Evaluation of current practice and outcome in autoimmune hepatitis (AIH)

Summary Although practice guidelines1,2 for the management of AIH exist, they are based on data from many years ago and may not be reflective of actual current practice. Therefore, this study investigated current practice and outcome in the UK’s first large-scale multicentre audit involving 28 hospitals. This has characterised 1267 patients presenting to hospitals of varying size, expertise and facilities across several regional areas. Major findings were: • Patients were older than those from other multicentre studies overseas and some single-centre studies, indicating that AIH may affect older people in the UK and should be considered in older patients more readily. • One-fifth of cases had ≥12-month diagnostic delay, though this study did not demonstrate worse overall outcome, one does not know the impact of this delay on longer-term outcome highlighting inefficiency in diagnosing this rare condition. • There is under-reporting of key histological features, especially in DGH’s. The effect of this on diagnosis is emphasised by findings that simplified-criteria, as utilised, failed to diagnose one third of patients. • Independent baseline predictors of all-cause mortality/transplantation were age, cardiac/respiratory co-morbidity, black ethnicity, cirrhosis, decompensation, low platelets and peak bilirubin. • Independent baseline predictors of liver-related mortality/transplantation were cirrhosis, decompensation, low platelets and peak bilirubin. • Failure to receive corticosteroids or SSA’s are independently associated with adverse outcome underlining the importance of always offering patients treatment in the absence of contraindications. • Higher dosages of prednisolone have a 2-fold increased risk of all-cause death/transplantation urging use of caution when considering dosing regimens. Type of steroid used does not affect overall outcome.13 • Serum ALT at 1 and 3-months was an independent predictor of outcome of LRD/transplantation and could be used as a useful prognosticator. • There is variability in service provision between hospitals, with better provision of specialist clinician’s and nurses at UH’s, with AIH often managed by a larger number of clinicians than necessary. Liver blood test monitoring was inadequate and referral to/discussion with transplant teams were not done in all decompensated patients potentially eligible for transplantation. This supports the case for AIH to be managed by a smaller number of designated clinicians, improving patient monitoring and the rate of transplant referral. • Histopathologists with a specialist-interest in liver disease improved reporting of at least some histopathological findings of AIH calling for the expansion of Histopathologist numbers, improved liaison between centres, sharing clinical experience and encouraging adherence to guidelines to improve patient care.