Autoimmune hepatitis

　　The pathogenesis of autoimmune hepatitis is not yet clear, and it is currently believed that heredity is the main factor in autoimmune hepatitis, and genetic susceptibility can affect the immunoreactivity of self-antigens and their clinical manifestations. Human leukocyte antigen and DR are independent risk factors for autoimmune hepatitis research. In addition, viral infection, drugs, and environment can act as precipitating factors, promoting the onset of autoimmune hepatitis. Due to the defect in immune regulatory function, patients produce an immune response to self-liver cell antigens, manifested as cell-mediated cytotoxicity and the binding of specific antigens on the surface of liver cells to autoantibodies, with the latter being predominant.

　　The prognosis of AIH varies greatly, untreated patients can slowly progress to liver cirrhosis, or develop into acute, subacute, or fulminant liver disease, and ultimately die from various complications. Retrospective analysis shows that the survival rate of severe AIH patients without treatment is 50% after 3 years and 10% after 5 years. The 20-year survival rate of patients after treatment reaches 80%, and their lifespan is not significantly different from that of the normal healthy population of the same gender and age. Patients without symptoms and carriers of HLA-DR3 have a relatively good prognosis. Early diagnosis and appropriate treatment are important means to improve the prognosis.

　　This disease is more common in women, with a male-to-female ratio of 1:4, and two peaks of onset age, 10-30 years and over 40 years old. Most patients present with chronic hepatitis, about 34% of patients have no symptoms at all, and they visit the hospital only because of abnormal liver function detected during physical examination; 30% of patients present with liver cirrhosis when they visit the hospital; 8% of patients visit the hospital due to symptoms of decompensated liver cirrhosis such as hematemesis and/or melena; some patients start with acute, even fulminant onset (accounting for about 26%), with high levels of transaminases and bilirubin, and a severe clinical course. About 17% to 48% of AIH patients have other autoimmune diseases, common ones include rheumatoid arthritis, thyroiditis, ulcerative colitis, type 1 diabetes, and even some patients visit the hospital for the first time due to these diseases. About 17% to 48% of AIH patients have other autoimmune diseases, common ones including rheumatoid arthritis, thyroiditis, ulcerative colitis, type 1 diabetes, and even some patients visit the hospital for the first time due to these diseases.

　　Autoimmune hepatitis is closely related to genetic factors, so it is difficult to prevent this kind of hepatitis, but it can be well controlled. Therefore, early detection and timely treatment of the disease are extremely important. Especially for patients with liver disease who have no changes in alcohol, drugs, viruses, pathogens, and other risk factors, they should be more vigilant about autoimmune hepatitis.

　　Symptoms 1 of autoimmune hepatitis, the symptoms expressed by patients:Common symptoms include fatigue, jaundice, enlargement of the liver and spleen, pruritus, and no significant weight loss. When the condition progresses to liver cirrhosis, symptoms such as ascites, hepatic encephalopathy, and esophageal variceal bleeding may occur.

　　Symptoms of autoimmune hepatitis 2, signs of laboratory examination:Patients with autoimmune hepatitis often have extrapulmonary systemic immune diseases, the most common being thyroiditis, ulcerative colitis, and others. Laboratory tests show a significant increase in gamma globulin, generally more than twice the normal value. Liver function tests show that serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase can all increase, while serum albumin and cholesterol esters decrease, reflecting the characteristic of autoimmune hepatitis with liver cell damage as the main feature.

　　What should be paid attention to in the diet of patients with autoimmune hepatitis? The diet of patients with autoimmune hepatitis should pay attention to:

　　1. Avoid alcohol, lamb, pumpkin, and cold and hard foods.

　　2. Control one's emotions.

　　3. Take appropriate rest and prevent overexertion.

　　4. Control the amount of food to 70-80% of the full capacity.

　　5. Patients can eat green vegetables, tofu, and freshwater fish. Once the condition improves, they can consume high-protein, moderate carbohydrate, and fat diets with sufficient calories. This includes fresh fish, liver, lean meat, eggs, milk, tofu, and its products, as well as staple foods like congee and noodles.

　　Medication treatment

　　The primary goal of AIH treatment is to alleviate symptoms, improve liver function and pathological tissue abnormalities, and slow the progression to liver fibrosis. The standard treatment plan for AIH currently is the use of glucocorticoids alone or in combination with azathioprine.

　　1. Indications for Treatment:

　　(1) Absolute Indications: Serum AST ≥ 10 times the upper limit of the normal value, or serum AST ≥ 5 times the upper limit of the normal value with gamma globulin ≥ 2 times the upper limit of the normal value; bridge necrosis or multiple lobular necrosis shown by histological examination.

　　(2) Relative Indications: Patients with symptoms such as fatigue, joint pain, jaundice, abnormal serum AST and/or gamma globulin levels but below the absolute indication criteria, and interface hepatitis shown by histological examination.

　　2. Initial Treatment Plan

　　(1) Monotherapy with prednisone is suitable for patients with明显 decreased white blood cells, pregnancy, associated tumors, or defects in thymine methyltransferase, or those who only need short-term treatment (≤6 months). The dose of prednisone is: the first week: 60mg/d; the second week: 40mg/d; the third week: 30mg/d; the fourth week: 30mg/d; from the fifth week onwards: 20mg/d, maintained until the end of treatment.

　　(2) The combination therapy of prednisone and azathioprine is suitable for postmenopausal women, osteoporosis, brittle diabetes, obesity, acne, psychological instability, or those with hypertension. The dose of prednisone is: the first week: 30mg/d; the second week: 20mg/d; the third week: 15mg/d; the fourth week: 15mg/d; from the fifth week onwards: 10mg/d. Azathioprine 50mg/d is started simultaneously in the first week and maintained until the end of treatment.

　　3. Endpoints and Countermeasures of Initial Treatment:Adult AIH should be treated continuously until remission, treatment failure, incomplete response, or occurrence of drug toxicity, etc. (see Table 3). 90% of patients show improvement in serum transaminases, bilirubin, and gamma globulin levels within 2 weeks of starting treatment, but histological improvement lags 3 to 6 months, so it usually takes more than 12 months of treatment to achieve complete remission. Although some patients can maintain remission after stopping treatment, most patients need maintenance therapy to prevent recurrence.

　　4. Relapse and Countermeasures:Relapse refers to the recurrence of elevated transaminases to more than 3 times the normal upper limit value and/or serum gamma globulin levels exceeding 2000 mg/dL after the disease has been relieved and medication has been stopped. It usually occurs within 2 years after stopping medication. Patients with relapse have a higher risk of progressing to liver cirrhosis, developing gastrointestinal bleeding, and dying from liver failure. For the first relapse, the initial treatment plan can be reselected, but for patients with at least 2 relapses, the treatment plan needs to be adjusted, the principle being to use lower doses and longer-term maintenance therapy to alleviate symptoms and keep transaminases below 5 times the normal value. Generally, after prednisone induction therapy, the dose is reduced by 2.5mg per month until the minimum dose required to maintain the above indicators (the average minimum dose for most patients is 7.5mg/d) is reached, and then long-term maintenance therapy is performed. To avoid the adverse effects of long-term use of glucocorticoids, prednisone can also be reduced by 2.5mg per month while azathioprine is increased to 2mg/kg per day after the disease has been relieved, until the minimum maintenance dose of prednisone is withdrawn and azathioprine is used alone. In addition, the lowest dose of combined therapy can also be used.

　　5. Alternative Therapy:Patients who still have no histological remission under high-dose glucocorticoid therapy or those who cannot tolerate drug-related adverse reactions may consider using other drugs as alternative treatments. Such as cyclosporine A, tacrolimus, budesonide, etc., which may be effective for adult patients resistant to glucocorticoids, and for those who cannot tolerate azathioprine, 6-mercaptopurine or mycophenolate mofetil can be tried. In addition, drugs such as ursodeoxycholic acid, methotrexate, cyclophosphamide can also be tried, but the efficacy of the above drugs still needs to be confirmed by large-scale clinical trials.

　　Liver Transplantation

　　Liver transplantation is an effective method for treating end-stage AIH liver cirrhosis. Patients with acute onset presenting as fulminant liver failure that is ineffective to hormone treatment and those with chronic onset with or without liver dysfunction in routine treatment should undergo liver transplantation. The 5-year survival rate after transplantation is 80% to 90%, and the 10-year survival rate is 75%. Most patients have negative autoantibodies within one year after liver transplantation, and hypergammaglobulinemia is relieved. There may be recurrence of AIH after surgery, and the recurrence rate is high in patients with fulminant liver failure before liver transplantation. The treatment for recurrent patients is still prednisone alone or in combination with azathioprine, and most patients can effectively control the condition, improve the success rate of transplantation, and increase survival rate.