A 45-year-old woman with autoimmune hepatitis on azathioprine and prednisolone achieves remission (ALT normal, liver biopsy shows no interface hepatitis). After 2 years of sustained remission, she requests to discontinue therapy. What is the recurrence rate after stopping immunosuppression, and what factor predicts a higher risk of relapse?
- A 5–10% recurrence; higher risk if initial presentation was acute hepatitis
- B 50–80% recurrence; higher risk if cirrhosis is present and anti-smooth muscle antibody positive ✓
- C 20–30% recurrence; higher risk in HLA DR3-positive patients
- D <5% recurrence; safe to stop therapy after sustained biochemical remission for 2 years
Explanation
Relapse after stopping immunosuppression in AIH occurs in 50–80% of patients, which is why indefinite therapy is recommended for most patients, especially those with cirrhosis. Prior to stopping therapy, histological remission (no interface hepatitis, portal hepatitis, or lobular hepatitis) must be confirmed on biopsy — biochemical remission alone is insufficient. Risk factors for relapse include cirrhosis, persistently elevated IgG, HLA DR3 genotype (typically younger patients with more aggressive disease), and incomplete histological response. EASL guidelines recommend at least 3 years of therapy and 2 years of complete histological/biochemical remission before considering treatment withdrawal.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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