Factors predicting relapse and poor outcome in type I autoimmune hepatitis: role of cirrhosis development, patterns of transaminases during remission and plasma cell activity in the liver biopsy.
OBJECTIVE
To determine factors predicting relapse and poor outcome in patients with type I autoimmune hepatitis (AIH).


METHODS
Patients with AIH were retrospectively recruited. Definitions-remission: AST/ALT < 2 ULN; relapse: AST/ALT > or = 2 ULN; poor outcome: cirrhosis complications, transplantation (OLTx), and death; abnormal transaminases: AST/ALT > ULN but within the remission range; abnormal transaminases index (ATI): number of occasions AST/ALT abnormal/years of remission. Liver biopsies were assessed by Ishak system, and additional score given for portal and parenchymal plasma cells. Data are presented as median (range).


RESULTS
Seventy-one patients were identified. Twenty (28%) had cirrhosis at presentation, 14 (20%) developed it during follow-up of 52 months (18-336). Of the 14, four had histological confirmation, and the remainder had clinical/radiological evidence of cirrhosis. Factors independently associated with cirrhosis development were inability to have consistently normal transaminases during remission, OR 19.3 (95% CI 2.2-40), p = 0.002. Treatment was discontinued in 40/69 patients of whom 30 (75%) relapsed within 2 months (1-23), culminating in one death. Factors independently associated with relapse were: time to initial remission, OR 5.5, 95% CI 1.3-22, p = 0.01; failure to have consistently normal transaminases during remission OR 11.8, 95% CI 1.3-100, p = 0.02; and portal plasma cell score (PPCS) OR 10.6 (95% CI 1.0-107), p = 0.04. Time to remission > or = 5 months, PPCS > or = 3 and ATI > or = 2 was associated with > 90% probability of relapse (PPV 100%). Fifteen percent had a poor outcome. Independent predictors of poor outcome were: globulins at onset OR 3.4 (95% CI 1.1-10.1), p = 0.02 and cirrhosis development, OR 23 (95% CI 1.7-307), p = 0.


CONCLUSIONS
Seventy percent of patients with AIH relapse upon drug cessation. Time to remission > or = 5 months, ATI > or = 2 and PPCS > or = 3 were associated with > 90% probability of relapse. Factors predicting poor outcome were globulins at onset and cirrhosis development.
Verma
Sumita
S
USC Liver Unit, Rancho Los Amigos Medical Center, California, USA.
Gunuwan
Basuki
B
Mendler
Michel
M
Govindrajan
Sugantha
S
Redeker
Allan
A
D000293:Adolescent; D000328:Adult; D000368:Aged; D000410:Alanine Transaminase / Q000097:blood; D001219:Aspartate Aminotransferases / Q000097:blood; D001706:Biopsy; D002648:Child; D005260:Female; D019693:Hepatitis, Autoimmune / Q000150:complications / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy; D006801:Humans; D008099:Liver / Q000473:pathology*; D008103:Liver Cirrhosis / Q000150:complications*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010950:Plasma Cells / Q000473:pathology*; D011379:Prognosis; D012008:Recurrence; D012074:Remission Induction; D012189:Retrospective Studies; D012307:Risk Factors; D012712:Serum Globulins / Q000032:analysis
D012712:Serum Globulins; D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase