Adherence to guidelines in the diagnosis and management of autoimmune hepatitis
Introduction: Autoimmune hepatitis (AIH) patients can have high morbidity and mortality; many present late having already developed advanced disease, with around 30% being cirrhotic at diagnosis.1 Prompt initiation of appropriate management and early identification of remission can prevent complicat...
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| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-07-01
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| Series: | Clinical Medicine |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1470211825000752 |
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| Summary: | Introduction: Autoimmune hepatitis (AIH) patients can have high morbidity and mortality; many present late having already developed advanced disease, with around 30% being cirrhotic at diagnosis.1 Prompt initiation of appropriate management and early identification of remission can prevent complications, including those associated with steroid use.2 We aimed to evaluate the standard of care provided to confirmed AIH patients managed at Wexham Park Hospital (WPH) against the European Association for the Study of the Liver guidelines, to identify opportunities for improved practice. Materials and Method: Records for AIH patients managed at WPH were retrospectively reviewed. Baseline characteristics, presentation and work-up at diagnosis, steroid provision, immunosuppressive management and achievement of biochemical remission as of November 2024 were analysed. Results and Discussion: 27 patients were included: 85% women with mean age of 59 years (range 19–88). Several patients were diagnosed outside of WPH (non-UK, private and other Trusts). 37% of patients were symptomatic on presentation, of whom only 4% also had deranged liver function tests (LFTs). A separate 26% presented only with deranged LFTs and no symptoms. Fig 1 demonstrates overall presenting complaints, with the most prevalent symptom being jaundice. 14% presented acutely unwell as inpatients.LFTs, viral screen, immunoglobulin and autoantibody levels were checked in 100%, 78%, 85% and 96% of patients, respectively, with 100% receiving liver imaging. Biopsy was discussed in 89% of cases and successfully conducted in 74% overall. 60% of biopsy reports were deemed appropriate, with a mean wait of 41 days from date of biopsy to report. Of those biopsied, 35% had cirrhosis, 20% were known to have had steroids pre-biopsy and 75% had seen a hepatologist. Post-biopsy, the latter rose to 95%. Mean simplified AIH score was 4.94 (range 3–7).In all, 85% were managed solely as hepatology (52%) or gastroenterology (48%) outpatients. 65% of the 20 patients on steroids at point of data collection were on a weaning regime. 44% of all patients were on immunosuppressants: 33% azathioprine, 7% mycophenolate mofetil and 4% both. 48% and 15% of cases were discussed in local and regional multidisciplinary meetings (MDMs), respectively.Only 48% of patients had achieved biochemical remission; reasons for persistently active biochemistry included superimposed viral hepatitis, drug toxicity causing hepatic injury, suboptimal medication dosing and the need for further assessment of overlap syndromes under tertiary centres. Few patients poorly engaged with outpatient services and some were empirically started on steroids in primary care or before biopsy, with subsequent loss to follow-up. Conclusion: For WPH AIH patients, a holistic work-up before diagnosis was well achieved, comprising a thorough panel of bloods, imaging and consideration of biopsy. However, clinical practice can be improved with consistency in documenting disease course, appropriate and timely reporting of biopsies, referring for MDM, organising early and ongoing hepatologist review and closely monitoring for other liver disease, including drug-induced injury. Careful titration of pharmacological management and treating precipitating causes for deranged LFTs can achieve better biochemical remission. |
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| ISSN: | 1470-2118 |