Evaluation

Age of patient

years

Patient's gender

Does the patient have a definite autoimmune disease?

Does the patient have a first degree relative with an autoimmune disease?

Average daily alcohol consumption

g/day

Does the patient have a history of exposure to a hepatotoxic drug?

Has the patient received one or more blood products in the past?

Serum alkaline phosphatase

Upper limit of reference range for alkaline phosphatase,

Serum AST (SGOT)

Upper limit of reference range for AST (SGOT)

Total serum globulin in g/dL

Upper limit of reference range for globulin

Serum IgG level

Upper limit of reference for serum IgG

Does the patient show IgM anti-HAV antibodies?

Is the patient HBsAg positive?

Does the patient show IgM anti-HBc (hepatitis B core) antibodies?

Does the patient show anti-HBc antibodies on ELISA or RIBA testing?

Does the patient show HCV RNA by PCR?

Does the patient show a recent, positive serologic response to any hepatotropic virus?

Titer of anti-nuclear antibodies (ANA) (enter X for a titer of 1:X)

Titer of anti-smooth muscle antibodies (SMA) (enter Y for a titer of 1:Y)

Titer of antibodies to LKM-1 (enter Z for a titer of 1:Z)

Does the patient show antimitochondrial antibodies?

Does the patient show anti-SLA antibodies?

Does the patient show anti-ASGP-R antibodies?

Does the patient show anti-LSP antibodies?

Does the patient show anti-LC1 antibodies?

Does the patient show anti-LP antibodies?

Does the patient show anti-HHPM antibodies?

Does the patient show anti-sulfatide antibodies?

Is the patient HLA type B8?

Is the patient HLA type DR3?

Is the patient HLA type DR4?

Does the liver biopsy show evidence of biliary tract damage?

Are there any changes on liver histology suggestive of a different etiology to the liver disease (granulomas, siderosis, copper deposits, etc.)?

Has the patient been treated for autoimmune hepatitis?

Select an appropriate answer for each question

Histology

Response to therapy

Results

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