Review article: Immunosuppression in Decompensated Autoimmune Hepatitis Cirrhosis ‐ To Suppress or Not to Suppress?

BACKGROUND: The management of decompensated autoimmune hepatitis (AIH) cirrhosis is one of the most challenging and controversial scenarios in hepatology. Clinicians face a high-stakes dilemma: whether to initiate immunosuppression to halt inflammatory activity or prioritize liver transplantation (LT) referral to avoid treatment futility and life-threatening infections. AIMS: To critically appraise the evidence regarding immunosuppression in decompensated AIH cirrhosis and propose a biologically grounded, risk-stratified framework for clinical decision-making. METHODS: This review synthesizes current observational data and retrospective studies, focusing on patient selection, the 'therapeutic window' for medical intervention and the physiological impact of cirrhosis-associated immune dysfunction. RESULTS: The risks of infection, treatment futility and delayed transplant access must be weighed against the possibility of halting inflammatory activity and achieving clinical stabilization. A narrow therapeutic window exists for medical therapy. Clinical 'recompensation' is achievable in 19%-31% of cases, though this is less frequent than in other etiologies. Early dynamic response assessment-specifically changes in bilirubin and MELD-Na at weeks 1 and 4-helps distinguish responders from those requiring urgent LT. While LT offers excellent long-term survival, recurrence occurs in 20% of cases. CONCLUSIONS: Management must shift from a 'one-size-fits-all' approach to an individualized, protocolized strategy. We advocate for a time-limited trial of immunosuppression in selected candidates, governed by strict 'stop rules' and immediate LT evaluation for non-responders or high-risk patients.