LAUSR

Autoimmune hepatitis (AIH) may present with features of acute liver failure (severe jaundice, coagulopathy and encephalopathy) which is called as acute severe AIH (ASAIH). Diagnosis and management of this group of patients is very difficult while classical laboratory features of AIH (autoantibody positivity and elevated gammaglobulin levels) may not be apparent and corticosteroid response rates are not optimal. Liver transplantation remains the only rescue therapy for AS-AIH patients failing to corticosteroid therapy [1]. In the recent issue of Scandinavian Journal of Gastroenterology study by Roberts et al. [2], evaluated efficacy and safety of tacrolimus AIH patients who were nonresponder or intolerant to corticosteroid. To provide additional information to their findings, we would like to present our experience of patients with AS-AIH who treated by tacrolimus. During last two years, we used tacrolimus as alternative therapy in four cases of AS-AIH who were non-responder to corticosteroid. Patients diagnosed and classified according to criteria proposed by Rahim et al. [1]. General characteristics of the patients with AS-AIH are presented in Table 1. Hepatic encephalopathy was noticed in only case-4. Tacrolimus was given with 4–8mg daily doses. One patient developed mild kidney injury that successfully managed by dose reduction. Any opportunistic infections were not developed in our patients. In three complete responders to tacrolimus, therapy was successfully switched to azathioprine during follow up. Several studies [2–4] showed that tacrolimus is safe and effective alternative therapy in AIH patients failing or intolerant to corticosteroid and/or azathioprine. However, its efficacy has not been reported in patients with AS-AIH. Our cases suggest that tacrolimus may reverse liver injury in patients with severe AIH. Future prospective studies evaluating efficacy and safety of tacrolimus will provide useful information to clinicians in the selection of an appropriate alternative therapy for patients with AS-AIH.