Treatment of autoimmune hepatitis.

First described in 1950, autoimmune hepatitis (AIH) was the first chronic liver disease with a favorable response to drug therapy and a dismal prognosis when left untreated. In the decades since the first treatment studies, the basic strategic principle of inducing remission with steroids and azathioprine has not been modified. The main problems are a timely diagnosis before cirrhosis develops, the avoidance of immunosuppressant side effects, nonresponders to standard induction therapy, and adherence to therapy. Alternative drugs for immunosuppression have been tested in small series and include transplant immunosuppressants. A large multicenter prospective treatment trial suggests that budesonide may offer an alternative in noncirrhotic AIH patients and can minimize unwanted steroid effects. The ultimate treatment approach upon drug treatment failure is liver transplantation. Although only 4% of transplant candidates are AIH patients, the risk for graft loss because of recurrence has to be considered, and recurrent AIH should be treated after transplantation.