Autoimmune hepatitis and liver transplantation: indications, results, and management of recurrent disease.

For those with autoimmune hepatitis (AIH), indications for liver transplantation include end-stage liver failure (as suggested by a MELD score >16), the onset of liver cancer, intractable symptoms that make the patient's life intolerable, and fulminant liver failure; outcomes are excellent, with 10-year survival in excess of 70%. For those with a fulminant presentation, the impact of corticosteroids is controversial and liver transplantation may be required. Autoimmune hepatitis recurs in approximately one third and may be detected up to 10 years or more post-transplant. There are no agreed-on criteria for the diagnosis, and differentiation from rejection and other causes of graft damage can be difficult. There is no strong correlation between the prevalence of recurrent AIH (rAIH) and graft loss from rAIH. Treatment of recurrent disease with the addition or increase in corticosteroids is often successful, although long-term data are lacking and some may progress to graft failure despite increased treatment. There remains controversy over the role for protocol liver biopsies to detect recurrent disease and the best immunosuppressive strategies to prevent and treat recurrence.