Clin Mol Hepatol > Epub ahead of print
Komori: Reply to correspondence regarding “Evaluation of the histological scoring systems for autoimmune hepatitis: A significant step towards the optimization of clinical diagnosis”
Dear Editor,
I would like to appreciate Dr. Haeryoung Kim and Dr. Sook-Hyang Jeong for their Correspondence [1] as a reply to my editorial entitled “Evaluation of the histological scoring systems of autoimmune hepatitis: A significant step towards the optimization of clinical diagnosis.” [2] As a general hepatologist, I read the Correspondence with great interest. First, although their study, titled “Comparison of four histological scoring systems for autoimmune hepatitis to improve diagnostic sensitivity,” [3] clearly validated lobular hepatitis as an important histological component in diagnosing autoimmune hepatitis (AIH), even in cases with acute presentation, they highlighted and pondered the relevance of co-occurrence of at least mild interface hepatitis in lobular hepatitis-predominant AIH cases in their Correspondence. Indeed, while lobular and portal interface hepatitis are topologically distinct pathological features, they not only may coexist but also might transit in the liver of patients with AIH [4,5]. Moreover, lymphoplasmacytic infiltrates are common components of each lesion [5]. I could paraphrase this issue into the outstanding question: how are lobular and interface hepatitis in AIH spatiotemporally associated? Spatial transcriptomic analysis of the lobular hepatitis-predominant AIH cases with mild interface hepatitis may provide us with clues to this question and deepen our understanding of the pathognomonic features of each hepatitis pattern in AIH.
Second, they highlighted another diagnostic conundrum in their Correspondence: differentiation between AIH and druginduced liver injury with AIH-like features (DI-AIH) [6], again in the context of demarcated hepatic inflammation. Although a previous study involving a relatively large cohort of patients diagnosed at the Mayo Clinic failed to distinguish between classical AIH (n=237) and DI-AIH (n=24) in histological analysis [7], the fact that suspected drugs in the study were predominantly limited to minocycline (n=11) and nitrofurantoin (n=11) raises concern about the external validity of their analysis. In that regard, I agree with their comment for the importance of reassessing histological differences between AIH and DI-AIH using existing histological scoring systems through a multicenter or multinational study. Such a study should include cases involving a wide range of suspected drugs and be coupled with sufficient clinical information.
I would like to conclude this Reply by encouraging our colleagues, hepatologists and pathologists to continue active communication in order to optimize the histological diagnosis of AIH, as underscored by Dr. Haeryoung Kim and Dr. Sook-Hyang Jeong. Bidirectional dialogue regarding laboratory findings, medication history, and histopathological interpretation of liver biopsies among us, potentially with assistance from artificial intelligence in the future, will undoubtedly serve as a driving force in addressing the unmet needs of AIH, a disease characterized by dynamic and heterogeneous manifestations.

FOOTNOTES

Conflicts of Interest
The author has no conflicts to disclose.

Abbreviations

AIH
autoimmune hepatitis

REFERENCES

1. Kim H, Jeong SH. Reply to: “Evaluation of the histological scoring systems of autoimmune hepatitis: A significant step towards the optimization of clinical diagnosis”. Clin Mol Hepatol 2024;30:291-292.
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2. Komori A. Evaluation of the histological scoring systems of autoimmune hepatitis: A significant step towards the optimization of clinical diagnosis. Clin Mol Hepatol 2024;30:157-159.
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3. 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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4. Komori A. Recent updates on the management of autoimmune hepatitis. Clin Mol Hepatol 2021;27:58-69.
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5. 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.
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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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7. Björnsson E, Talwalkar J, Treeprasertsuk S, Kamath PS, Takahashi N, Sanderson S, et al. Drug-induced autoimmune hepatitis: clinical characteristics and prognosis. Hepatology 2010;51:2040-2048.
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