Management of autoimmune hepatitis-related decompensated cirrhosis: current evidence and clinical decision-making

PURPOSE OF REVIEW: Autoimmune hepatitis (AIH) presenting with decompensated cirrhosis poses a major therapeutic dilemma for clinicians. Although the prompt initiation of immunosuppression (IS) can reverse disease activity and lead to the clinical resolution of decompensation, avoiding the need for liver transplantation (LT), it may also be futile or even harmful. International guidelines and cohort studies have begun to address this challenge, making it timely to synthesize available evidence and provide practical guidance for clinicians. RECENT FINDINGS: Emerging data highlight that the benefit of IS in AIH-related decompensated cirrhosis is closely related to disease activity, as well as to the type and severity of decompensation. In this context, patients with "burn-out" cirrhosis, advanced hepatic encephalopathy and severely elevated prognostic scores have a low probability to benefit from IS and face a greater risk of developing treatment-related complications. Therefore, international guidelines emphasize individualized decision-making, integrating clinical scores and predictors of treatment benefit, as well as timely evaluation for LT. SUMMARY: This review summarizes the current evidence and evolving recommendations for managing AIH-related decompensated cirrhosis, providing a structured approach to help clinicians identify candidates for IS and balance treatment decisions to optimize outcomes.