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González IA, Lu HC, Alipour Z, Kulkarni SS, Stoll JM, Liss KH, Dehner LP, He M. Clinicopathologic Characteristics of Centrilobular Injury in Pediatric Liver Transplantation. Liver Transpl 2021; 27:416-424. [PMID: 33253466 PMCID: PMC10619582 DOI: 10.1002/lt.25958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/18/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022]
Abstract
Centrilobular injury (CLI) is defined as the presence of perivenular mononuclear inflammation, hepatocyte dropout, and extravasated erythrocytes. In pediatric liver allografts, CLI has been associated with advanced fibrosis and chronic rejection (CR). We sought to better characterize the clinicopathologic features of CLI in the setting of T cell-mediated rejection (TCMR) and its association with complement component 4d (C4d) deposition. A total of 206 posttransplant pediatric patients (491 allograft liver biopsies) were available from 2000 to 2018, of which 63 patients (102 biopsies) showed evidence of TCMR and were included in the study. Of the patients, 35 (55.6%) had CLI on their initial episode of TCMR; those patients with CLI were significantly associated with the type of immunosuppression treatment (P = 0.03), severity of TCMR (P < 0.001), higher gamma-glutamyltransferase (P = 0.01), and advanced fibrosis (P = 0.03). There was a trend to shorter time interval from transplantation to presentation of CLI compared with those without CLI (P = 0.06). No difference was observed in graft or overall survival in the patients with CLI. In 20 patients with CLI, additional biopsies were available; in 45% of these patients, CLI was a persistent/recurrent finding. C4d deposition was noted in 12% of all biopsies (6 patients) with CLI. No significant correlation was noted in C4d deposition and CLI, CR, or graft/overall survival. In conclusion, CLI, although not significantly associated with worse graft survival, was significantly associated with severe TCMR and degree of fibrosis, which highlights the importance of active clinical management and follow-up for these patients.
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Affiliation(s)
- Iván A. González
- Lauren V. Ackerman Laboratory of Surgical Pathology, Department of Pathology and Immunology
| | - Hsiang-Chih Lu
- Lauren V. Ackerman Laboratory of Surgical Pathology, Department of Pathology and Immunology
| | - Zahra Alipour
- Lauren V. Ackerman Laboratory of Surgical Pathology, Department of Pathology and Immunology
| | - Sakil S. Kulkarni
- Department of Pediatrics, St. Louis Children’s Hospital, Washington University Medical Center, St. Louis, MO
| | - Janis M. Stoll
- Department of Pediatrics, St. Louis Children’s Hospital, Washington University Medical Center, St. Louis, MO
| | - Kim H. Liss
- Department of Pediatrics, St. Louis Children’s Hospital, Washington University Medical Center, St. Louis, MO
| | - Louis P. Dehner
- Lauren V. Ackerman Laboratory of Surgical Pathology, Department of Pathology and Immunology
| | - Mai He
- Lauren V. Ackerman Laboratory of Surgical Pathology, Department of Pathology and Immunology
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Fels Elliott DR, Tavakol M, Lucas CH, Sheahon K, Kakar S, Hameed B, Ferrell LD, Gill RM. Clinicopathological features and outcomes of parenchymal rejection in liver transplant biopsies. Histopathology 2020; 76:822-831. [PMID: 31894595 DOI: 10.1111/his.14058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/26/2019] [Accepted: 12/30/2019] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to perform a comprehensive retrospective analysis of liver transplant biopsies with parenchymal rejection (PR) at our institution, including histological features, laboratory values and follow-up biopsies, and to compare PR with portal-based acute cellular rejection (ACR). METHODS AND RESULTS Biopsies from 173 patients were evaluated (retrospective database search 1990-2017), including 49 isolated PR, 35 PR with portal ACR (PR/ACR), 34 mild ACR and 52 moderate ACR cases. The rise and fall of serum liver enzymes was calculated as a measure of acute liver injury and response to immunotherapy, respectively. Isolated PR was associated with delayed-onset acute rejection (P < 0.001), as well as younger age (P = 0.004), and showed a similar rise in liver enzymes to mild ACR. PR/ACR and moderate ACR showed the highest elevations in transaminases (P < 0.05). Isolated PR on an initial biopsy was associated with recurrent episodes of PR (P = 0.01), chronic ductopaenic rejection (P = 0.002) and chronic vascular rejection (P = 0.017). Immunohistochemistry for C4d was performed, and strong C4d staining of venules was only detected in one severe isolated PR case (one of three, 33%) and one moderate ACR case (one of 20, 5%). CONCLUSIONS Isolated PR represents a form of late acute rejection with distinct clinical and histological features. There is value in reporting PR in liver transplant biopsies to identify patients at higher risk of developing recurrent PR and chronic rejection. Standardisation of terminology and histological criteria of PR can help in uniform reporting and ensure appropriate management.
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Affiliation(s)
| | - Mehdi Tavakol
- Division of Transplant Surgery, University of California, San Francisco, CA, USA
| | - Calixto-Hope Lucas
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Kathleen Sheahon
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Bilal Hameed
- Hepatology and Liver Transplantation, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Linda D Ferrell
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Ryan M Gill
- Department of Pathology, University of California, San Francisco, CA, USA
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Uchida H, Sakamoto S, Shimizu S, Takeda M, Yanagi Y, Fukuda A, Uchiyama T, Irie R, Kasahara M. Efficacy of Antithymocyte Globulin Treatment for Severe Centrilobular Injury Following Pediatric Liver Transplant: Clinical Significance of Monitoring Lymphocyte Subset. EXP CLIN TRANSPLANT 2020; 18:325-333. [PMID: 32281527 DOI: 10.6002/ect.2019.0387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Central perivenulitis can occur in association with T-cell-mediated rejection and can sometimes require strong immunosuppressant therapy as refractory rejection. Furthermore, patients with central perivenulitis are more likely to have subsequent episodes of T-cell-mediated rejection and develop chronic rejection than those without central perivenulitis. We retrospectively analyzed clinical data of pediatric patients with episodes of T-cell-mediated rejection according to severity of central perivenulitis and monitored HLA-DR-positive CD8-positive T cells and recent thymic emigrants during treatment for T-cell-mediated rejection. MATERIALS AND METHODS We identified biopsy-proven T-cell-mediated rejection in 50 liver transplant recipients (45 with living-related donors, 5 with deceased donors) between September 2014 and August 2018. Lymphocyte subsets in peripheral blood samples were analyzed. RESULTS Of 50 pediatric patients, 30 were boys and 20 were girls (median age at transplant of 1.1 y; interquartile range, 0.6-6.2 y). Central perivenulitis was found in 46 patients (92%), which was mild in 13, moderate in 16, and severe in 17. Antithymocyte globulin was more frequently administered to patients with severe central perivenulitis than others (P < .05). Patients with antithymocyte globulin treatment were less likely to have subsequent episodes of T-cell-mediated rejection than those without this treatment (P < .05). The absolute number of CD8-positive HLA-DR-positive T cells in patients during treatment was significantly higher than in control patients (P < .05). The absolute number of recent thymic emigrants in patients with active infection was significantly lower than in patients without infection (P < .05). CONCLUSIONS Our results suggest the efficacy and safety of antithymocyte globulin for treating T-cell-mediated rejection with severe central perivenulitis in pediatric liver transplant recipients and suggest that antithymocyte globulin can prevent subsequent episodes of T-cell-mediated rejection. Analyzing lymphocyte subsets during treatment for rejection may help highlight viable therapeutic strategies for achieving a good outcome.
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Affiliation(s)
- Hajime Uchida
- From the Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Koo J, Wang HL. Acute, Chronic, and Humoral Rejection: Pathologic Features Under Current Immunosuppressive Regimes. Surg Pathol Clin 2018; 11:431-452. [PMID: 29751884 DOI: 10.1016/j.path.2018.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Under current immunosuppressive regimes, T-cell-mediated acute and chronic rejection remain common and important posttransplant complications. The definition of humoral (antibody-mediated) rejection has been greatly expanded in recent years. The histopathologic assessment of allograft biopsies continues to serve an important role in the diagnosis of rejection and to facilitate patient management. The diagnosis of both acute and chronic antibody-mediated rejection requires integration of the results of donor-specific antibody testing and C4d immunostaining, as well as exclusion of other potential etiologies of allograft dysfunction. Chronic antibody-mediated rejection should also be included in the differential diagnosis for unexplained allograft fibrosis.
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Affiliation(s)
- Jamie Koo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 8707, Los Angeles, CA 90048, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 27-061-C8 CHS, Los Angeles, CA 90095, USA.
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Fernández-Rodríguez OM, Ríos A, Palenciano C, Ramírez P, Navarro JL, Martínez-Alarcón L, Martínez C, Fuente T, Pons JA, Navarro JA, Majado M, Martínez P, Parrilla P. A hemodynamic, metabolic and histopathological study of a heterotopic auxiliary swine liver graft with portal vein arterialization. Cir Esp 2015; 94:77-85. [PMID: 26615737 DOI: 10.1016/j.ciresp.2015.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/18/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Auxiliary heterotopic liver transplantation with portal vein arterialization (AHLT-PVA) is a model that has been hardly studied, despite its therapeutic potential. METHODS Hemodynamic and biochemical characterization was carried out during graft implantation, in a pig-to-pig model (n=15 AHLT-PVA). Furthermore a histopathological study was performed to establish microscopic alterations due to PVA. RESULTS Reperfusion of the arterialized graft produced an increase in heart rate (HR) vs. baseline (P=.004) and vs. inferior vena cava clamping phase (P=.004); and a decrease in systemic vascular resistance vs. cava clamping phase (P=.021). At the end of implantation, cardiac output remained elevated (P=.001), likewise HR remained increased vs. baseline phase (P=.002). Mean arterial pressure decreased with cava clamping, but was not affected by the reperfusion of the graft, nor the skin closure. The histopathological study at 3, 10, and 21 days post-PVA revealed that functional liver structure was maintained although it is common to find foci of perilobular necrosis on day 3 (P=.049), and perilobular connective tissue proliferation at day 10 (P=.007), vs. native liver. CONCLUSIONS The described arterialized liver graft model minimizes the number of vascular anastomoses vs. previously described models. It is hemodynamically and metabolically well tolerated and the double arterial vascularization of the graft does not cause significant changes in liver histology.
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Affiliation(s)
- Olga M Fernández-Rodríguez
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Antonio Ríos
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - Carlos Palenciano
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Anestesia, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pablo Ramírez
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Luis Navarro
- Departamento de Medicina Nuclear, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Laura Martínez-Alarcón
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Carlos Martínez
- Departamento de Patología, Facultad de Veterinaria, Universidad de Murcia, España
| | - Teodomiro Fuente
- Departamento de Medicina Nuclear, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Antonio Pons
- Departamento de Medicina Interna, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Antonio Navarro
- Departamento de Patología, Facultad de Veterinaria, Universidad de Murcia, España
| | - Maruja Majado
- Departamento de Hematología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pedro Martínez
- Departamento de Hematología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pascual Parrilla
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
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Shigeta T, Sakamoto S, Uchida H, Sasaki K, Hamano I, Kanazawa H, Fukuda A, Kawai T, Onodera M, Nakazawa A, Kasahara M. Basiliximab treatment for steroid-resistant rejection in pediatric patients following liver transplantation for acute liver failure. Pediatr Transplant 2014; 18:860-7. [PMID: 25311536 DOI: 10.1111/petr.12373] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2014] [Indexed: 01/08/2023]
Abstract
An IL-2 receptor antagonist, basiliximab, decreases the frequency of ACR in liver transplant (LT) recipients as induction therapy. The aim of this study was to evaluate the effectiveness of basiliximab against SRR as rescue therapy in pediatric LT patients with ALF. Forty pediatric ALF patients underwent LT between November 2005 and July 2013. Among them, seven patients suffering from SRR were enrolled in this study. The median age at LT was 10 months (6-12 months). SRR was defined as the occurrence of refractory rejection after more than two courses of steroid pulse therapy. Basiliximab was administered to all patients. The withdrawal of steroids without deterioration of the liver function was achieved in six patients treated with basiliximab therapy without patient mortality, although one patient developed graft loss and required retransplantation for veno-occlusive disease. The pathological examinations of liver biopsies in the patients suffering from SRR revealed severe centrilobular injuries, particularly fibrosis within one month after LT. We demonstrated the effectiveness and safety of rescue therapy consisting of basiliximab for SRR in pediatric LT recipients with ALF.
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Affiliation(s)
- Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Shetty S, Adams DH, Hubscher SG. Post-transplant liver biopsy and the immune response: lessons for the clinician. Expert Rev Clin Immunol 2014; 8:645-61. [DOI: 10.1586/eci.12.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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8
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Sembera S, Lammert C, Talwalkar JA, Sanderson SO, Poterucha JJ, Hay JE, Wiesner RH, Gores GJ, Rosen CB, Heimbach JK, Charlton MR. Frequency, clinical presentation, and outcomes of drug-induced liver injury after liver transplantation. Liver Transpl 2012; 18:803-10. [PMID: 22389256 PMCID: PMC3396746 DOI: 10.1002/lt.23424] [Citation(s) in RCA: 28] [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: 01/15/2023]
Abstract
Drug-induced liver injury (DILI) is increasingly being recognized as a common cause of acute hepatitis. The clinical impact of DILI after liver transplantation (LT) is not known. The aim of this study was to describe the frequency, clinical presentation, and outcomes of DILI in LT recipients. LT recipients with possible DILI were identified with electronic pathology records and clinical note database retrieval tools. Diagnostic criteria were applied to identify cases of DILI. Twenty-nine of 1689 LT recipients (1.7%) were identified with DILI. The mean age was 52 years, and 52% were women. The major indications for LT were primary sclerosing cholangitis (28%), cholangiocarcinoma (14%), and hepatocellular carcinoma (14%). The severity of DILI was mild or moderate in 92% of the cases. Nausea or diarrhea (31%), jaundice (24%), and pruritus (10%) were the most common symptoms at the time of diagnosis. The mean biochemistry values were as follows: alanine aminotransferase, 204 ± 263 U/L; aspartate aminotransferase, 108 ± 237 U/L; alkaline phosphatase, 469 ± 689 U/L; and total bilirubin, 1.9 ± 10.3 mg/dL. The median duration of medication use until the diagnosis of DILI was 57 days, and the major agent classes were antibiotics (48%), immunosuppressive agents (14%), and antihyperlipidemic drugs (7%). Trimethoprim-sulfamethoxazole was the most common implicated agent (n = 11). Serum liver enzymes improved within a median time of 34 days (range = 5-246 days) after drug withdrawal. Hepatic retransplantation or death did not occur. Among the 50 cases with possible DILI explained by other causes, 13 individuals (26%) had no alternative diagnosis despite histological findings compatible with DILI. In conclusion, DILI is a rare yet underrecognized event among LT recipients. The majority of cases are not clinically severe, and they resolve after drug cessation without hepatic retransplantation or death.
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Affiliation(s)
- Stepan Sembera
- William J. von Leibig Transplant Center, Mayo Clinic, Rochester, MN 55905, USA
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9
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What is the long-term outcome of the liver allograft? J Hepatol 2011; 55:702-717. [PMID: 21426919 DOI: 10.1016/j.jhep.2011.03.005] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/11/2011] [Accepted: 03/13/2011] [Indexed: 12/11/2022]
Abstract
With improved long-term survival following liver transplantation (LT), issues relating to the assessment of the liver allograft in long-term survivors are becoming increasingly relevant. Histological abnormalities are commonly present in late post-transplant biopsies, including protocol biopsies from patients who appear to be well with good graft function. Recurrent disease is the commonest recognised cause of abnormal graft histology, but may be modified by the effects of immunosuppression or interactions with other graft complications, resulting in complex or atypical changes. Other abnormalities seen in late post-transplant biopsies include rejection (which often has different appearances to those seen in the post-transplant period), de novo disease, "idiopathic" post-transplant hepatitis (IPTH) and nodular regenerative hyperplasia. In many cases graft dysfunction has more than one cause and liver biopsy may help to identify the predominant cause of graft damage. Problems exist with the terminology used to describe less well understood patterns of graft injury, but there is emerging evidence to suggest that late rejection, de novo autoimmune hepatitis and IPTH may all be part of an overlapping spectrum of immune-mediated injury occurring in the late post-transplant liver allograft. Careful clinico-pathological correlation is very important and the wording of the biopsy report should take into account therapeutic implications, particularly whether changes in immunosuppression may be indicated. This article will provide an overview of the main histological changes occurring in long-term survivors post-LT, focusing on areas where the assessment of late post-transplant biopsies is most relevant clinically.
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10
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Abstract
Histological assessments continue to play an important role in the diagnosis and management of liver allograft rejection. The changes occurring in acute and chronic rejection are well recognized and liver biopsy remains the 'gold standard' for diagnosing these two conditions. Recent interest has focused on the diagnosis of late cellular rejection, which may have different histological appearances to early acute rejection and instead has features that overlap with so-called 'de novo autoimmune hepatitis' and 'idiopathic post-transplant chronic hepatitis'. There is increasing evidence to suggest that 'central perivenulitis' may be an important manifestation of late rejection, although other causes of centrilobular necro-inflammation need to be considered in the differential diagnosis. There are also important areas of overlap between rejection and recurrent hepatitis C infection and the distinction between these two conditions continues to be a problem in the assessment of liver allograft biopsies. Studies using immunohistochemical staining for C4d as a marker for antibody-mediated damage have found evidence of C4d deposition in liver allograft rejection, but the functional significance of these observations is currently uncertain. This review will focus on these difficult and controversial areas in the pathology of rejection, documenting what is currently known and identifying areas where further clarification is required.
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Affiliation(s)
- Desley A H Neil
- Department of Pathology, University of Birmingham, Birmingham, UK
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11
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Drebber U, Torbenson M, Wedemeyer I, Dienes H. Aktuelle Aspekte zur Histopathologie im Rahmen der Lebertransplantation. DER PATHOLOGE 2011; 32:113-23. [DOI: 10.1007/s00292-010-1405-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Song DE, Jung DH, Hwang S, Park BH, Yu E. Characterization of Histopathological Features that Differentiate Hepatitis B Virus Infection from Acute Cellular Rejection. KOREAN JOURNAL OF PATHOLOGY 2009. [DOI: 10.4132/koreanjpathol.2009.43.6.535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Dong Eun Song
- Department of Pathology, Ewha Womans University School of Medicine, Ewha Medical Research Institute, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Bong-Hee Park
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Eunsil Yu
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Abstract
Central perivenulitis (CP) encompasses dropout of zone 3 hepatocytes, red blood cell extravasation, and perivenular mononuclear inflammation. In the liver transplant setting, CP can occur in isolation or it can occur in association with portal-based disease such as acute cellular rejection (PB-ACR). Some CP is also thought to be a manifestation of chronic rejection, particularly when accompanied by zone 3 fibrosis. Prior studies of CP in pediatric liver allografts have been hampered by lack of protocol biopsies and low rates of histologic follow-up. We studied 62 consecutive liver allografts from 55 pediatric patients (age: < or =18 y) who underwent transplant from the years 1995 to 2007. Forty-nine allografts (79%) had > or =1 year of histologic follow-up, 32 (52%) > or =3 years, and 24 (39%) > or =5 years. We reviewed a total of 445 allograft biopsies (mean: 7.2 per allograft) obtained at 2 days to 11 years; 213 (48%) of these were protocol biopsies. Seven explanted livers that were removed during the course of retransplantation for graft failure in this group were also reviewed. All specimens were scored for the following features: (1) CP (mild, moderate, and severe), (2) portal ACR (mild, moderate, and severe), (3) zone 3 fibrosis (mild=perivenular or severe=bridging), and (4) ductopenia. CP was present in 120 (27%) of 445 biopsies, including 73 with CP+PB-ACR, 16 with CP within 1 month of PB-ACR, 27 with isolated CP, 3 with CP+de-novo autoimmune hepatitis, and 1 with CP+Epstein-Barr virus infection. Overall, CP was observed on at least 1 occasion in 41 (66%) allografts. It was not associated with any specific liver function test abnormality or pattern of liver function test abnormalities, it was not associated with vascular compromise as judged by Doppler ultrasound examinations, and it was not related to type of immunosuppression. CP overall was equally prevalent in the early (< or =3 mo) and late (>3 mo) post-transplant periods, but isolated CP increased in the late period. On follow-up, 6 (15%) of 41 allografts with CP developed ductopenic chronic rejection (4 requiring retransplantation) and 10 (25%) developed zone 3-based fibrosis without ductopenia (2 severe, 8 mild). In contrast, none of the 21 allografts without CP developed chronic rejection (P=0.09) and none had zone 3-based fibrosis on their last biopsy (P<0.001). All patients who developed ductopenia had 1 or more episodes of CP+PB-ACR. In contrast, isolated CP [seen in 17 (27%) allografts on at least 1 occasion] was associated with zone 3-based fibrosis in 50%, but did not lead to ductopenic chronic rejection. These results underscore the high frequency of CP in pediatric liver transplantation, occurring in 27% of all allograft biopsies and 66% of allografts overall. CP is most common in conjunction with portal ACR, where it carries a significant risk for the development of zone 3 fibrosis and a trend toward the development of ductopenic chronic rejection.
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14
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Demetris AJ, Sebagh M. Plasma cell hepatitis in liver allografts: Variant of rejection or autoimmune hepatitis? Liver Transpl 2008; 14:750-5. [PMID: 18508366 DOI: 10.1002/lt.21518] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Hübscher SG. Central perivenulitis: a common and potentially important finding in late posttransplant liver biopsies. Liver Transpl 2008; 14:596-600. [PMID: 18433067 DOI: 10.1002/lt.21451] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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Krasinskas AM, Demetris AJ, Poterucha JJ, Abraham SC. The prevalence and natural history of untreated isolated central perivenulitis in adult allograft livers. Liver Transpl 2008; 14:625-32. [PMID: 18433038 DOI: 10.1002/lt.21404] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Central perivenulitis (CP) in the allograft liver can be associated with portal-based acute cellular rejection and autoimmune hepatitis or can occur in isolation (isolated CP). Although several studies have demonstrated the significance of CP, the prevalence and natural history of untreated isolated CP have not been well studied. We examined 100 adult allograft liver recipients who had long-term follow-up, had routine protocol biopsies, and received no treatment for isolated CP. Isolated CP was identified in 28 (28%) patients. It occurred late at a mean of 658 days. Interestingly, patients with late isolated CP (defined as >3 months posttransplant) usually manifested only mildly to modestly elevated liver function tests. However, late isolated CP was associated with prior and subsequent allograft complications. Nearly all (94%) cases of late isolated CP occurred in patients who had early episodes of CP and/or acute cellular rejection. Of 13 patients who developed adverse outcomes in their allografts (zone 3 fibrosis in 10, de novo autoimmune hepatitis in 3, and ductopenia in 3), all experienced episodes of prior CP, and 12 (92%) had late CP; 1 patient required retransplant for chronic rejection, but all were alive within the last year. In summary, "transplant-associated" isolated CP occurs in 28% of adult patients, early CP is predictive of late CP, and late CP (often present as isolated CP) is associated with long-term liver injury in some patients.
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Affiliation(s)
- Alyssa M Krasinskas
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15213-2546, USA.
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17
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Demirhan B, Bilezikçi B, Haberal AN, Sevmiş S, Arat Z, Haberal M. Hepatic parenchymal changes and histologic eosinophilia as predictors of subsequent acute liver allograft rejection. Liver Transpl 2008; 14:214-9. [PMID: 18236397 DOI: 10.1002/lt.21360] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
During the first episode of acute cellular rejection (ACR) after liver transplantation, centrilobular changes in liver biopsy specimens may be possible indicators of subsequent episodes of ACR, early chronic rejection, or acute graft loss. The purpose of this study was to identify differences between the histopathological findings in liver biopsy specimens obtained during the first rejection episode in patients who subsequently developed further episodes of ACR and those who did not. The histopathological findings in 22 patients who had a single episode of acute rejection (group 1) were compared with those in 23 patients who had multiple episodes of acute rejection (group 2). Only the first liver biopsy samples of the latter group were taken into consideration. We assessed the predictive value of centrilobular necrosis, central vein endothelialitis, pericentral inflammation, hepatocellular ballooning, cholestasis, hepatocellular apoptosis, lobular inflammation, the degree of portal eosinophilia, and characteristic portal tract features in poor responders to antirejection treatment. The time to the first episode of ACR and the rejection activity index were similar in patients in both groups. Hepatocellular apoptosis, hepatocellular ballooning, and central vein endothelialitis were common features of both groups. The incidences of pericentral inflammation, centrilobular necrosis, and portal eosinophilia were significantly higher in patients in group 2 than in those in group 1 (P < 0.05). Patients with pericentral inflammation, centrilobular necrosis, and marked portal eosinophilia during an initial episode of acute rejection may be more likely to develop subsequent episodes of ACR.
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Affiliation(s)
- Beyhan Demirhan
- Department of Pathology, Baskent University School of Medicine, Bahçelievler, Ankara, Turkey.
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Höroldt BS, Burattin M, Gunson BK, Bramhall SR, Nightingale P, Hübscher SG, Neuberger JM. Does the Banff rejection activity index predict outcome in patients with early acute cellular rejection following liver transplantation? Liver Transpl 2006; 12:1144-51. [PMID: 16799959 DOI: 10.1002/lt.20779] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Banff schema incorporates a semiquantitative scoring system for grading of acute cellular rejection (ACR) of the liver allograft. The Banff rejection activity index (RAI) comprises 3 components scored from 0 to 3: venous endothelial inflammation (E); bile duct damage (B); and portal inflammation (P); the scores are combined to an overall score (the RAI). The purpose of this research was to determine the prognostic value of the Banff RAI score in predicting the response to increased immunosuppression and the long-term outcome of the graft. A retrospective study was done of patients undergoing primary liver transplantation between January 2000 and October 2004 with tacrolimus-based immunosuppression; 495 patients were included, 231 had histologically-confirmed ACR, 193 responded to 1 cycle of high-dose steroids. There was no correlation between the total RAI score and response to steroids, resistant rejection, development of chronic rejection, or graft survival. The E score was related to patient survival, a lower score being associated with a worse outcome (P = 0.048). In multivariable analysis, serum bilirubin, serum aspartate aminotransferase, and E score were significant predictors of death (P = 0.012). In univariable analysis, B score and bilirubin were significantly related to "resistant rejection" (P = 0.018 and 0.002, respectively), but only bilirubin was significant in multivariable analysis (logistic regression). In conclusion, although the Banff RAI score is a useful marker of the severity of rejection, neither the total RAI score nor any of the individual components correlated with response to steroids or graft survival.
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Górnicka B, Ziarkiewicz-Wróblewska B, Bogdańska M, Ołdakowska-Jedynak U, Wróblewski T, Morton M, Ziółkowski J, Paczek L, Krawczyk M, Wasiutyński A. Pathomorphological Features of Acute Rejection in Patients After Orthotopic Liver Transplantation: Own Experience. Transplant Proc 2006; 38:221-5. [PMID: 16504708 DOI: 10.1016/j.transproceed.2006.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Acute hepatic allograft rejection remains an important problem following liver transplantation. Liver biopsy specimens show a combination of characteristic changes, first observed by Snover as a diagnostic triad: portal inflammation, bile duct damage, and central or portal vein endothelial inflammation (endothelitis or endothelialitis). The aim of this study was to describe our histopathological assessment of liver transplants. MATERIALS AND METHODS In the period between September 2000 and June 2004, we evaluated 150 liver biopsy specimens from 105 liver recipients. RESULTS Acute rejection was diagnosed in 26.6% of liver biopsies taken from 31.4% patients who demonstrated clinical symptoms of liver damage. In 90% of cases the rejection was described as minimal or mild, and in 10% as moderate. There was no episode of severe acute rejection. Only four biopsies (10%) showed nothing but Snover triad changes. In 9 (22.5%) cases only acute rejection was diagnosed; the remaining showed in addition to acute rejection the possibility of other concomitant pathologies: viral infection in 15 cases (37.5%), biliary flow obstruction in 11 cases (28.5%), functional cholestasis in two cases (5%), and ischemic complications in three cases (7.5%). CONCLUSIONS Histologically confirmed acute rejection episodes were diagnosed in 14.9% liver recipients. Liver biopsy specimens, aside from Snover triad features, often showed other unspecific morphological changes. Differentiation of acute rejection from other accompanying diseases is sometimes difficult, requiring precise clinical data and pathologist experience.
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Affiliation(s)
- B Górnicka
- Department of Pathology, Warsaw Medical University, ul. Pawińskiego 7, 02-106 Warsaw, Poland.
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Sundaram SS, Melin-Aldana H, Neighbors K, Alonso EM. Histologic characteristics of late cellular rejection, significance of centrilobular injury, and long-term outcome in pediatric liver transplant recipients. Liver Transpl 2006; 12:58-64. [PMID: 16382471 DOI: 10.1002/lt.20661] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cellular rejection is a common event in orthotopic liver transplantation, leading to significant morbidity and mortality. Late acute cellular rejection, which occurs at least 3 months post-transplant, affects 8-32% of pediatric liver transplant recipients. The histopathology and clinical outcome of patients affected by late cellular rejection are incompletely understood. The aims of this study were 1) to characterize late cellular rejection in the pediatric liver transplant population and describe the histopathology of late cellular rejection, with specific attention to centrilobular injury, including necrosis, inflammation, and endothelialitis and 2) to characterize the long-term outcome of pediatric liver transplant recipients with centrilobular injury, including necrosis, inflammation, and endothelialitis. All liver biopsies performed from August 1997 to August 2002 on pediatric patients at least 6 months post-transplant were reviewed, scored for rejection by Banff criteria and examined for centrilobular inflammatory changes. Histology was then correlated with clinical outcomes. Fifteen percent of biopsies had late cellular rejection by Banff criteria. Centrilobular inflammation, necrosis and central vein endothelialitis were common in these biopsies. In patients with similar centrilobular changes, but not meeting Banff criteria for rejection, 29% were treated for rejection and responded well clinically. The long-term outcome of patients with isolated centrilobular injury is similar to that of patients with centrilobular changes associated with portal based rejection. In conclusion, the presence of centrilobular inflammation, necrosis, or central vein endothelialitis should prompt consideration of late cellular rejection.
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Affiliation(s)
- Shikha S Sundaram
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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Abstract
PURPOSE OF REVIEW This review highlights recent publications on hepatobiliary pathology concerning several unusual types of hepatitis, fatty liver disease, disorders of the biliary tree and other topics that have a substantial impact on liver biopsy interpretation. RECENT FINDINGS In the outbreak of severe acute respiratory syndrome (SARS), many patients had abnormalities in liver function tests. Liver biopsy findings in three cases were reported that showed a generic picture of hepatitis, with exceptionally increased mitotic activity. The role of portal myofibroblasts in cirrhosis was examined in several studies. A newly described lesion, isolated ductular hyperplasia (IDH) was found in patients with prolonged abnormalities of liver function tests of uncertain origin. Hyperplastic, well-differentiated bile ductules were seen on liver biopsy in the absence of any identifiable biliary disease. Hereditary hemochromatosis is now a complex entity with various clinicopathological forms based on mutations in the HFE gene and other iron-homeostatic genes such as transferrin receptor 2 and ferroportin 1. In some of these heritable forms of primary iron overload, stainable iron is present in both hepatocytes and Kupffer cells. After liver transplantation, differentiating recurrent HCV infection from acute rejection on liver biopsy is problematic, with exceptionally low inter- and intra-observer reliability shown in one study. SUMMARY The hepatitis associated with the SARS coronavirus, Isolated Ductular Hyperplasia in patients with liver function test abnormalities and other topics with pathologic relevance are reviewed.
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Affiliation(s)
- Jay H Lefkowitch
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Affiliation(s)
- Mylène Sebagh
- Laboratoire d'Anatomopathologie, Centre Hépatobiliaire, Hôpital Paul Brousse, 14 avenue Paul-Vaillant-Couturier, 94800 Villejuif, France
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