Autoimmune Hepatitis (AIH)
What is autoimmune hepatitis
Hepatitis is inflammation of the liver. Autoimmune hepatitis occurs when the body’s own immune system causes injury to healthy liver cells, leading to inflammation and damage. This is a chronic (long-term) condition that can result in cirrhosis (severe scarring of the liver). It more commonly affects women. It can occur alongside other autoimmune conditions such as rheumatoid arthritis and hypothyroidism. Medications that work on the immune system are used to manage this disease and prevent cirrhosis and liver failure.
What causes autoimmune hepatitis
The cause of AIH is not known. It is likely due to a combination of genetic (can run in families) and environmental (exposure to viruses, toxins, or medications) factors. Certain medications (such as nitrofurantion, an antibiotic) can trigger an AIH-like condition.
What are the symptoms of autoimmune hepatitis
Not everyone will have symptoms at the time of diagnosis, and some people are completely asymptomatic despite severe hepatitis. Some early symptoms include fatigue, joint pain, skin rashes or abdominal pain. Jaundice (yellowing of the skin and eyes), itch and nausea can occur due to a build-up of bile in the bloodstream. Other symptoms can appear at a later stage due to liver damage such as swollen abdomen or ankles, easy bruising or bleeding, or confusion.
How is AIH diagnosed
Abnormal liver blood tests are often the first clue to having AIH. Your doctor will then obtain a detailed medical history including a history of any medications or remedies taken. A full physical examination will be performed, and further blood tests to check for other causes of hepatitis may be taken. A abdominal/liver ultrasound may also be performed.
If AIH is suspected, you will be referred to a Hepatologist or Gastroenterologist. He/she will then arrange more detailed blood tests, scans and a biopsy of the liver if needed. This will be to diagnose AIH and also see the level of liver damage.
Bloods
o liver enzymes – alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
o autoantibodies – anti-smooth muscle antibodies (SMA), anti-liver kidney microsomal antibodies (LKM) and anti-nuclear antibodies (ANA)
o immunoglobulin G (IgG) levels
Scans
o Ultrasound (US)
o Transient Elastography (Fibroscan)
o CT
o MRI
Liver biopsy
o A needle is used to take a small sample from the liver to examine in the laboratory under a microscope. This is a very important part of diagnosing AIH as the blood tests and scans may not give a definitive answer. The biopsy can also give an indication of the degree of liver damage at diagnosis, and rule out other causes of liver disease.
What treatments are available
AIH cannot be cured but it can be managed with medications to control symptoms and prevent damage to the liver. The treatments used work on suppressing the immune system to reduce its activity and the inflammation caused. The treatment goal for AIH is to induce, and maintain ‘remission’ long-term
Steroids – most people will start on a corticosteroid (usually prednisolone) to reduce the inflammation. Budesonide is also a steroid that may be used
The response is measured using blood tests (ALT and IgG levels in particular) and assessing your symptoms regularly
Steroids do have several side effects if used long-term and so the goal is to limit their use as much as possible, and prevent complications, for example by supplementing vitamin D to protect from osteoporosis
Other immunosuppressive treatments are then started so that steroids can be reduced to as low a dose as possible or stopped. Azathioprine is the most commonly used immunosuppression medication long-term. Others include 6-mercaptopurine, mycophenolate, or tacrolimus. Their use is guided by your Specialist physician and team.
What are the chances that my disease will get worse
Your disease will be monitored regularly on an ongoing basis. You will also be monitored for any side effects or reactions to treatment. The majority of patients with moderate to severe disease will respond to treatment within 2 weeks and achieve remission (bloods returning to normal range) within a year. The aim is to achieve normal blood tests long-term. If treatment is stopped completely, there is a significant risk of relapse (symptoms and abnormal bloods), meaning many people can require long term treatment. This can be discussed with your specialist. A liver transplant may be required in some cases should treatment not be effective.
Advice for living with AIH
It is important to take the medicines as prescribed and attend for regular appointments
You should also let your doctor know as soon as possible if you feel unwell or symptoms return
Your immune system is suppressed so it is important to be up to date with vaccinations
It is recommended that you eat well, avoid significant weight gain and avoid alcohol
If you are planning to become pregnant, please inform your doctor
Useful links:
https://britishlivertrust.org.uk/information-and-support/liver-conditions/autoimmune-hepatitis
https://aihsupport.org.uk/about-aih/
https://liverfoundation.org/liver-diseases/autoimmune-liver-diseases/autoimmune-hepatitis-aih/