Review article: Immunosuppression in Decompensated Autoimmune Hepatitis Cirrhosis ‐ To Suppress or Not to Suppress?
Pedro Robson Costa Passos, Valbert Oliveira Costa Filho, Guilherme Grossi Lopes CançadoABSTRACT
Background
The management of decompensated autoimmune hepatitis (AIH) cirrhosis is one of the most challenging and controversial scenarios in hepatology. Clinicians face a high‐stakes dilemma: whether to initiate immunosuppression to halt inflammatory activity or prioritize liver transplantation (LT) referral to avoid treatment futility and life‐threatening infections.
Aims
To critically appraise the evidence regarding immunosuppression in decompensated AIH cirrhosis and propose a biologically grounded, risk‐stratified framework for clinical decision‐making.
Methods
This review synthesizes current observational data and retrospective studies, focusing on patient selection, the ‘therapeutic window’ for medical intervention and the physiological impact of cirrhosis‐associated immune dysfunction.
Results
The risks of infection, treatment futility and delayed transplant access must be weighed against the possibility of halting inflammatory activity and achieving clinical stabilization. A narrow therapeutic window exists for medical therapy. Clinical ‘recompensation’ is achievable in 19%–31% of cases, though this is less frequent than in other etiologies. Early dynamic response assessment—specifically changes in bilirubin and MELD‐Na at weeks 1 and 4—helps distinguish responders from those requiring urgent LT. While LT offers excellent long‐term survival, recurrence occurs in 20% of cases.
Conclusions
Management must shift from a ‘one‐size‐fits‐all’ approach to an individualized, protocolized strategy. We advocate for a time‐limited trial of immunosuppression in selected candidates, governed by strict ‘stop rules’ and immediate LT evaluation for non‐responders or high‐risk patients.