Introduction We have reported (Hoeroldt 2010; J Hepatol 59:A13) that, of patients with AIH who attain biochemical remission (normal serum transaminases) on standard treatment (Prednisolone plus Azathioprine 1 mg/kg/day), persistent inflammation (Ishak histological activity index (HAI) >3) is found on repeat liver biopsy (biopsy 2) in 40% and is associated with increased long term mortality. We have developed an enhanced immunosuppression (EI) regime in these patients: continuation of Prednisolone and an increased dose of Azathioprine to 2 mg/kg/day (or Mycophenolate (MMF) if Azathioprine intolerant), with repeat biopsy (biopsy 3) after at least 1 year. We aim to assess efficacy of this EI strategy in achieving histological remission.
Method Assessment of results of biopsy 3 in patients with HAI >3 on biopsy 2 and who then received EI. Comparison with (a) those with HAI >3 on biopsy 2 but who did not receive EI and (b) those in remission (HAI≤3) on biopsy 2 and who had a third biopsy to confirm persistence of remission. Biopsies were assessed by a single Liver Histopathologist (AKD).
Results All patients had AIH by 1999 International Group criteria. Twenty eight (20 female, age at diagnosis (median (range) 57 (16–75)yr) had persistent inflammation (HAI 5 (4–12)) on biopsy 2 after 26 (17–98) months on standard treatment. Of these, 19 received IE: 13 patients had 2mg/kg and 2 had 1.5mg/kg Azathioprine and 4 had their MMF dose doubled. On biopsy 3, after a further 18 (12–80) months, HAI had fallen from 5 (4–12) to 4 (2–11) (NS (p = 0.436)) but only 6 of the 19 patients (32%) achieved remission (HAI≤3). Ishak fibrosis score was unchanged: 3(0–6) on biopsy 2 vs 3(1–6) on biopsy 3, but the number of patients with cirrhosis increased from 2 to 4. In the remaining 9 patients, not receiving EI, HAI was 5 (4–8) on biopsy 2 and 4(2–11) on biopsy 3, performed 47(16–97) months later (NS (p = 0.836)). 3 patients (33%) achieved remission. In a further 12 patients (11 female, age 44(9–76) yr) who had achieved histological remission on biopsy 2, HAI on biopsy 3, performed 25 (17–85) months later was 2(0–4) and 11 of the 12 (92%) remained in histological remission.
Conclusion This enhanced immunosuppression regime is of limited efficacy in achieving histological remission in patients with AIH who fail to do so on standard treatment. Such patients may require other therapies. However, if histological remission is achieved on standard therapy, this is usually maintained.
Disclosure of interest None Declared.