When to Consider Liver Transplant in Autoimmune Hepatitis
Liver transplantation should be considered in AIH patients with acute liver failure, decompensated cirrhosis with MELD score ≥15, or hepatocellular carcinoma meeting transplant criteria. 1
Primary Indications for Transplant Evaluation
Acute Severe AIH Presentations
Immediate transplant evaluation is indicated for patients who show no improvement or worsening after 2 weeks of high-dose corticosteroid therapy (prednisone 1 mg/kg/day with or without azathioprine). 2
Development or worsening of hepatic encephalopathy despite corticosteroid treatment mandates urgent transplant consideration. 2
Poor prognostic indicators requiring early transplant referral include:
The SURFASA Score for Early Decision-Making
Within 3 days of initiating corticosteroids, the SURFASA score can identify non-responders requiring urgent transplant referral. 3 This score combines:
- Baseline INR at corticosteroid initiation (D0-INR) 3
- Change in INR from day 0 to day 3 (Δ%3-INR ≥0.1%) 3
- Change in bilirubin from day 0 to day 3 (Δ%3-bilirubin ≥-8%) 3
A SURFASA score >1.75 indicates 85-100% risk of death or need for transplantation, while a score <-0.9 suggests 75% chance of responding to medical therapy. 3
Chronic Decompensated Disease
Decompensated cirrhosis with MELD score ≥15 is a Class I indication for liver transplantation. 1
Ascites, the most common decompensation manifestation, should prompt transplant evaluation even in patients with lower MELD scores if refractory to medical management. 2
Progressive liver disease despite optimal immunosuppression warrants transplant consideration. 4
Hepatocellular Carcinoma
- HCC meeting standard transplant criteria (typically Milan criteria) in the setting of AIH-related cirrhosis is an indication for transplantation. 1
Critical Timing Considerations
The 2-Week Rule
All decompensated AIH patients should receive a trial of high-dose corticosteroids before transplantation, but the decision to proceed should not be delayed beyond 2 weeks if no response occurs. 2, 5 This applies even to patients with:
Early Referral is Critical
Immediate referral to a transplant center is indicated for ACLF grade 2-3, King's College criteria fulfillment, and AIH not responding to corticosteroids after 2 weeks. 5 Delaying transplant evaluation beyond this window is a critical pitfall to avoid. 5
Post-Transplant Considerations
Excellent Outcomes
- 5-year survival rates post-transplant exceed 75-92% in adults, with 10-year actuarial survival of 75%. 2
- 1-year survival for ACLF patients receiving early transplant is 78%, compared to <10% without transplant. 5
Recurrent Disease
- Recurrent AIH occurs in approximately 32% of adults post-transplant but is typically mild and easily managed with adjusted immunosuppression. 2
- Retransplantation must be considered for patients with refractory recurrent AIH progressing to allograft loss. 1
Special Pediatric Considerations
- Treatment failure occurs in 5-15% of children with AIH, and deterioration despite corticosteroid compliance mandates transplant evaluation. 2
- Recurrent AIH frequency is greater in children than adults, with less uniform treatment response and higher risk of graft loss. 2
Common Pitfalls to Avoid
- Do not continue corticosteroids beyond 2 weeks in acute severe AIH without improvement – this delays necessary transplant evaluation and worsens outcomes. 5
- Do not delay transplant evaluation waiting for "one more medication trial" in patients with worsening synthetic function or encephalopathy. 2
- Do not assume all patients with elevated transaminases and autoantibodies have chronic AIH – acute severe presentations require different management algorithms. 6