Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
Aliment Pharmacol Ther. 2013 Aug;38(4):343-64. doi: 10.1111/apt.12381. Epub 2013 Jun 30.
Consensus guidelines aid in the diagnosis and management of autoimmune hepatitis, but they are frequently based on low-quality clinical evidence, conflicting experiences and divergent opinions. Recommendations may be weak, discrepant or non-existent at critical decision points.
To identify the decision points where guidelines are weak or non-existent and review the evidence essential in the decision process.
Full-text articles published in English using the keyword 'autoimmune hepatitis' were identified by PubMed from 1972 to 2013. Personal experience and investigations in autoimmune hepatitis also identified important contributions.
Seventy per cent of the guidelines developed by the American Association for the Study of Liver Diseases and 48% of those proposed by the British Society of Gastroenterology are based on low-quality evidence, conflicting experiences or divergent opinions. The key uncertainties in diagnosis relate to the timing of liver biopsy, recognising acute severe (fulminant) disease, interpreting coincidental nonclassical histological changes, accommodating atypical or deficient features in non-White patients, differentiating drug-induced from classical disease and identifying overlap syndromes. The key uncertainties in management relate to pre-treatment testing for thiopurine methyltransferase activity, treating asymptomatic mild disease, determining treatment end points, managing suboptimal responses, incorporating nonstandard medications as front-line and salvage agents, using azathioprine in pregnancy and instituting surveillance for hepatocellular carcinoma.
Consensus guidelines are fraught with uncertainties in the diagnosis and management of autoimmune hepatitis. Each decision point must counterbalance the current available evidence and tailor the application of this evidence to the individual patient.
共识指南有助于自身免疫性肝炎的诊断和治疗，但它们通常基于低质量的临床证据、相互冲突的经验和不同的观点。在关键决策点，建议可能很薄弱、不一致或不存在。
确定指南薄弱或不存在的决策点，并审查决策过程中必不可少的证据。
通过 PubMed 使用关键字“自身免疫性肝炎”从 1972 年到 2013 年确定发表的全文文章。个人经验和自身免疫性肝炎的调查也确定了重要的贡献。
美国肝病研究协会制定的 70%的指南和英国胃肠病学会提出的 48%的指南都是基于低质量的证据、相互冲突的经验或不同的观点。诊断中的关键不确定性与肝活检的时机、识别急性严重（暴发性）疾病、解释偶然的非典型组织学变化、适应非白种人群中的非典型或缺乏特征、区分药物诱导与经典疾病以及识别重叠综合征有关。管理中的关键不确定性与硫嘌呤甲基转移酶活性的治疗前检测、治疗无症状轻度疾病、确定治疗终点、管理治疗反应不佳、将非标准药物作为一线和挽救药物、在妊娠期间使用硫唑嘌呤以及建立肝细胞癌监测有关。
共识指南在自身免疫性肝炎的诊断和治疗中存在诸多不确定性。每个决策点都必须权衡当前可用的证据，并将这些证据的应用调整到个体患者身上。
