Letter: Elderly AS‐AIH patients need more attention—Authors' reply

They raised a relevant and controversial point regarding the opti-mal time point for evaluating corticosteroid response in acute severe autoimmune hepatitis (AS- AIH) (3 vs 7 vs 14 days). Our results indicate that the response to corticosteroids in this setting should be evaluated within the first 7 days of therapy. First, our model based on the absolute MELD score and the presence of hepatic encephalopathy and ascites on day 7 showed high accuracy in the prediction of a poor outcome with a C - index of 0.91, which was slightly higher than that of the day 3 model ( C - index, 0.85). Our findings align with those of the multicentre French study that developed the SURFASA score, which comprises the INR before corticosteroids and changes in the INR and bilirubin on day 3 of treatment and which showed an AUC of 0.93 for non- response prediction. 3 Interestingly, the predictive value of our nomogram includ-ing only baseline data ( C - index, 0.82) was not significantly different from those of the day 3 and 7 models. Second, corticosteroid prolonga-tion beyond 7 days may increase the risk of systemic fungal infection. We showed that corticosteroids do not increase the risk of bacterial infection but do increase that of invasive aspergillosis, which developed in seven patients, all of whom had been taking corticosteroids for at least seven days. Thus, our results and those of the French study in - dicate that corticosteroids should not be continued beyond day 7 in patients with a lack of response. At that point, non- response should prompt transplant evaluation because treatment extension is futile and may