
lobular and periportal inflammation and transaminases on one hand (20, 21), and the overall
progression of the disease on the other hand (22-24). Therefore, these definitions tend to
substitute not only histological criteria of response, but also biochemical criteria used in
studies of the Mayo Clinic (AST <2 x ULN for the remission and AST> 3 x ULN for the
Few studies have been addressed to this subject because, as the benefit of immunosuppressive
therapy has been firmly and formerly established, most of the patients are treated. The
analysis of small series shows that a first attack may be followed by spontaneous remission,
but the risk of a difficult to treat relapse is high in the following months. The long-term
progression of these forms may be less favorable than that of the forms that are treated from
Progression under immunosuppressive therapy
It is now perfectly clear that the maintenance of prolonged remission is associated with a
normal life expectancy after adjusting for age and sex (17, 27, 28). Prolonged remission can
be maintained in more than 85% of patients either after discontinuation of
immunosuppressive therapy (25-50% of patients), or through a maintenance treatment with
low doses of immunosuppressive drugs (50-75% patients). As a result, overall life expectancy
of patients with autoimmune hepatitis in general is excellent. It is also clear that the lesions of
fibrosis and even cirrhosis may regress when remission is maintained (28-31). However,
cirrhosis develops during treatment in 10 to 30% of cases according to the series.
Relapse usually occurs during reduction or discontinuation of immunosuppressive therapy.
Prognosis of relapse is not worse than those forms in which prolonged remission is
The risk of hepatocellular carcinoma in the long term has been specified. It is about 0.5-1%
per year. It concerns exclusively patients who developed cirrhosis, particularly those with
severe portal hypertension. The role of prolonged immunosuppressive treatment remains to be
Prognostic factors of response to immunosuppressive treatment
This involves the prediction of remission in response to the treatment of an attack, relapse
during or at the discontinuation of maintenance therapy, and finally the occurrence of
- Prediction of remission. The high frequency of remission under immunosuppressive therapy
(>85%) did not allow to study with good power the predictive factors of failure. In a study
where the rate of treatment failure was 7% (14/214) factors associated with the failure were
group HLA DRB1*03 (93% versus 53%), younger age (33 versus 48 years) and a higher
initial bilirubinemia (68 versus 40 µmol/L). However, multivariate analysis showed that the
score MELD alone, summarized the previous prognostic markers (35). Similar data were
- Prediction of relapse. It was widely confirmed that abnormal transaminases and higher than
normal serum -globulin or IgG are of value in predicting relapse during maintenance
treatment or at its cessation (22). These two factors are largely but not completely redundant
(22). More recent is the demonstration that a marked portal infiltration by plasma cells is also
a powerful marker of risk of relapse (23, 37). This is probably redundant with the increase in
-globulin or IgG. It was suggested that the duration of the remission under
immunosuppressive therapy is also a major risk factor for relapse: in a recently published
series, the risk of relapse was 33% after a successful treatment for more than 4 years, while it
was 83% after treatment for 2-4 years and 90% after treatment for only 1-2 years (38).
- Prediction of complications of advanced disease or death. These long-term complications are
mainly related to the absence of prolonged complete response, in other words, the lack of
persistent normalization of transaminases (22-24). The role of cirrhosis is much less clear
whether it was present from the onset, or developed during progression: highly discordant
data were reported on this subject without an evident explanation of divergence (17, 23).
The principle of treatment of an attack by decreasing doses of immunosuppressives, followed
by maintenance therapy once remission obtained was kept in all the recently published
studies. The principle of treatment of attack by corticosteroids as a first choice was also
conserved. Finally, the principle of combination with azathioprine to halve the dose of
steroids - and hence their side effects - has only been followed in half of the patients included
in most recent large series. Recent publications were addressed to the usefulness of
pharmacological tests to adjust the dose of azathioprine, rescue treatments in case of failure of
conventional treatment and finally, the substitution of predniso(lo)ne with budesonide.
Randomized controlled trials have clearly established that azathioprine (a) allows a reduction
in corticosteroid dose while maintaining the efficacy of the treatment of attack, and (b)
monotherapy at a dose of 2 mg/kg/day prevents relapse. However, these beneficial effects are
limited by well-known side effects, gastrointestinal and hematological. By extension of
studies performed in inflammatory bowel disease (IBD), several studies have investigated the
relationship between genotype and phenotype of thiopurine methyl transferase (TMPT), or the
concentration of metabolites 6-TGN, and the risk of toxicity or inefficacy of azathioprine (39-
41). A poor relationship was observed between the phenotype or genotype of TPMT
deficiency and manifestations of intolerance or inefficacy. Therefore, these determinations are
not recommended. The monitoring must be carried out throughout the treatment using full
The failure of conventional treatment is rarely due to the inefficacy of treatment of an attack
administered at the usual dose (predniso(lo)ne 0.5 mg/kg/day and azathioprine 1 mg/kg/day)
and more often due to intolerance of treatment.
The management of inefficacy has not been addressed in any robust clinical trial. Several
- Increasing doses of predniso(lo)ne 1 mg/kg/day, in combination with azathioprine 1 mg/kg/j
until remission, then gradual reduction of corticosteroid;
- Increasing the dose of azathioprine to 2 mg/kg/day, in combination with predniso(lo)ne 0.5
mg/kg/day until remission, then gradual reduction of corticosteroid;
- Increasing both doses of azathioprine and predniso(lo)ne;
- The addition of another immunosuppressant and decreasing the dose of corticosteroid and
azathioprine from the start or once response is observed. The proposed immunosuppressants
were tacrolimus, cyclosporine, mycophenolate mofetyl, methotrexate and cyclophosphamide.
The efficacy of these attitudes has not really been evaluated. Such levels of
immunosuppression pose a significant risk of opportunistic infections (pneumocystosis,
aspergillosis, viral reactivations), and may be malignancy. These may, in themselves,
compromise liver transplantation. These potent immunosuppressive therapies can not be
maintained unless under close monitoring, while preventing pneumocystosis, and provided
that the efficacy is proven. The excellent efficacy and tolerability of budesonide (see below)
made it probably the first choice in case of inefficacy of conventional treatment.
Intolerance or containdication of azathioprine
is easily managed by substitution by
mycophenolate mophetyl. Although the side effects of these two products are close to each
other (digestive and hematopoietic), there is no cross intolerance to these products.
Intolerance or contraindication of predniso(lo)ne
deserves a substitution by budesonide (see
below). However, in patients with cirrhosis and portosystemic shunt, reduction or abolition of
the first-pass effect should add prudence.
The budesonide-azathioprine combination: standard treatment of attack
A high scale controlled trial was presented to the last 2 annual EASL and AASLD
conferences. Two hundred and three patients, never treated for autoimmune hepatitis, were
included. They were randomly assigned for treatment with either budesonide, 3 mg 3
times/day until remission, then 3 mg 2 times/day; or prednisone 40 mg/day for 4 weeks,
gradually reducing the dose to 10 mg/day for 2 months then 10 mg/day for 3 months. All
patients received azathioprine, 1-2 mg/kg/day for 6 months. The main criterion ('complete
response') was the complete normalization of transaminases in the absence of 6 characteristic
complications of corticosteroid therapy (acne, cushingoid facies, buffalo hump, striae,
diabetes and glaucoma). At 6 months, by intention-to-treat as well as per-protocol analysis,
the criterion of success was achieved in 47% of patients treated with budesonide and only
18% of patients treated with prednisone (46). It should be noted that the benefit was due to
both improved efficacy (biochemical remission 60% versus 39%) and lack of side effects
(72% versus 47%). At the end of the first 6 months of treatment, all patients received
budesonide alone, 3 mg 2 times/day. Six months later, a complete response (as defined above)
was observed in 55% of cases, biochemical remission in 59% of cases, AST <2 x ULN in
93% of cases and lack of side effects in 93% of cases (47).
The combination of azathioprine (1-2 mg/kg/day) and budesonide (3 mg 3 times/day, reduced
to 3 mg 2 times/day once remission obtained) deserves to become the standard treatment of
For maintenance treatment, a study comparing azathioprine alone and budesonide alone is
necessary. Already, we can consider that budesonide at a dose of 3 mg 2 times/day is an
interesting option in case of intolerance to azathioprine alone for maintenance treatment.
• Simplified diagnostic criteria (autoantibodies, IgG, and liver biopsy) are highly specific for
diagnosis of autoimmune hepatitis. When they are unhelpful, it is useful to use the modified
• The diagnosis of autoimmune hepatitis is not surprising in a man, an elderly, or a black race
subject. Differences in clinical manifestations or response to treatment between these different
populations have no implications on managment.
• The isolated anti-mitochondrial type M2, without cholangitis or cholestasis, does not reflect
• In the absence of viral infection or history of drug intake, giant multinucleated hepatocytes
orient towards an autoimmune cause. Pure centrilobular lesions may constitute the initial
• The two essential prognostic factors for autoimmune hepatitis are the complete
normalization of transaminases and serum immunoglobulins. Therefore, these two criteria are
• The treatment of choice for induction of remission is the combination of budesonide and
• The treatment of choice for the maintenance of remission is azathioprine. Mycophenolate
mofetyl or budesonide (3 mg 2times/day) are effective options in case of intolerance to
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