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Clinicians face a high\u2010stakes dilemma: whether to initiate immunosuppression to halt inflammatory activity or prioritize liver transplantation (LT) referral to avoid treatment futility and life\u2010threatening infections.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>To critically appraise the evidence regarding immunosuppression in decompensated AIH cirrhosis and propose a biologically grounded, risk\u2010stratified framework for clinical decision\u2010making.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This review synthesizes current observational data and retrospective studies, focusing on patient selection, the \u2018therapeutic window\u2019 for medical intervention and the physiological impact of cirrhosis\u2010associated immune dysfunction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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 \u2018recompensation\u2019 is achievable in 19%\u201331% of cases, though this is less frequent than in other etiologies. Early dynamic response assessment\u2014specifically changes in bilirubin and MELD\u2010Na at weeks 1 and 4\u2014helps distinguish responders from those requiring urgent LT. While LT offers excellent long\u2010term survival, recurrence occurs in 20% of cases.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Management must shift from a \u2018one\u2010size\u2010fits\u2010all\u2019 approach to an individualized, protocolized strategy. We advocate for a time\u2010limited trial of immunosuppression in selected candidates, governed by strict \u2018stop rules\u2019 and immediate LT evaluation for non\u2010responders or high\u2010risk patients.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/apt.70893","type":"journal-article","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T10:16:14Z","timestamp":1785752174000},"page":"897-918","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Review article: Immunosuppression in Decompensated Autoimmune Hepatitis Cirrhosis \u2010 To Suppress or Not to Suppress?"],"prefix":"10.1111","volume":"64","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-9049-0996","authenticated-orcid":false,"given":"Pedro Robson Costa","family":"Passos","sequence":"first","affiliation":[{"name":"Center of Research and Drug Development (NPDM), Federal University of Cear\u00e1  Fortaleza Cear\u00e1 Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2864-0966","authenticated-orcid":false,"given":"Valbert Oliveira Costa","family":"Filho","sequence":"additional","affiliation":[{"name":"Biomedical Research Center (NUBIMED), Federal University of Cear\u00e1  Fortaleza Cear\u00e1 Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7824-2152","authenticated-orcid":false,"given":"Guilherme Grossi Lopes","family":"Can\u00e7ado","sequence":"additional","affiliation":[{"name":"Hospital das Cl\u00ednicas Federal University of Minas Gerais  Belo Horizonte Minas Gerais Brazil"},{"name":"Hospital da Pol\u00edcia Militar de Minas Gerais  Belo Horizonte Minas Gerais Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"key":"e_1_2_15_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2018.11.006"},{"key":"e_1_2_15_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)62163-1"},{"key":"e_1_2_15_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.humpath.2022.06.019"},{"key":"e_1_2_15_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/liv.15829"},{"key":"e_1_2_15_6_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2011.02.065"},{"key":"e_1_2_15_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.27983"},{"key":"e_1_2_15_8_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10620-024-08439-0"},{"key":"e_1_2_15_9_1","doi-asserted-by":"publisher","DOI":"10.1080\/00365521.2016.1253768"},{"key":"e_1_2_15_10_1","doi-asserted-by":"publisher","DOI":"10.1097\/MEG.0000000000002714"},{"key":"e_1_2_15_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/liv.14082"},{"key":"e_1_2_15_12_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41575-021-00520-7"},{"key":"e_1_2_15_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-1253(24)00078-5"},{"key":"e_1_2_15_14_1","doi-asserted-by":"publisher","DOI":"10.1002\/lt.25451"},{"key":"e_1_2_15_15_1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000041378"},{"issue":"2","key":"e_1_2_15_16_1","first-page":"453","article-title":"European Association for the Study of the Liver. 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