Clin Mol Hepatol > Volume 30(2); 2024 > Article
Kim and Jeong: Reply to: “Evaluation of the histological scoring systems of autoimmune hepatitis: A significant step towards the optimization of clinical diagnosis”
Dear Editor,
We would like to thank Dr. Atsumasa Komori for his interest in our study entitled “Comparison of four histological scoring systems for autoimmune hepatitis (AIH) to improve diagnostic sensitivity” and for the kind comments [1,2].
As highlighted in the editorial, the histopathological diagnosis of AIH poses challenges. This is especially true in cases of acute presentation, because the classical features of AIH (dense lymphoplasmacytic portal infiltrates with moderate/severe interface hepatitis) are not always seen in such cases. Moreover, the degree of lobular necroinflammation may significantly outweigh that of interface hepatitis or portal lymphoplasmacytic infiltration, potentially leading to a completely different histopathological interpretation. In our study, combining the simplified International AIH Group scoring system (“2008 IAIHG”) with the newly proposed histological scoring systems either by Balitzer et al. [3] (“2017 UCSF”) or by the International AIH Pathology Group (“2022 IAHPG”) [4] enhanced the sensitivity in diagnosing AIH compared to using the 2008 IAIHG alone. Similar results were observed in the subgroup analysis of AIH cases with acute presentation. Thus, unlike the 2008 IAIHG criteria, where histological scores are assigned only if there is evidence of interface hepatitis, emperipolesis, and hepatocytic rosettes (“typical”), or at least a chronic hepatitis picture with lymphocytic infiltration (“compatible”), the 2017 UCSF and 2022 IAHPG systems encompass cases with lobular hepatitis patterns that are more frequently observed in AIH with acute presentation. However, it is noteworthy that although the presence of interface hepatitis and portal lymphoplasmacytic infiltration is not mandatory for diagnosing AIH according to the two recent systems, there is still a component of at least mild interface hepatitis in the lobular hepatitis-predominant acute AIH cases. Indeed, all cases in our study demonstrated at least a mild degree of interface hepatitis, including those with acute hepatitis patterns.
We would also like to highlight another diagnostic conundrum, which is the differentiation between AIH and drug-induced liver injury with AIH-like features (DI-AIH) [5,6]. The histological differences between AIH and DI-AIH remain poorly characterized. Recently, Alkashash et al. compared nine cases of AIH and six cases of DI-AIH and found a higher degree of portal and interface inflammation and more prominent plasma cell infiltration in AIH compared to DI-AIH, while central perivenular inflammation was present in both scenarios [5]. In addition, fibrosis has been shown to be more common in AIH compared with DI-AIH [6]. However, it should be noted that fibrosis may not be as prominent in acute AIH cases. Our study did not include a control group consisting of other etiologies, such as DI-AIH or chronic viral hepatitis. As clinically verified liver biopsy cases of DI-AIH are relatively rare, a multicenter or multinational study would be necessary to evaluate the histological differences between AIH and DI-AIH and the applicability of existing histological scoring systems for diagnosing DI-AIH.
Finally, clinicopathological correlation and active communication between the pathologist and hepatologist are crucial in optimizing the histological diagnosis of AIH. The current IAIHG systems include histology scores, suggesting that histology is pivotal in making a clinical diagnosis of AIH. For the pathologist, having access to clinical information, including laboratory findings and medication history, facilitates the histopathological interpretation of liver biopsies in this context.


Authors’ contribution
Original draft: H.K.; Critical revision: H.K., S-H.J.
Conflicts of Interest
The authors have no relevant financial or non-financial interests to disclose.


autoimmune hepatitis
International Autoimmune Hepatitis Group
International Autoimmune Hepatitis Pathology Group


1. Ahn S, Jeong SH, Cho EJ, Lee K, Kim G, Kim H. Comparison of four histological scoring systems for autoimmune hepatitis to improve diagnostic sensitivity. Clin Mol Hepatol 2024;30:37-48.
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2. Komori A. Evaluation of the histological scoring systems of autoimmune hepatitis (AIH): A significant step towards the optimization of clinical diagnosis. Clin Mol Hepatol 2024;30:157-159.
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3. Balitzer D, Shafizadeh N, Peters MG, Ferrell LD, Alshak N, Kakar S. Autoimmune hepatitis: review of histologic features included in the simplified criteria proposed by the international autoimmune hepatitis group and proposal for new histologic criteria. Mod Pathol 2017;30:773-783.
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4. Lohse AW, Sebode M, Bhathal PS, Clouston AD, Dienes HP, Jain D, et al. Consensus recommendations for histological criteria of autoimmune hepatitis from the International AIH Pathology Group: Results of a workshop on AIH histology hosted by the European Reference Network on Hepatological Diseases and the European Society of Pathology: Results of a workshop on AIH histology hosted by the European Reference Network on Hepatological Diseases and the European Society of Pathology. Liver Int 2022;42:1058-1069.
5. Alkashash A, Zhang X, Vuppalanchi R, Lammert C, Saxena R. Distinction of autoimmune hepatitis from drug induced autoimmune like hepatitis: The answer lies at the interface. J Hepatol 2024 Feb 1;doi: 10.1016/j.jhep.2024.01.023.
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6. Andrade RJ, Aithal GP, de Boer YS, Liberal R, Gerbes A, Regev A, et al. Nomenclature, diagnosis and management of drug-induced autoimmune-like hepatitis (DI-ALH): An expert opinion meeting report. J Hepatol 2023;79:853-866.
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