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

AIM: 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 greater than or equal to 2 ULN; poor outcome: cirrhosis complications, transplantation (OLTx), and death; abnormal transaminases: AST/ALT > ULN but within the remission range; abnormal transaminases index (AT[): 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% Cl 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% Cl 1.3-22, p = 0.01; failure to have consistently normal transaminases during remission OR 11.8, 95% Cl 1.3-100, p = 0.02; and portal plasma cell score (PPCS) OR 10.6 (95% Cl 1.0-107), p = 0.04. Time to remission > 5 months, PPCS > 3, and ATI > 2 were 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% Cl 1.1-10.1), p = 0.02 and cirrhosis development, OR 23 (95% Cl 1.7-307), P = 0. CONCLUSIONS: Seventy percent of patients with AIH relapse upon drug cessation. Time to remission > 5 months, ATI > 2, and PPCS > 3 were associated with>90% probability of relapse. Factors predicting poor outcome were globulins at onset and cirrhosis development.