Need for risk stratification in treatment of patients with autoimmune hepatitis

We read with keen interest the study by Plagiannakos CG and colleagues 1 Plagiannakos C.G. Hirschfield G.M. Lytvyak E. et al. Treatment response and clinical event-free survival in autoimmune hepatitis: a Canadian multicentre cohort study. J Hepatol. 2024; https://doi.org/10.1016/j.jhep.2024.03.021 Abstract Full Text Full Text PDF Google Scholar , which explored the association between sustained elevated aminotransferase levels and long-term outcomes in patients with autoimmune hepatitis (AIH) 1 Plagiannakos C.G. Hirschfield G.M. Lytvyak E. et al. Treatment response and clinical event-free survival in autoimmune hepatitis: a Canadian multicentre cohort study. J Hepatol. 2024; https://doi.org/10.1016/j.jhep.2024.03.021 Abstract Full Text Full Text PDF Google Scholar . This large multicenter cohort study provides robust evidence for good treatment response and clinical event-free survival in AIH patients. While previous research suggested that lower serum immunoglobin G (IgG) levels could predict the biochemical response of AIH patients 2 Li Y. Yan L. Wang R. et al. Serum Immunoglobulin G Levels Predict Biochemical and Histological Remission of Autoimmune Hepatitis Type 1: A Single-Center Experience and Literature Review. Clin Rev Allergy Immunol. 2022; 62: 292-300https://doi.org/10.1007/s12016-021-08833-w Crossref PubMed Scopus (9) Google Scholar , Plagiannakos CG et al. demonstrated that elevated IgG levels were not correlated with alanine transaminase (ALT) levels or clinical events. However, higher IgG levels are a very distinctive feature of patients with AIH cirrhosis 3 Laschtowitz A. Zachou K. Lygoura V. et al. Histological activity despite normal ALT and IgG serum levels in patients with autoimmune hepatitis and cirrhosis. JHEP Rep. 2021; 3100321https://doi.org/10.1016/j.jhepr.2021.100321 Abstract Full Text Full Text PDF Scopus (18) Google Scholar , and the guidelines suggest normalization of both transaminase and IgG levels as a diagnostic marker of full biochemical remission in these patients 4 Mack C.L. Adams D. Assis D.N. et al. Diagnosis and management of autoimmune hepatitis in adults and children: 2019 practice guidance and guidelines from the American Association for the study of liver diseases. Hepatology. 2019; https://doi.org/10.1002/hep.31065 Crossref PubMed Scopus (443) Google Scholar . Therefore, we speculate that the disparity in the findings may be attributed to the lower proportion of cirrhotic AIH patients in their study (23.4%), whereas in some developing regions, cirrhosis is diagnosed at initial presentation in approximately 40%-60% of AIH patients 5 Guedes L.R. Cancado G.G.L. Santos B.C. et al. Clinical, biochemical and histological features related to treatment response and prognosis in autoimmune hepatitis. Ann Hepatol. 2024; 101497https://doi.org/10.1016/j.aohep.2024.101497 Crossref Google Scholar , 6 Li Y.N. Zhou L. Zhang J. et al. Characteristics of initial diagnosis in autoimmune liver disease: an 18-year, retrospective single-center study]. Zhonghua Nei Ke Za Zhi. 2019; 58: 366-371https://doi.org/10.3760/cma.j.issn.0578-1426.2019.05.007 Crossref Scopus (0) Google Scholar . To further explore this discrepancy, we conducted a verification study among Chinese AIH patients at the largest hospital in Southwest China. Treatment response and clinical event-free survival in autoimmune hepatitis: a Canadian multicentre cohort studyJournal of HepatologyPreviewWe sought to identify predictors of outcome for people living with autoimmune hepatitis (AIH). Full-Text PDF Open Access