Systematic review and meta-analysis of biopsy-guided versus clinically guided withdrawal in autoimmune hepatitis

Long-term immunosuppression in autoimmune hepatitis (AIH) carries substantial side effects, making treatment withdrawal an important consideration after sustained biochemical remission. Whether biopsy-guided withdrawal based on histological assessment reduces relapse compared with clinically guided withdrawal remains uncertain. We conducted a systematic review and meta-analysis to compare relapse rates between these two strategies. This meta-analysis followed PRISMA 2020. PubMed, Embase, Web of Science, Scopus and the Cochrane Library were searched from inception to identify studies reporting relapse after treatment withdrawal in AIH using biopsy-guided or clinically guided strategies. Pooled relapse rates were estimated using random-effects models of transformed proportions. Prespecified subgroup, sensitivity and meta-regression analyses evaluated the impact of relapse definitions, histological stringency and follow-up duration. Twelve studies (518 patients) were included. The pooled relapse rate after treatment withdrawal was 51.1%. Relapse rates were not significantly different between biopsy-guided (48.3%) and clinically guided withdrawal (56.3%; p = 0.604). Studies defining relapse by transaminase elevation alone reported higher relapse rates than those incorporating IgG elevation. Within biopsy-guided cohorts, stricter histological remission thresholds were associated with lower relapse rates and reduced heterogeneity.Relapse after treatment withdrawal in AIH remained common and did not differ significantly between biopsy-guided and clinically guided strategies. In the context of existing guideline recommendations, current evidence does not clearly support routine prewithdrawal liver biopsy in all patients with sustained biochemical remission. TRIAL REGISTRATION: PROSPERO registration number: 4202511295.