Treatment of autoimmune hepatitis: what is the optimal end point on follow-up biopsy?
Introduction The authors have reported1 that following immunosuppressive treatment of Autoimmune Hepatitis (AIH), many patients fail to achieve histological remission (necro-inflammatory score (NIS) ≥3), despite attaining biochemical remission (normal serum ALT). A recent report2 suggests that, foll...
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Published in | Gut Vol. 60; no. Suppl 1; p. A229 |
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Main Authors | , , , , , |
Format | Journal Article |
Language | English |
Published |
London
BMJ Publishing Group Ltd and British Society of Gastroenterology
01.04.2011
BMJ Publishing Group LTD |
Subjects | |
Online Access | Get full text |
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Summary: | Introduction The authors have reported1 that following immunosuppressive treatment of Autoimmune Hepatitis (AIH), many patients fail to achieve histological remission (necro-inflammatory score (NIS) ≥3), despite attaining biochemical remission (normal serum ALT). A recent report2 suggests that, following treatment, a NIS≥5 is not associated with fibrosis progression and hence, may be an acceptable treatment outcome.2 The authors therefore aimed to assess the associations of NIS on follow-up biopsy within the range 0–5, with change in fibrosis and survival. Methods The authors studied 114 patients with AIH by IAIHG criteria (81 definite, 94 female, mean age 48.7±1.7 years), treated initially with reducing dose prednisolone and 1 mg/kg azathioprine, who had achieved normal serum ALT and a NIS between 0 and 5 on follow-up biopsy (performed at median (range) 2.16 (0.65–13.67) years) after diagnosis (paired diagnostic and follow-up biopsies available in 93 patients). Biopsies were graded using the Ishak system. Results Fibrosis score between baseline and follow-up biopsy decreased in patients with follow-up NIS 0–3 (mean 3.4±0.24 to 2.7±0.21, n=59 p=0.001) but was unchanged in those with follow-up NIS of 4 or 5 (3.5±0.3 to 3.4±0.3, n=34 p=0.846). Fibrosis score on follow-up biopsy was higher in patients with NIS 4–5 (n=40) than with NIS 0–3 (n=72) (mean 3.3±0.3 vs 2.4±0.2, p=0.014). Regression of fibrosis was independently associated with lower NIS (p=0.014) and less portal inflammation (p=0.006) on follow-up biopsy, and with longer interval between the two biopsies (p=0.001). All cause death/transplantation rate was higher in those with NIS of 4–5 than in those with NIS 0–3 (18% vs 6% and 64% vs 24% after 10 and 20 years respectively; p<0.001) and this categorisation was independently associated with survival (p=0.001). A similar trend for liver death/transplantation just failed to reach significance (p=0.07). Conclusion In patients with AIH treated with immunosupression, even mild histological activity (NIS 4 or 5) on follow-up biopsy is associated with more fibrosis and with reduced survival and hence may not be an optimal end point of treatment. |
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Bibliography: | ark:/67375/NVC-SB9N76DW-S local:gutjnl;60/Suppl_1/A229-a ArticleID:gutjnl239301.483 href:gutjnl-60-A229-1.pdf istex:797DF5492CC40CEACBFCBE5224625D144FBF9278 ObjectType-Article-2 SourceType-Scholarly Journals-1 ObjectType-Feature-1 content type line 23 |
ISSN: | 0017-5749 1468-3288 |
DOI: | 10.1136/gut.2011.239301.483 |