Outcome after Discontinuation of Immunosuppression in Children with Autoimmune Hepatitis: A Population-Based Study

Abstract

To assess sustained immunosuppression-free remission (SIFR) in children with autoimmune hepatitis (AIH). We retrospectively reviewed all children with AIH in the region between 1986 and 2011 using a population-based methodology. We identified 56 children with AIH (62.5% females; median age, 11.1years [IQR, 5.7-14.4years], followed for a median of 5.6years [IQR, 2.8-8.6years]). Liver disease was characterized by type II AIH in 8.9%, cirrhosis in 14.0%, and primary sclerosing cholangitis in 21.4%. Coexisting nonhepatic immune-mediated diseases occurred in 37.5%. Biochemical remission on immunosuppressive therapy was achieved in 76.4% of all patients with AIH at a median of 1.2years (IQR, 0.4-3.6years); 23.1% of these patients experienced a subsequent relapse. Discontinuation of all immunosuppressive medications was attempted in 16 patients and was successful in 14 patients (87.5%) with type 1 AIH (median age at discontinuation, 8.9years [IQR, 3.5-17.9years], treated for a median of 2.0years [IQR, 1.3-3.5years] after diagnosis), with SIFR occurring at a median of 3.4years (IQR, 2.6-5.8years) of follow-up. Excluding patients with inflammatory bowel disease who received immunosuppressive therapy independent of their liver disease, the probability of achieving SIFR within 5years of diagnosis of AIH was 41.6% (95% CI, 25.3%-62.9%). Baseline patient characteristics associated with an inability to achieve biochemical remission on immunosuppression or SIFR were elevated international normalized ratio, positive antineutrophil cytoplasmic antibody titer, cirrhosis, and a nonhepatic autoimmune disorder. We found a high rate of successful discontinuation of all immunosuppressive medications in carefully selected patients with AIH in a population-based cohort. SIFR is an achievable goal for children with AIH, particularly those with type I disease in stable biochemical remission on immunosuppressive therapy.