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Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, 3rd Floor, Nuffield House, Edgbaston, Birmingham B15 2TH, UK.
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2
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Abstract
Liver transplantation remains the only effective treatment for end-stage primary biliary cirrhosis (PBC). It appears now well accepted that the disease recurs in the allograft. The diagnosis of recurrent PBC is made on the basis of a consistent history and demonstrating the histologic features of PBC on liver biopsy and exclusion of other causes of bile duct damage.
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Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom.
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3
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Abstract
Transplantation has become the accepted form of therapy for patients with end-stage liver disease. The diagnosis of recurrent disease in the allograft has been a matter of controversy, partly because of the difficulties in making the diagnosis in the allograft situation. The conventional criteria for diagnosing PBC may be inappropriate and there are many causes of bile duct damage in the graft. That the PBC-specific autoantibodies [such as antimitochondrial antibody (AMA) and gp-210] persist after transplantation is universally found, and some have reported the aberrant distribution of E2 in the allograft that is typical of PBC in the native liver, whether or not there is histological evidence of PBC recurrence. Most studies now accept that histological features of PBC, such as granulomatous bile duct damage, ductopenia and biliary-type fibrosis, may be found in the allograft; the histological features of PBC are variable and do not mirror the liver tests. The rate of recurrence increases with time, so that by 10 years, recurrence may be found in 30-50% of biopsies. There are no clear factors which identify those at risk of recurrence, but the pattern and degree of immunosuppression may be implicated. Cirrhosis has only rarely been reported. In the medium term, recurrence of PBC has little clinical impact. Ursodeoxycholic acid is used in some centres but there is no clear evidence for benefit.
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Affiliation(s)
- J Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
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4
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Balan V, Abu-Elmagd K, Demetris AJ. Autoimmune liver diseases. Recurrence after liver transplantation. Surg Clin North Am 1999; 79:147-52. [PMID: 10073186 DOI: 10.1016/s0039-6109(05)70011-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PBC and AIH recur after OLTx. The recurrence of PSC is less clear. Recurrence of these diseases seems to be of relatively little importance in the short term; however, longer follow-up is required to address the significance of recurrent disease. Immunosuppression in these patients may alter the natural history of these entities in the post-transplant setting.
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Affiliation(s)
- V Balan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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5
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Abstract
Liver biopsy remains the 'gold standard' for monitoring rejection in liver transplant patients. Portal inflammation, bile duct damage and endothelialitis are recognized features of hepatic allograft rejection. The pathogenesis of the bile duct injury during rejection, however, remains unclear. To define the mechanism of bile duct damage, we studied the light- and electronmicroscopic appearance of hepatic tissue from selected patients in whom allograft failure was solely due to rejection. Of the 25 orthotopic liver transplant rejection cases examined, 17 were mild, seven were moderate and one was severe rejection. Light microscopy examination of the damaged bile duct epithelium revealed evidence of apoptosis which was confirmed by electronmicroscopy. Furthermore, there appeared to be a positive correlation between the grade of rejection and the number of apoptotic cells. Also included in the study were 13 cases of chronic active hepatitis and 10 normal livers which showed the least apoptotic cells. We conclude that the identification of apoptotic cells in damaged bile ducts in allograft biopsies might be helpful in the diagnosis of rejection and in assessment of the severity of rejection.
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Affiliation(s)
- S Nawaz
- Department of Pathology, University of Colorado Health Sciences Center, Denver 80262-0216
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6
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Hubscher SG, Elias E, Buckels JA, Mayer AD, McMaster P, Neuberger JM. Primary biliary cirrhosis. Histological evidence of disease recurrence after liver transplantation. J Hepatol 1993; 18:173-84. [PMID: 8409333 DOI: 10.1016/s0168-8278(05)80244-2] [Citation(s) in RCA: 140] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Histological evidence of primary biliary cirrhosis (PBC) recurring after orthotopic liver transplantation (OLT) was looked for in a 'blinded' study of 353 biopsies from 188 patients, 12-100 months post-transplant. Biopsies (172) were obtained from 83 patients transplanted for PBC and 181 biopsies from 105 patients with other liver diseases. Sixteen biopsies from 13 PBC patients (16%) had features suggestive of recurrent disease. The main diagnostic findings were: mononuclear portal inflammatory infiltration (n = 16), portal lymphoid aggregates (n = 14), portal epithelioid granulomas (n = 14) and bile duct damage (n = 15). This combination of changes was not seen in any biopsy from the non-PBC group. Additional features supporting a diagnosis of recurrent disease were ductopenia (n = 7), bile ductular proliferation (n = 7), portal fibrosis (n = 6) and copper deposition (n = 5). Thirteen biopsies from 12 patients were classified as stage I or II histologically. The other patient developed progressive damage in three serial biopsies resulting in an early micronodular cirrhosis, 5 years post-transplant. These observations provide further evidence that PBC recurs after OLT. More studies are required to determine the natural history and clinical significance of the predominantly early histological changes documented so far.
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Affiliation(s)
- S G Hubscher
- Department of Pathology, Medical School, University of Birmingham, UK
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7
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Howell CD, Yoder TY, Vierling JM. Suppressor function of liver mononuclear cells isolated during murine chronic graft-vs-host disease. II. Role of prostaglandins and interferon-gamma. Cell Immunol 1992; 140:54-66. [PMID: 1531454 DOI: 10.1016/0008-8749(92)90176-p] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mononuclear inflammatory cells (MC) isolated from the livers and spleens of mice with chronic graft-vs-host disease (CGVHD) to minor histocompatibility antigens (B10.D2----BALB/c) show defective proliferation when stimulated with Con A and LPS. In turn, both CGVHD liver and spleen cells suppress the proliferation of mitogen-stimulated normal spleen cells in a genetically unrestricted manner. The suppressor activity of CGVHD spleen cells is mediated by plastic nonadherent null (natural suppressor) cells and involves a soluble suppressor factor(s). In contrast, the suppressor activity of CGVHD liver cells is mediated by macrophages (M phi). In the current studies we show that the suppressor activity of CGVHD liver cells is also mediated by soluble factors and compare the roles of prostaglandins and interferon (IFN)-gamma in mediating defective proliferation and suppressor activities of CGVHD liver and spleen MC. Monoclonal antibody to IFN-gamma partially reversed the defective mitogen-stimulated proliferation of CGVHD spleen MC but had no effect on proliferative response of CGVHD liver MC. Indomethacin did not alter the low proliferative response of either CGVHD liver or spleen MC. Anti-IFN-gamma inhibited the ability of CGVHD spleen cells to suppress proliferation of Con A and LPS-stimulated B10.D2 spleen cells. In contrast, anti-IFN-gamma resulted in a small decrease in the ability of liver MC to suppress Con A (but not LPS)-stimulated cell proliferation. Indomethacin decreased the ability of both CGVHD liver and spleen cells to suppress Con A-stimulated proliferation but had inconsistent effects on LPS-stimulated proliferation. These results show that IFN-gamma and prostaglandins partially mediate the suppressor activity of CGVHD spleen MC. The suppressor activity of CGVHD liver MC also involves prostaglandins but is relatively independent of IFN-gamma.
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Affiliation(s)
- C D Howell
- University of Colorado School of Medicine, Denver
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8
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Dietze O, Königsrainer A, Habringer C, Krausler R, Klima G, Margreiter R. Histological features of acute pancreatic allograft rejection after pancreaticoduodenal transplantation in the rat. Transpl Int 1991; 4:221-6. [PMID: 1786060 DOI: 10.1007/bf00649107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
For characterization of histopathological changes during pancreas graft rejection, pancreaticoduodenal transplants were performed in three groups: (1) Brown Norway into diabetic Lewis rats without immunosuppression, (2) Brown Norway into diabetic Lewis rats with cyclosporin A, and (3) Lewis into Lewis rats. Diffuse inflammatory infiltration of the acini by mononuclear cells indicated the onset of rejection (stage I). Shortly after acinar infiltration, damage to small and large interlobular excretion ducts occurred. This took the form of florid circumferential inflammation and vacuolar degeneration of epithelium similar to the bile duct damage seen in primary biliary cirrhosis, graft-versus-host disease, and liver allograft rejection (stage II). Thereafter, endothelialitis and destruction of islets were evident, consistent with a more advanced and irreversible stage of rejection (stage III). Acinar inflammation and moderate duct lesions were not prevented by immunosuppression but were delayed. Nonetheless, severe vascular changes and loss of islets were avoided. We conclude that duct lesions are a reliable criterion for pancreas allograft rejection. They are more sensitive than vascular changes and more specific than cellular infiltration of acinar tissue, which may also occur in infection.
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Affiliation(s)
- O Dietze
- Department of Pathology, University of Innsbruck, Austria
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9
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Dietze O, Königsrainer A, Habringer C, Krausler R, Klima G, Margreiter R. Histological features of acute pancreatic allograft rejection after pancreaticoduodenal transplantation in the rat. Transpl Int 1991. [DOI: 10.1111/j.1432-2277.1991.tb01984.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Howell CD, Yoder TD, Vierling JM. Suppressor function of hepatic mononuclear inflammatory cells during murine chronic graft-vs-host disease. I. Macrophage-enriched cells mediate suppression in the liver. Cell Immunol 1991; 132:256-68. [PMID: 1829654 DOI: 10.1016/0008-8749(91)90024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Murine chronic graft-vs-host disease (CGBHD) to minor histocompatibility antigens (B10.D2----BALB/c) is characterized by inflammatory destruction of intrahepatic bile ducts, scleroderma-like skin lesions, and lymphoid involution. Spleen cells isolated from this model proliferate poorly when stimulated with mitogens. Previous reports indicate defective lymphocyte proliferation in this model is the result of active suppression induced by the graft-vs-host reaction in the spleen and is mediated by Thy 1.2-, sIg-, plastic nonadherent, splenic natural suppressor (NS) cells. To determine whether the intense CGVHD in the liver is associated with induction of suppression, we compared the suppressor activity of hepatic and splenic mononuclear inflammatory cells isolated concurrently during murine CGVHD. Both hepatic and splenic MC suppressed the proliferation of mitogen-stimulated normal spleen cells in a non-MHC, non-Mls restricted manner. T cells contributed to the suppressor activity of both populations. However, the suppressor activity of hepatic MC was mediated largely by a macrophage-enriched population of MC while that of splenic MC was mediated largely by NS cells.
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Affiliation(s)
- C D Howell
- University of Colorado School of Medicine, Denver
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11
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Polson RJ, Portmann B, Neuberger J, Calne RY, Williams R. Evidence for disease recurrence after liver transplantation for primary biliary cirrhosis. Clinical and histologic follow-up studies. Gastroenterology 1989; 97:715-25. [PMID: 2666253 DOI: 10.1016/0016-5085(89)90643-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Twenty three patients with primary biliary cirrhosis surviving for greater than 1 yr after liver transplantation were studied. All reported marked symptomatic improvement, and had significant falls in serum bilirubin, alkaline phosphatase (p less than 0.0001), immunoglobulin M, and antimitochondrial antibody levels (p less than 0.005). Beyond 1 yr, liver biopsies showed features compatible with disease recurrence in 9 of 10 patients, and a further 4 patients developed pruritus or associated abnormalities. Immunoglobulin M levels were raised in 80%, with elevated antimitochondrial antibody titers in all those tested. Cyclosporine treatment in some patients initially given prednisone and azathioprine was followed by regression of histologic abnormalities. Of 102 patients with nonprimary biliary cirrhosis followed similarly, 50 underwent biopsy, and although 12 showed features of bile duct damage, all had additional histologic and clinical changes supporting an alternative diagnosis. These findings are consistent with previous reports that primary biliary cirrhosis can recur after transplantation, possibly modified by the use of cyclosporine.
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Affiliation(s)
- R J Polson
- Liver Unit, King's College Hospital, London, United Kingdom
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12
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Lerut J, Demetris AJ, Stieber AC, Marsh JW, Gordon RD, Esquivel CO, Iwatsuki S, Starzl TE. Intrahepatic bile duct strictures after human orthotopic liver transplantation. Recurrence of primary sclerosing cholangitis or unusual presentation of allograft rejection? Transpl Int 1989. [PMID: 3075471 DOI: 10.1111/j.1432-2277.1988.tb01799.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
One of 55 patients transplanted for sclerosing cholangitis during the cyclosporin-steroid era (March 1980-June 1986) developed intrahepatic biliary strictures in the absence of allograft rejection within the 1st year posttransplantation. Although many causes underlie biliary pathology in the postoperative period (i.e., arterial injury, ischemia, chronic rejection, cholangitis), recurrent disease remains a possibility.
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Affiliation(s)
- J Lerut
- Department of Surgery, University Health Center of Pittsburgh, PA 15213
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13
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Lerut J, Demetris AJ, Stieber AC, Marsh JW, Gordon RD, Esquivel CO, Iwatsuki S, Starzl TE. Intrahepatic bile duct strictures after human orthotopic liver transplantation. Recurrence of primary sclerosing cholangitis or unusual presentation of allograft rejection? Transpl Int 1989. [PMID: 3075471 DOI: 10.1111/j.1432-2277.1988.tbo1799.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
One of 55 patients transplanted for sclerosing cholangitis during the cyclosporin-steroid era (March 1980-June 1986) developed intrahepatic biliary strictures in the absence of allograft rejection within the 1st year posttransplantation. Although many causes underlie biliary pathology in the postoperative period (i.e., arterial injury, ischemia, chronic rejection, cholangitis), recurrent disease remains a possibility.
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Affiliation(s)
- J Lerut
- Department of Surgery, University Health Center of Pittsburgh, PA 15213
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Kemnitz J, Ringe B, Cohnert TR, Gubernatis G, Choritz H, Georgii A. Bile duct injury as a part of diagnostic criteria for liver allograft rejection. Hum Pathol 1989; 20:132-43. [PMID: 2644165 DOI: 10.1016/0046-8177(89)90177-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The decisive criterium of acute liver allograft rejection was found to be the presence of the diagnostic triad of acute rejection; ie, the presence of portal inflammatory mixed infiltrates, venous endothelialitis (both portal and central), and bile duct injury. On the basis of the presence of each of the components of the diagnostic triad, criteria for the diagnosis of different degrees of acute rejection were developed, particularly focusing attention on a detailed analysis of bile duct injury. Bile duct injury was shown to be an essential part of the histopathologic changes in all grades of acute rejection in the liver allograft, the grade of severity of bile duct injury correlating to a certain extent with the grade of severity of acute rejection. Our analyses have made it evident that bile duct injury, which most probably occurs earlier in the process of acute rejection than endothelialitis, is a more sensitive parameter than endothelialitis in the diagnosis of acute rejection. Furthermore, our analyses have revealed that bile duct injury in acute rejection is likely to be an irreversible process, depending on the number of episodes of acute rejection that previously occurred. On the other hand, it has become clear from our results that bile duct injury must not be considered to be an absolute histopathologic marker of acute rejection; however, it does have to be judged synoptically in connection with the other components of the diagnostic triad and the changes that the triad cause in the hepatic parenchyma. Additional analyses of the grade of severity of cholostases have shown that the cholostases are, to a certain degree, an accompanying phenomenon of the histopathologic changes characterizing acute rejection rather than a histopathologic change that is as significant as the presence of the components of the diagnostic triad.
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Affiliation(s)
- J Kemnitz
- Institute of Pathology, Hannover Medical School, Lower Saxony, FRG
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Gouw AS, Snover DC, Grond J, Huitema S, Gips CH, Sloof MJ, Poppema S. Acute rejection in human liver grafts: a comparative histologic study of cases maintained on azathioprine and prednisone versus cyclosporine A and low-dose steroids. Hum Pathol 1988; 19:1036-42. [PMID: 3047051 DOI: 10.1016/s0046-8177(88)80083-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The morphology of acute rejection (AR) in biopsies of liver allografts obtained in the first 2 weeks after transplantation was analyzed. Material from patients maintained on azathioprine and prednisone (AZA; Groningen, The Netherlands) was compared with that of patients receiving cyclosporine A and prednisone (with or without azathioprine) in low doses (CSA; Minneapolis). Strict selection criteria were applied to exclude circulatory and biliary complications and viral infection in this early observation period after transplantation. Follow-up biopsies ranged from 3 weeks to 1 year after transplantation. Time zero biopsies and/or pretransplant biopsies served as baseline histology, Our data revealed an identical morphologic picture during AR early after transplantation in both patient groups, except for a more marked degree of venous endothelialitis and hepatocyte ballooning in the Minnesota material. The follow-up biopsies suggested a spontaneous resolution of these early rejection episodes without antirejection treatment in six of the ten AZA patients. No differences in the long-term survival rate between the CSA- and AZA-treated patients were observed.
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Affiliation(s)
- A S Gouw
- Department of Pathology, University of Groningen, The Netherlands
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Esquivel CO, Van Thiel DH, Demetris AJ, Bernardos A, Iwatsuki S, Markus B, Gordon RD, Marsh JW, Makowka L, Tzakis AG. Transplantation for primary biliary cirrhosis. Gastroenterology 1988; 94:1207-16. [PMID: 3280389 PMCID: PMC3095835 DOI: 10.1016/0016-5085(88)90014-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Primary biliary cirrhosis is a frequent indication for liver transplantation. The purpose of this report is to present our experience with liver transplantation for primary biliary cirrhosis. Attention is given to the causes of hepatic dysfunction seen in allografts. In addition, we review the postoperative problems encountered and the quality of life at time of last follow-up in patients with transplants for primary biliary cirrhosis. A total of 97 orthotopic liver transplant procedures were performed in 76 patients with advanced primary biliary cirrhosis at the University of Pittsburgh from March 1980 through September 1985. The transplant operation was relatively easy to perform. The most common technical complications experienced were fragmentation and intramural dissection of the recipient hepatic artery, which required an arterial graft in 20% of the cases. Most of the postoperative mortality occurred in the first 6 mo after transplantation, with an essentially flat actuarial life survival curve from that time point to a projected 5-yr survival of 66%. Common causes of death included rejection and primary graft nonfunction. Thirteen of the 76 patients had some hepatic dysfunction at the time of the last follow-up, although none were jaundiced. Recurrence of primary biliary cirrhosis could not be demonstrated in any of the patients. Antimitochondrial antibody was detected in the serum of almost all of the patients studied postoperatively for it. Most important, almost all of the 52 surviving patients have been rehabilitated socially and vocationally.
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Affiliation(s)
- C O Esquivel
- Department of Surgery, University of Pittsburgh, Pennsylvania
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Abstract
Considerable improvement in quality of life can be achieved by treating the complications of primary biliary cirrhosis. However, once fibrosis, cirrhosis, portal hypertension and hyperbilirubinaemia occur, it is unlikely that 'medical' treatment will cure the disorder. Trials of medical therapy should aim to delay or halt the progression of the early phase of the disease and clinicians should refer patients to centres conducting clinical trials. If the disease progresses, and the quality of life is seriously impaired, liver transplantation offers the realistic chance of a new life.
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Affiliation(s)
- O Epstein
- Department of Medicine and Gastroenterology, Royal Free Hospital, School of Medicine, London, UK
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20
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Wiedmann KH, Weber P, Lauchart W. Was ist gesichert in der Therapie der primär-biliären Zirrhose? Internist (Berl) 1988. [DOI: 10.1007/978-3-662-39609-4_125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Van Thiel DH, Gavaler JS. Recurrent disease in patients with liver transplantation: when does it occur and how can we be sure? Hepatology 1987; 7:181-3. [PMID: 3542778 DOI: 10.1002/hep.1840070133] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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22
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Haagsma EB, Manns M, Klein R, Grond J, Huizenga JR, Slooff MJ, Meyer zum Büschenfelde KH, Berg PA, Gips CH. Subtypes of antimitochondrial antibodies in primary biliary cirrhosis before and after orthotopic liver transplantation. Hepatology 1987; 7:129-33. [PMID: 3542774 DOI: 10.1002/hep.1840070125] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Antimitochondrial antibodies are markers for primary biliary cirrhosis and probably reflect a specific defect in immunoregulation underlying this disease. Antimitochondrial antibodies and their primary biliary cirrhosis-specific subtypes were tested before and up to 6 years after orthotopic liver transplantation. Sera from 31 consecutive patients were tested, 15 patients had primary biliary cirrhosis and 16 non-primary biliary cirrhosis. Antimitochondrial antibodies were investigated under code by immunofluorescence, and primary biliary cirrhosis-specific subtypes were determined by radioimmunoassay (anti-p62, anti-p48) and complement fixation test (anti-M2, anti-M4, anti-M8). Before orthotopic liver transplantation, antimitochondrial antibodies were detected by immunofluorescence in 13 of 15 patients with primary biliary cirrhosis. Of these patients, 12 were positive for anti-p62 and 8 for anti-p48. Ten patients were positive for anti-M2, 4 patients for anti-M4 and 7 patients for anti-M8. Two primary biliary cirrhosis patients and all non-primary biliary cirrhosis patients were negative with all tests. One month after orthotopic liver transplantation, antimitochondrial antibodies titers declined or became negative by antimitochondrial antibodies immunofluorescence, 3 patients became negative by radioimmunoassay for anti-p62 and 1 for anti-p48. With complement fixation test, 4 patients became negative for anti-M2, 2 for anti-M4 and 4 for anti-M8. Antimitochondrial antibody titer reduction observed 1 month after orthotopic liver transplantation remained unchanged in most sera during the following years. A rise was observed in two patients after 4 and 5 years.(ABSTRACT TRUNCATED AT 250 WORDS)
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Hubscher SG, Clements D, Elias E, McMaster P. Biopsy findings in cases of rejection of liver allograft. J Clin Pathol 1985; 38:1366-73. [PMID: 3908492 PMCID: PMC499494 DOI: 10.1136/jcp.38.12.1366] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Features of rejection were found in 21 needle biopsies obtained from seven patients after liver transplantation. Wedge biopsies taken peroperatively were used as a baseline for comparison. Rejection was diagnosed by excluding other known causes of graft dysfunction using appropriate methods. In cases in which these criteria were fulfilled a consistent picture of rejection was seen, and this was useful in clinical management. Two features constantly present in cases of acute rejection were: a dense mixed portal inflammatory infiltrate; and polymorphonuclear infiltration of biliary epithelium.
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26
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Vierling JM, Fennell RH. Histopathology of early and late human hepatic allograft rejection: evidence of progressive destruction of interlobular bile ducts. Hepatology 1985; 5:1076-82. [PMID: 3905558 DOI: 10.1002/hep.1840050603] [Citation(s) in RCA: 92] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cholestasis and injury of interlobular bile ducts occur during rejection of human hepatic allografts. However, knowledge of the nature and progression of bile duct injury during rejection remains incomplete. To define the role of inflammation in bile duct damage, we assessed the light microscopic appearance of hepatic tissue from selected patients in whom allograft failure was solely due to rejection. Nine patients with rejection were easily separated into two groups based on the duration of the allograft survival. The first group (early rejection) consisted of five patients in whom rejection occurred between 13 and 36 days. The second group (late rejection) consisted of four patients in whom rejection occurred between 170 and 912 days. Early rejection was characterized by distortion of bile ducts by adjacent inflammatory cell infiltrates, cytological changes of bile duct epithelial cells and occasionally by frank mononuclear cell inflammation of the epithelium with destruction of the duct. Late rejection was characterized by nonsuppurative destructive cholangitis culminating in the disappearance of interlobular bile ducts. Both groups exhibited histological cholestasis, intact limiting plates, preservation of hepatocytes and positive orcein stains for copper-binding protein. We conclude that the dominant histopathological feature of hepatic allograft rejection is progressive, nonsuppurative destructive cholangitis.
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Abstract
Recognition by biopsy of liver allograft rejection has been less successful than diagnosis of rejection of cardiac and kidney allografts. In a study of 138 failed liver allografts, we recognized damage to small interlobular bile ducts by lymphocytes as the most useful indicator of the presence of rejection. This is a report of the electron microscopic features of three patients with unequivocal allograft rejection. Lymphocytes and occasional granulocytes penetrated the epithelia of interlobular bile ducts. Ducts with diameters of 30 to 60 microM were preferentially affected but ducts up to 120 microM were also occasionally involved. Point contacts between infiltrating inflammatory cells and bile duct epithelial cells were observed occasionally. Degenerative changes of bile duct epithelial cells were conspicuous and involved nuclei and cellular organelles. Degeneration was often accompanied by aggregation of dense bundles of filaments in the cytoplasm. In severely affected ducts, epithelial cell disintegration was noted. In all involved bile ducts, the basement membrane was markedly thickened. Hepatocytes were well-preserved but contained lipid vacuoles, pigment granules, and blunted canalicular microvilli. The similarity between these observations and those seen in primary biliary cirrhosis and chronic graft-versus-host disease is striking.
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Snover DC, Sibley RK, Freese DK, Sharp HL, Bloomer JR, Najarian JS, Ascher NL. Orthotopic liver transplantation: a pathological study of 63 serial liver biopsies from 17 patients with special reference to the diagnostic features and natural history of rejection. Hepatology 1984; 4:1212-22. [PMID: 6094331 DOI: 10.1002/hep.1840040620] [Citation(s) in RCA: 145] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The histopathological features of orthotopic liver transplants were evaluated in 63 serial biopsy specimens from 17 patients. Biopsies were taken at the time of insertion of the liver (six biopsies), at the time of development of liver function abnormalities (11 biopsies) and as follow-up to previously abnormal biopsies (46 biopsies). The biopsies taken at the time of insertion all showed diffuse hepatocellular ballooning with confluent areas of necrosis in one case. Biopsies taken at the time of onset of rejection (nine cases) all showed a mixed portal inflammatory infiltrate, bile duct damage and central or portal vein endothelialitis (i.e., attachment of lymphocytes to the vein endothelium). Follow-up biopsies showed several patterns including: (i) resolution of changes of acute rejection with subsequent development of recurrent acute or chronic rejection (four cases); (ii) prolonged acute rejection simulating extrahepatic biliary obstruction (four cases); (iii) prolonged acute rejection with predominance of eosinophils simulating a drug reaction (one case); and (iv) rapidly progressive acute rejection leading to death (one case). Biopsy of the transplanted liver at the time of transplantation is useful to provide a baseline for comparison with later biopsies. Biopsy at the time of onset of changes in liver function is essential to confirm the presence of rejection prior to alteration of immunosuppression.
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Ludwig J, Czaja AJ, Dickson ER, LaRusso NF, Wiesner RH. Manifestations of nonsuppurative cholangitis in chronic hepatobiliary diseases: morphologic spectrum, clinical correlations and terminology. LIVER 1984; 4:105-16. [PMID: 6727581 DOI: 10.1111/j.1600-0676.1984.tb00914.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The features of nonsuppurative cholangitis were studied in liver biopsy specimens from 185 patients with chronic active hepatitis (CAH), 280 patients with primary biliary cirrhosis (PBC), and 55 patients with primary sclerosing cholangitis (PSC). Specimens from patients with other liver diseases in which the presence of nonsuppurative cholangitis had been recorded were also studied. We identified four types of nonsuppurative cholangitis: granulomatous cholangitis, lymphoid cholangitis, fibrous cholangitis, and pleomorphic cholangitis. Granulomatous cholangitis almost always seemed to be destructive; the other types were either destructive or nondestructive. Granulomatous cholangitis was, for all practical purposes, diagnostic of PBC and the obliterative form of fibrous cholangitis was similarly diagnostic for the hepatic manifestations of PSC in adults and paucity of intrahepatic bile ducts in infants. All other types of cholangitis were found in CAH, PBC, PSC, and other liver diseases. Thus, the term "nonsuppurative cholangitis" describes a spectrum of morphologic lesions that differ in incidence, morphogenesis, usefulness for liver biopsy diagnosis, and, probably, pathogenesis.
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Rolles K, Williams R, Neuberger J, Calne R. The Cambridge and King's College Hospital experience of liver transplantation, 1968-1983. Hepatology 1984; 4:50S-55S. [PMID: 6363259 DOI: 10.1002/hep.1840040715] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The postoperative course of 138 transplants performed in 137 patients in the Cambridge and King's College Hospital series between May 2, 1968 and April 1, 1983 is presented. During the last 15 years, criteria for selection of transplant candidates has been improved and types of disease categories, both suitable and unsuitable for liver transplantation, have been defined. The acceptance of the concept of brain death and the use of heart-beating donors in the United Kingdom since 1976 has greatly improved the quality of donor organs. Changes in surgical technique, particularly with regard to biliary tract drainage, have reduced morbidity and mortality from biliary tract complications since 1975. The use of partial cardiopulmonary bypass in selected cases and changes in immunosuppressive drug regimens have not significantly improved our overall results. Despite these changes based on our experience, the perioperative mortality in the Cambridge and King's College Hospital series remains disturbingly high.
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