Histology activity index: a benchmark for decision making

Excerpt

This year, the Hepatology International published a much-needed guideline of a challenging disease, i.e., autoimmune hepatitis and that also with reference to the Asia Pacific region titled: ‘The Asian Pacific Association for the Study of the Liver clinical practice guidance: the diagnosis and management of patients with autoimmune hepatitis’ [1]. The update in the article was the evolution of the indications for treatment as per different guidelines. There has been better understanding regarding the time duration for withdrawal of treatment and disease remission. Unlike clinical remission or biochemical remission which could be sometimes misleading and also comes with increased risk of relapse, histological remission is preferred [1]. Hepatitis score has been used for histological remission. Initially introduced by Knodell et al. [2] in 1981, hepatitis score has also undergone marked changes. However, this scoring system score also includes fibrosis and thus limiting the accuracy of assessment of ongoing inflammation. In 1995, going one step forward, Ishak et al. came with modification of the original histological activity index (HAI). The activity score was divided as: (a) inflammation with maximum score of 18 and (b) fibrosis with maximum score of 4 [3]. In 2015, EASL Autoimmune Hepatitis guidelines [4] came with the decision regarding the use of modified (m) HAI. According to mHAI, a score of 4 or more than 4 is the best indicator of on-going active inflammation [5]. In 2021, APASL came with an updated HAI score cut-off that is above 3. It is good to see the score lowered from 4 to 3 for, as it has always been tough for a treating physician to take a decision regarding withdrawal of medication which would eventually come with risk of relapse and further worsening of the disease. However, in page no. 236 [1] under the heading—Duration of Treatment there is likely a typo error, i.e., it has been mentioned mHAI > 3 which should be mHAI < 3 for alleviation of inflammation. …