Management of AIH in Pregnancy, Cirrhosis, ACLF

Pregnancy and cirrhosis require modification in the management protocol of AIH. Liver transplant remains the mainstay for AIHACLF. Recognize innate immune activation in patients with ACLF of any etiology.

Therapeutic plasma exchange (PLEX) can be a treatment option for ACLF-including AIH-ACLF. Following is the PLEX - “Vellore” protocol: Admit to a closely monitored setting under a dedicated multidisciplinary team. Prefer ultrasound-guided PLEX port insertion into the femoral vein. Start oral 10 mg prednisolone once daily a day prior to initiating PLEX. Prefer centrifugal PLEX, done daily for 3 days. 1:1 volume replaced with fresh frozen plasma, calcium given during PLEX to avoid citrate toxicity. Full session to be decided as per clinical assessment. Take surveillance blood culture. Give prophylactic antibiotics as follows - if no/suspected sepsis-IV cefoperazone-sulbactam; if suspected sepsis with organ dysfunction - IV meropenem. Prefer enteral nutrition. In follow-up: Steroid should be given: balancing its anti-inflammatory action and risk of sepsis, after periodic clinical assessment. OPD visit - once weekly for 4 weeks, then once a month for 3 months, then as needed.