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Tedla MG, Kahsay MM, Kidanu MG. Maintaining the optimum level of immunosuppressive agents minimizes risk of liver allograft fibrosis during pediatric liver transplantation. Int J Surg 2024; 110:3946-3947. [PMID: 38728859 PMCID: PMC11175788 DOI: 10.1097/js9.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 05/12/2024]
Affiliation(s)
- Mebrahtu G. Tedla
- Department of Pediatrics, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Mebrihit M. Kahsay
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa
| | - Mebrahtu G. Kidanu
- Department of Pediatrics, School of Medicine, College of Health Sciences, Axum University, Axum, Ethiopia
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2
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Vimalesvaran S, Verma A, Dhawan A. Pediatric Liver Transplantation: Selection Criteria and Post-transplant Medical Management. Indian J Pediatr 2024; 91:383-390. [PMID: 38150147 DOI: 10.1007/s12098-023-04963-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/10/2023] [Indexed: 12/28/2023]
Abstract
Pediatric liver transplantation remains the gold standard for life-threatening acute and chronic liver diseases and multiple liver-based inherited metabolic defects. Advances in surgical techniques, better perioperative care and immunosuppression regimes have resulted in excellent long-term graft and patient survival. The success of pediatric liver transplantation does however bring the additional challenge of long-term patient outcomes including graft hepatitis-related fibrosis and suboptimal biopsychosocial outcomes. In this review, authors will explore the current landscape of pediatric liver transplantation including indications, timing of referral for liver transplantation, surgical techniques and long-term outcomes such as recurrence of pre-transplant liver disease, idiopathic graft hepatitis and biopsychosocial outcomes. Ultimately, early identification and management of potential issues long-term helps ensure our recipients achieve a "meaningful survival".
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Affiliation(s)
- Sunitha Vimalesvaran
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anita Verma
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK.
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3
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Rao W, Jiang YP, Cai JZ, Xie M. Endoscopic ultrasound-guided liver biopsy in liver transplant recipients: A preliminary experience. Hepatobiliary Pancreat Dis Int 2024:S1499-3872(24)00044-4. [PMID: 38555248 DOI: 10.1016/j.hbpd.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Wei Rao
- Division of Hepatology, Liver Disease Center, the Affiliated Hospital of Qingdao University, Qingdao 266000, China; Department of Organ Transplantation, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Yue-Ping Jiang
- Department of Gastroenterology, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Jin-Zhen Cai
- Division of Hepatology, Liver Disease Center, the Affiliated Hospital of Qingdao University, Qingdao 266000, China; Department of Organ Transplantation, the Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Man Xie
- Department of Gastroenterology, the Affiliated Hospital of Qingdao University, Qingdao 266000, China.
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4
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Dong C, Song Z, Sun C, Wang K, Zhang W, Chen J, Zheng W, Yang Y, Wang Z, Han C, Jiao L, Zhang G, Xie E, Gao W, Shen Z. Basiliximab Induction and Postoperative Steroid-free Immunosuppression With Tacrolimus in Pediatric Liver Transplantation: A Randomized Clinical Trial. Transplantation 2024:00007890-990000000-00679. [PMID: 38419149 DOI: 10.1097/tp.0000000000004951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Optimizing the immunosuppressive regimen is essential to improve the long-term outcomes of pediatric liver transplant recipients. METHODS We conducted a prospective, randomized, open-label study to compare the safety and efficacy of 2 treatment approaches during pediatric liver transplantation: tacrolimus monotherapy following basiliximab induction (the study group) and a dual regimen of tacrolimus plus steroids (the control group). A total of 150 patients were enrolled, with 75 patients allocated to each group. RESULTS In both groups, recipients achieved graft and recipient overall survival rates exceeding 93%, with no statistically significant differences between them. However, the study group exhibited a significantly lower incidence of acute cellular rejection (ACR), delayed occurrence of ACR, and an improved ACR-free survival rate at 2 y compared with the control group. Notably, the study group also showed a significant reduction in the incidence of de novo donor-specific antibodies at 3-mo and 2-y posttransplant. Furthermore, 6 mo after the transplant, the study group demonstrated significant improvements in weight-for-age Z score and height-for-age Z score. No notable differences were observed in postoperative complications or the incidence of liver fibrosis between the 2 groups. CONCLUSIONS Basiliximab induction combine with tacrolimus (TAC) monotherapy is a safe and effective immunosuppressive regimen to reduce the episodes of ACR without influencing the development of liver fibrosis and graft and recipient survival rate after pediatric liver transplantation.
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Affiliation(s)
- Chong Dong
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Zhuolun Song
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Chao Sun
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Kai Wang
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Wei Zhang
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Jing Chen
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Weiping Zheng
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Yang Yang
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Zhen Wang
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Chao Han
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Lijun Jiao
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Guofeng Zhang
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Enbo Xie
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Wei Gao
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Zhongyang Shen
- Department of Pediatric Transplantation, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
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5
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Hartleif S, Hodson J, Lloyd C, Cousin VL, Czubkowski P, D'Antiga L, Debray D, Demetris A, Di Giorgio A, Evans HM, Fischler B, Gonzales E, Gouw ASH, Hübscher SG, Jacquemin E, Lacaille F, Malenicka S, McLin VA, Markiewicz-Kijewska M, Mazariegos GV, Rajanayagam JK, Scheenstra R, Singer S, Smets F, Sokal E, Squires JE, Sturm E, Verkade H, Kelly DA. Long-term Outcome of Asymptomatic Patients With Graft Fibrosis in Protocol Biopsies After Pediatric Liver Transplantation. Transplantation 2023; 107:2394-2405. [PMID: 37143195 DOI: 10.1097/tp.0000000000004603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The histological prevalence of allograft fibrosis in asymptomatic children after liver transplantation (LT) is well documented. However, long-term graft and patient survival remain unclear. This retrospective multicenter study aims to determine the prevalence of allograft fibrosis and analyze the long-term outcome for patients transplanted in childhood. METHODS We reviewed clinical data of children who had undergone 10-y protocol liver biopsies. We excluded patients with autoimmune hepatitis, primary sclerosing cholangitis, hepatitis B or C, and retransplantation. In total, 494 patients transplanted in childhood across 12 international transplant centers were included. We evaluated the development of fibrosis by comparing the results with biopsies obtained 5 and 15 y post-LT. Histological findings were correlated with graft and patient survival up to 20 y post-LT. RESULTS In the 10-y biopsies, periportal or pericentral fibrosis was observed in 253 patients (51%), 87 (18%) had bridging fibrosis, 30 (6%) had cirrhosis, and 124 (25%) had no fibrosis. The prevalence and stage of graft fibrosis significantly progressed from 5 to 10 y. At 10 y, the severity of fibrosis correlated significantly with inflammation. Patients with graft cirrhosis in the 10-y biopsy were more likely to die or require retransplantation subsequently ( P = 0.027). CONCLUSIONS At 10 y post-LT, most patients transplanted in childhood developed fibrosis, based on the protocol liver biopsies. Although mild-to-moderate graft fibrosis did not largely affect patient or graft survival up to 20 y post-LT, this progressive fibrosis finding has substantial implications for developing cirrhosis and portal hypertension in adult care.
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Affiliation(s)
- Steffen Hartleif
- Pediatric Gastroenterology and Hepatology, University Hospital Tübingen, Tübingen, Germany
| | - James Hodson
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Translational Medicine, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Carla Lloyd
- Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Vladimir L Cousin
- Swiss Pediatric Liver Centre, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | - Piotr Czubkowski
- Department of Liver Disorders and Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Dominique Debray
- Pediatric Liver Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Anthony Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Angelo Di Giorgio
- Pediatric Hepatology, Gastroenterology and Transplantation, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Helen M Evans
- Department of Pediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Björn Fischler
- Pediatric Digestive Diseases, Astrid Lindgren Children's Hospital, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Emmanuel Gonzales
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FSMR FILFOIE, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Kremlin-Bicêtre, France
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stefan G Hübscher
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Emmanuel Jacquemin
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FSMR FILFOIE, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Kremlin-Bicêtre, France
| | - Florence Lacaille
- Pediatric Liver Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Silvia Malenicka
- Pediatric Digestive Diseases, Astrid Lindgren Children's Hospital, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Valerie A McLin
- Swiss Pediatric Liver Centre, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | | | - George V Mazariegos
- Department of Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jeremy K Rajanayagam
- Paediatric Gastroenterology, Hepatology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - René Scheenstra
- Pediatric Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan Singer
- Institute of Pathology, University Hospital Tübingen, Tübingen, Germany
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies," University of Tübingen, Tübingen, Germany
| | - Françoise Smets
- UClouvain, Clinical and Experimental Research Institute and Cliniques Universitaires Saint Luc, Service de Gastroentérologie Hépatologie Pédiatrique, Brussels, Belgium
| | - Etienne Sokal
- UClouvain, Clinical and Experimental Research Institute and Cliniques Universitaires Saint Luc, Service de Gastroentérologie Hépatologie Pédiatrique, Brussels, Belgium
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ekkehard Sturm
- Pediatric Gastroenterology and Hepatology, University Hospital Tübingen, Tübingen, Germany
| | - Henkjan Verkade
- Pediatric Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
- University of Birmingham, Birmingham, United Kingdom
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6
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Dumont C, Lanthier N, Dahlqvist G. Fibrosis and steatosis of the liver graft: Are non-invasive tests useful? A short review. Clin Res Hepatol Gastroenterol 2023; 47:102194. [PMID: 37567467 DOI: 10.1016/j.clinre.2023.102194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
As life expectancy of liver transplanted patients improves, new questions are arising to avoid progressive graft loss. The spectrum of chronic inflammation and fibrosis are known to be important triggers in the alteration of graft function. Liver biopsy remains the gold standard to better understand progressive, normal, and abnormal histological modifications of the graft. In parallel, the interest for metabolic steatosis development in post-transplantation is also growing. Long-term survival of these patients involves the management of comorbidities including metabolic syndrome and cardiovascular diseases. Early detection of altered graft parenchyma, and monitoring of its evolution are undoubtedly essential. Non-invasive methods including transient elastography and fibrosis biomarkers are attractive tools to avoid drawbacks and complications of liver biopsy. Accuracy of these methods are well-known in a pre-transplantation setting, but evidence is lacking in post-transplantation setting. We review current knowledge of progressive liver fibrosis and steatosis development after transplantation and non-invasive methods of their assessment.
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Affiliation(s)
- Colin Dumont
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Nicolas Lanthier
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium; Laboratory of Gastroenterology and Hepatology, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Géraldine Dahlqvist
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium.
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7
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Velagala VR, Velagala NR, Singh A, Kumar T, Thakre S, Lamture Y. Immunological Nuances and Complications of Pediatric Organ Transplant: A Narrative Review. Cureus 2023; 15:e46309. [PMID: 37916238 PMCID: PMC10616683 DOI: 10.7759/cureus.46309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
Organ transplantation is considered an exaggerated immune state in which the body reacts in an elaborate cascade of reactions against the lifesaving graft transplanted. Unrepairable organ damage is the main indication for a pediatric patient to undergo a transplant. The host and the donor must fulfill the criteria for a successful transplant to have as few side effects as possible. There has been much-needed research in the domain of surgery of organ transplantation, thereby extending into the pediatric age group. This article elaborates on the post-transplant management, the immuno-biochemistry aspect, and its post-surgery treatment. The post-surgery period requires great emphasis as morbidity and mortality are highest. There is much to understand about managing transplant patients to avoid complications such as infections, hypertension, or side effects of immunosuppressive drugs. The treating clinician faces the challenges of managing the dose and frequency of immuno-suppressive medicines to prevent complications in the patients. If the dose is inadequate, there are chances of graft rejection. If the immuno-suppression is prolonged, there may be chances of infections in the patient. This article aims to summarize the mechanism of graft rejection and put forth the need for further research about creating a universal protocol for managing a patient's immune system post-transplant. The authors hope this protocol will help the clinician better understand the patient's current state and help in appropriately using immuno-suppressive drugs. It calls upon the need for a reliable and easily repeatable battery of investigations that will help solve this dilemma.
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Affiliation(s)
- Vivek R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Namrata R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arihant Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tanishq Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swedaj Thakre
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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8
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Montano-Loza AJ, Rodríguez-Perálvarez ML, Pageaux GP, Sanchez-Fueyo A, Feng S. Liver transplantation immunology: Immunosuppression, rejection, and immunomodulation. J Hepatol 2023; 78:1199-1215. [PMID: 37208106 DOI: 10.1016/j.jhep.2023.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 05/21/2023]
Abstract
Outcomes after liver transplantation have continuously improved over the past decades, but long-term survival rates are still lower than in the general population. The liver has distinct immunological functions linked to its unique anatomical configuration and to its harbouring of a large number of cells with fundamental immunological roles. The transplanted liver can modulate the immunological system of the recipient to promote tolerance, thus offering the potential for less aggressive immunosuppression. The selection and adjustment of immunosuppressive drugs should be individualised to optimally control alloreactivity while mitigating toxicities. Routine laboratory tests are not accurate enough to make a confident diagnosis of allograft rejection. Although several promising biomarkers are being investigated, none of them is sufficiently validated for routine use; hence, liver biopsy remains necessary to guide clinical decisions. Recently, there has been an exponential increase in the use of immune checkpoint inhibitors due to the unquestionable oncological benefits they provide for many patients with advanced-stage tumours. It is expected that their use will also increase in liver transplant recipients and that this might affect the incidence of allograft rejection. Currently, the evidence regarding the efficacy and safety of immune checkpoint inhibitors in liver transplant recipients is limited and cases of severe allograft rejection have been reported. In this review, we discuss the clinical relevance of alloimmune disease, the role of minimisation/withdrawal of immunosuppression, and provide practical guidance for using checkpoint inhibitors in liver transplant recipients.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, AB, Canada.
| | - Manuel L Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Universidad de Córdoba, IMIBIC, Córdoba, Spain; CIBER de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - George-Philippe Pageaux
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom
| | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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9
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Haller W, Hodson J, Brown R, Lloyd C, Hubscher S, McKiernan P, Kelly D. The role of immunosuppression in long-term graft hepatitis and fibrosis after paediatric liver transplant - comparison of two treatment protocols. FRONTIERS IN TRANSPLANTATION 2023; 1:1042676. [PMID: 38994383 PMCID: PMC11235287 DOI: 10.3389/frtra.2022.1042676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/22/2022] [Indexed: 07/13/2024]
Abstract
Background and aims We have previously demonstrated high rates of chronic allograft hepatitis and fibrosis in liver transplant patients on long-term cyclosporine monotherapy. We subsequently changed practice to add low-dose prednisolone to maintenance treatment with tacrolimus post-transplant. The aim of the study was to assess the impact of the immunosuppression change on graft histopathology. Methods Patients treated in this era (Tac + Pred, 2000-2009, N = 128) were compared to a historical cohort, who had been maintained on a steroid-free, cyclosporine-based regime (CSA-Only, 1985-1996, N = 129). Protocol liver biopsies and laboratory tests were performed five- and ten-years post-transplant in both groups. Results Compared to CSA-Only, the Tac + Pred cohort had significantly lower rates of chronic hepatitis (CH) at five (20% vs. 44%, p < 0.001) and ten (15% vs. 67%, p < 0.001) years post-transplant, with similar trends observed in inflammation and fibrosis at five years. The Tac + Pred cohort also had significantly lower hepatic transaminases and IgG levels and was less likely to be autoantibody positive at both time points. However, the degree of graft fibrosis at ten years did not differ significantly between eras (p = 0.356). Conclusion Increased immunosuppression effectively reduced chronic allograft hepatitis and fibrosis at five years, suggesting it is an immunologically driven variant of rejection. However, there was no significant reduction in the degree of fibrosis at ten years, indicating a multifactorial origin for long term graft fibrosis.
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Affiliation(s)
- Wolfram Haller
- Department of Gastroenterology & Nutrition, Birmingham Woman's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Research Development and Innovation, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Rachel Brown
- Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Carla Lloyd
- Liver Unit, Birmingham Woman's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Stefan Hubscher
- Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute for Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Patrick McKiernan
- Liver Unit, Birmingham Woman's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Deirdre Kelly
- Liver Unit, Birmingham Woman's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Institute for Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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10
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Wischlen E, Boillot O, Rivet C, Lachaux A, Bouvier R, Hervieu V, Scoazec JY, Collardeau-Frachon S, Dumortier J, Laverdure N. Are protocol graft biopsies after pediatric liver transplantation useful? Experience in a single center over 20 years. Clin Transplant 2023; 37:e14898. [PMID: 36585804 DOI: 10.1111/ctr.14898] [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: 08/12/2022] [Accepted: 12/16/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The role of protocol liver biopsies (PLB) in the follow-up of pediatric liver transplant recipients remains questionable. This single-center retrospective study aimed to evaluate their clinical impact on the long-term management of pediatric liver transplant recipients. METHODS We described histopathological lesions and clinical consequences for patient management of PLB performed 1, 5, 10, 15, 20, and 25 years after pediatric liver transplantation (LT). RESULTS A total of 351 PLB performed on 133 patients between 1992 and 2021 were reviewed. PLB found signs of rejection in 21.7% of cases (76/351), and moderate to severe fibrosis in 26.5% of cases (93/351). Overall, 264 PLB (75.2%) did not cause any changes to patient care. Immunosuppression was enhanced after 63 PLB, including 23 cases of occult rejection. The 1-year PLB triggered significantly more changes, while biopsies at 15, 20, and 25 years produced the lowest rates of subsequent modifications. PLB had a significantly higher probability of inducing therapeutic changes if the patient had abnormal biological or imaging results (odds ratio [OR] 2.82 and 2.06), or a recent history of rejection or bacterial infection (OR 2.22 and 2.03). CONCLUSION Our results suggest that, although it often does not prompt any treatment changes, PLB could be performed because of its ability to detect silent rejection requiring an increase in immunosuppression. PLB could be carried out 1, 5, and 10 years after LT and then every 10 years in patients with normal biological and imaging results and no recent complications, while other patients could be kept on a 5-year protocol.
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Affiliation(s)
- Emma Wischlen
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Olivier Boillot
- Department of Digestive Diseases, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Christine Rivet
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alain Lachaux
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Raymonde Bouvier
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Valérie Hervieu
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Jean-Yves Scoazec
- Institut Gustave Roussy, Department of Pathology, Villejuif and Université Paris Saclay, France
| | - Sophie Collardeau-Frachon
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Dumortier
- Department of Digestive Diseases, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Noémie Laverdure
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
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11
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Liver Transplantation from a Human Leukocyte Antigen-Matched Sibling Donor: Effectiveness of Direct-Acting Antiviral Therapy against Hepatitis C Virus Infection. REPORTS 2022. [DOI: 10.3390/reports5040049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Through living-donor liver transplantation (LDLT) from a human leukocyte antigen (HLA)-matched sibling donor, it may be possible to stop the use of immunosuppressants. It is possible that acute antibody-mediated rejection and chronic active antibody-mediated rejection through the positivity of donor-specific anti-HLA antibodies and/or T cell-mediated rejection may affect the prognosis of liver transplantation. The etiologies of liver diseases of the recipient may also affect the post-transplantation course. Herein, we report on the successful re-treatment with direct-acting antiviral (DAA) therapy against hepatitis C virus (HCV) infection in a patient who underwent a LDLT from HLA-matched sibling donor. After liver transplantation for HCV-related liver diseases, it is easy for HCV to re-infect the graft liver under a lack of immunosuppressants. DAA therapy against HCV re-infection immediately after transplantation should be commenced, and it is important to eradicate HCV for better prognosis of the recipients in LDLT for HCV-related liver diseases.
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12
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Hübscher SG, Feng S, Gouw ASH, Haga H, Kang HJ, Kelly DA, Komuta M, Lesniak A, Popp BA, Verkade HJ, Yu E, Demetris AJ. Standardizing the histological assessment of late posttransplantation biopsies from pediatric liver allograft recipients. Liver Transpl 2022; 28:1475-1489. [PMID: 35429359 DOI: 10.1002/lt.26482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023]
Abstract
Excellent short-term survival after pediatric liver transplantation (LT) has shifted attention toward the optimization of long-term outcomes. Despite considerable progress in imaging and other noninvasive modalities, liver biopsies continue to be required to monitor allograft health and to titrate immunosuppression. However, a standardized approach to the detailed assessment of long-term graft histology is currently lacking. The aim of this study was to formulate a list of histopathological features relevant for the assessment of long-surviving liver allograft health and to develop an approach for assessing the presence and severity of these features in a standardized manner. Whole-slide digital images from 31 biopsies obtained ≥4 years after transplantation to determine eligibility for an immunosuppression withdrawal trial were selected to illustrate a range of typical histopathological findings seen in children with clinically stable grafts, including those associated with alloantibodies. Fifty histological features were independently assessed and, where appropriate, scored semiquantitatively by six pathologists to determine inter- and intraobserver reproducibility of the histopathological features using unweighted and weighted kappa statistics; the latter metric enabled distinction between minor and major disagreements in parameter severity scoring. Weighted interobserver kappa statistics showed a high level of agreement for various parameters of inflammation, interface activity, fibrosis, and microvascular injury. Intraobserver agreement for these features was even more substantial. The results of this study will help to standardize the assessment of biopsies from long-surviving liver allografts, aid the recognition of important histological features, and facilitate international comparisons and clinical trials aiming to improve outcomes for children undergoing LT.
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Affiliation(s)
- Stefan G Hübscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandy Feng
- Division of Transplantation, Department of Surgery, University of California, San Francisco, California, USA
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Hironori Haga
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hyo Jeong Kang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's & Children's NHS Trust and University of Birmingham, Birmingham, UK
| | - Mina Komuta
- Department of Pathology, Keio University, Tokyo, Japan
| | - Andrew Lesniak
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin A Popp
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Henkjan J Verkade
- Pediatric Gastroenterology/Hepatology, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Eunsil Yu
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Anthony J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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13
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Vij M, Rammohan A, Rela M. Long-term liver allograft fibrosis: A review with emphasis on idiopathic post-transplant hepatitis and chronic antibody mediated rejection. World J Hepatol 2022; 14:1541-1549. [PMID: 36157865 PMCID: PMC9453462 DOI: 10.4254/wjh.v14.i8.1541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is a life-saving surgical procedure and the current standard of care for most patients with end stage liver disease. With improvements in organ preservation techniques, perioperative care, and immunosuppression, there is better patient and graft survival following LT, and assessment of the liver allograft in long-term survivors is becoming increasingly important. Recurrent or de novo viral or autoimmune injury remains the most common causes of chronic hepatitis and fibrosis following liver transplantation in adults. However, no obvious cause can be identified in many adults with controlled recurrent disease and the majority of pediatric LT recipients, as they have been transplanted for non-recurrent liver diseases. Serial surveillance liver biopsies post LT have been evaluated in several adult and pediatric centers to identify long-term pathological changes. Pathological findings are frequently present in liver biopsies obtained after a year post LT. The significance of these findings is uncertain as many of these are seen in protocol liver biopsies from patients with clinically good allograft function and normal liver chemistry parameters. This narrative review summaries the factors predisposing to long-term liver allograft fibrosis, highlighting the putative role of idiopathic post-LT hepatitis and chronic antibody mediated rejection in its pathogenesis.
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Affiliation(s)
- Mukul Vij
- Department of Pathology, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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14
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Perito ER, Persyn E, Bucuvalas J, Martinez M, Mohammad S, Squires JE, Demetris AJ, Feng S. Graft Fibrosis Over 10 to 15 Years in Pediatric Liver Transplant Recipients: Multicenter Study of Paired, Longitudinal Surveillance Biopsies. Liver Transpl 2022; 28:1051-1062. [PMID: 35029022 DOI: 10.1002/lt.26409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Abstract
Previous single-center, cross-sectional studies have reported a steep increase in the prevalence and severity of fibrosis through 10 to 15 years after pediatric liver transplantation. We report a multicenter study of paired surveillance biopsies in a contemporary cohort. Children who underwent liver transplant when younger than 6 years old and had paired surveillance liver biopsies were enrolled (n = 78, 35% girls, median 1.2 years old at transplant). A central pathologist graded inflammation, assessed rejection activity index, and staged fibrosis in the portal, sinusoidal, and perivenular compartments, allowing for calculation of the Liver Allograft Fibrosis Score (LAFSc). Analysis of variance tested associations between fibrosis progression and clinical parameters. The first biopsy, at a median 8.2 years (interquartile range, 5.9-11.6 years) after transplantation, showed absent to mild fibrosis (LAFSc 0-2) in 29%, moderate (LAFSc 3-5) in 56%, and severe (LAFSc 6-7) in 14% of patients. The second biopsy, at a median 4.7 years (IQR, 4.3-5.1 years) later, showed fibrosis progression (LAFSc increased by ≥3) in 10 (13%) and regression (LAFSc decreased by ≥3) in 4 (5%) patients. After adjusting for baseline LAFSc, younger age at transplant was the only risk factor for fibrosis progression. Although fibrosis prevalence and severity 6 to 12 years after transplant was similar to previous reports, fibrosis trajectory during the next 4 to 5 years was stable. Our data may be reassuring for children with consistently normal liver tests. A comprehensive understanding of factors determining allograft health during the very long term is essential to optimizing allograft and patient health.
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Affiliation(s)
- Emily R Perito
- Department of Pediatrics, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Elodie Persyn
- Institute of Liver Studies, King's College London, London, UK
| | - John Bucuvalas
- Department of Pediatrics, Mount Sinai Kravis Children's Hospital and Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, NY
| | - Mercedes Martinez
- Department of Surgery, Center for Liver Diseases and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Saeed Mohammad
- Department of Pediatrics, Siragusa Transplantation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - James E Squires
- Department of Pediatrics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA
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15
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Vo HD, Radio SJ, Granader EJ, Wojkiewicz LE, Turner P, Mauch TJ. Diagnostic performance of 2D-shear wave elastography and serum fibrosis markers for evaluation of hepatic graft fibrosis in pediatric liver-inclusive transplant recipients: A prospective pilot study. Pediatr Transplant 2022; 26:e14225. [PMID: 35005824 DOI: 10.1111/petr.14225] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/03/2021] [Accepted: 01/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver biopsy is the gold standard for hepatic fibrosis staging, but it is invasive and has potential severe complications. We aimed to determine the diagnostic performance of 2D-SWE and serum markers to predict significant hepatic graft fibrosis (≥F2) in pediatric liver-inclusive transplant recipients. METHODS This prospective, cross-sectional pilot study included children younger than 19 years who had received a LT or LSBT and underwent a liver biopsy performed for clinical indications. LS was measured using 2D-SWE. The AUROC was calculated to evaluate the diagnostic performance of 2D-SWE and biomarkers (AST/ALT ratio, APRI, FIB4) for predicting significant fibrosis. RESULTS Twenty-two children (13 males, 8 LSBT) were included. Eighteen (81.8%) children received a whole liver graft. Thirteen (59.1%) patients had hepatic fibrosis (≥F1) and four (18.2%) had significant fibrosis. The AUROCs of AST/ALT ratio, APRI, and FIB4 for predicting significant hepatic graft fibrosis were 0.71 (p = .29), 0.85 (p = .0001), and 0.76 (p = .03), respectively. When FIB4 was calculated using the hepatic graft's age, its AUROC improved to 0.85 (p < .0001). The AUROC of 2D-SWE for predicting significant hepatic graft fibrosis was 0.80 (p = .046). When 2D-SWE was combined with APRI or FIB4, its AUROC improved to 0.82 (p = .08) and 0.87 (p = .002), respectively. CONCLUSIONS APRI and FIB4 can accurately predict significant hepatic graft fibrosis. 2D-SWE may serve as a valuable adjunct tool to detect significant graft fibrosis, especially when combined with these serum markers.
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Affiliation(s)
- Hanh D Vo
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Stanley J Radio
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elon J Granader
- Department of Radiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura E Wojkiewicz
- Department of Radiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Patricia Turner
- Pediatric Liver and Intestinal Transplantation Program, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Teri J Mauch
- Pediatric Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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16
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Rocque B, Zaldana A, Weaver C, Huang J, Barbetta A, Shakhin V, Goldbeck C, Yanni G, Zielsdorf S, Kwon Y, Etesami K, Genyk Y, Zhou S, Kohli R, Emamaullee J. Clinical Value of Surveillance Biopsies in Pediatric Liver Transplantation. Liver Transpl 2022; 28:843-854. [PMID: 34954868 PMCID: PMC9078451 DOI: 10.1002/lt.26399] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
Abstract
Although pediatric liver transplantation (LT) results in excellent long-term outcomes, a high incidence of early acute cellular rejection and late graft fibrosis persists. Routine measurement of allograft enzymes may not reliably detect rejection episodes, identify candidates for immunosuppression minimization, or indicate allograft fibrosis. Surveillance biopsies (SBs) can provide valuable information in this regard, but their role in pediatric LT is not fully established. A retrospective cohort of 236 pediatric LT recipients from a high-volume center was studied to characterize the risks and benefits of SB versus for-cause biopsies (FCBs). The study population was 47.1% male and 54.7% Hispanic, and 31% received living donor grafts. Our data suggest that patients in the SB group had better transplant outcomes (rejection-free, graft, and patient survival) compared with patients who had FCBs or who never underwent biopsy. Among 817 biopsies obtained from 236 patients, 150 (18.4%) were SBs. Only 6 patients had a biopsy-related complication, and none were observed in the SB subset. Graft biochemical blood tests did not accurately predict rejection severity on biopsy, with aspartate aminotransferase area under the receiver operating characteristic curve (AUROC) 0.66, alanine aminotransferase AUROC 0.65 (very poor predictions), and gamma-glutamyltransferase AUROC 0.58 (no prediction). SBs identified subclinical rejection in 18.6% of biopsies, whereas 63.3% of SBs had evidence of fibrosis. SBs prompted changes in immunosuppression including dose reduction. Our experience suggests that SB in pediatric LT is safe, offers valuable information about subclinical rejection episodes, and can guide management of immunosuppression, including minimization. Improved outcomes with SB were likely multifactorial, potentially relating to a more favorable early posttransplant course and possible effect of management optimization through SB. Further multicenter studies are needed to examine the role of SBs on long-term outcomes in pediatric LT.
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Affiliation(s)
- Brittany Rocque
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Aaron Zaldana
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Carly Weaver
- Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Julia Huang
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Arianna Barbetta
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Victoria Shakhin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Cameron Goldbeck
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - George Yanni
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Shannon Zielsdorf
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Yong Kwon
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Kambiz Etesami
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Yuri Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Shengmei Zhou
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, CA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital Los Angeles, Los Angeles, CA
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17
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Squires JE, Demetris AJ. Surveillance Biopsies in Pediatric Liver Transplantation: Is the Juice Worth the Squeeze? Liver Transpl 2022; 28:754-755. [PMID: 35092345 DOI: 10.1002/lt.26420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 01/13/2023]
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
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18
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Gambella A, Mastracci L, Caporalini C, Francalanci P, Mescoli C, Ferro J, Alaggio R, Grillo F. Not only a small liver - The pathologist's perspective in the pediatric liver transplant setting. Pathologica 2022; 114:89-103. [PMID: 35212319 PMCID: PMC9040542 DOI: 10.32074/1591-951x-753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/30/2022] Open
Abstract
Pediatric liver transplantation represents a safe and long-lasting treatment option for various disease types, requiring the pathologist’s input. Indeed, an accurate and timely diagnosis is crucial in reporting and grading native liver diseases, evaluating donor liver eligibility and identifying signs of organ injury in the post-transplant follow-up. However, as the procedure is more frequently and widely performed, deceptive and unexplored histopathologic features have emerged with relevant consequences on patient management, particularly when dealing with long-term treatment and weaning of immunosuppression. In this complex and challenging scenario, this review aims to depict the most relevant histopathologic conditions which could be encountered in pediatric liver transplantation. We will tackle the conditions representing the main indications for transplantation in childhood as well as the complications burdening the post-transplant phases, either immunologically (i.e., rejection) or non-immunologically mediated. Lastly, we hope to provide concise, yet significant, suggestions related to innovative pathology techniques in pediatric liver transplantation.
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Affiliation(s)
| | - Luca Mastracci
- Department of Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy.,Pathology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Chiara Caporalini
- Pathology Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Paola Francalanci
- Unit of Pathology, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Claudia Mescoli
- Department of Pathology, Azienda Ospedale, Università Padova, Padova, Italy
| | - Jacopo Ferro
- Department of Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Rita Alaggio
- Unit of Pathology, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Federica Grillo
- Department of Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy.,Pathology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
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19
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Junge N, Di Giorgio A, Girard M, Demir Z, Kaminska D, Janowska M, Urbonas V, Varnas D, Maggiore G, Alterio T, Leiskau C, Vondran FWR, Richter N, D’Antiga L, Mikolajczyk R, Pfister ED, Baumann U. Cold Ischemia Time and Graft Fibrosis Are Associated with Autoantibodies after Pediatric Liver Transplantation: A Retrospective Cohort Study of the European Reference Network TransplantChild. CHILDREN 2022; 9:children9020275. [PMID: 35204995 PMCID: PMC8870233 DOI: 10.3390/children9020275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 11/25/2022]
Abstract
The reported prevalence of autoantibodies (AAB) (ANA, SMA, LKM, SLA) after pediatric liver transplantation (pLTX) varies considerably from 26–75%, but their clinical impact on outcome is uncertain. We aimed to study the prevalence of AAB after pLTX, their association with donor-, transplant-, and recipient-characteristics, and their relation to outcome. In our multicenter retrospective study, we aimed to clarify conflicting results from earlier studies. Six ERN TransplantChild centers reported data on 242 patients, of whom 61% were AAB positive. Prevalence varied across these centers. Independent of the interval between pLTX and AAB analysis, a one-hour increase in CIT resulted in an odds ratio (OR) of 1.37 (95% CI 1.11–1.69) for SMA positivity and an OR of 1.42 (95%CI 1.18–1.72) for ANA positivity. Steroid-free immunosuppression (IS) versus steroid-including IS (OR 5.28; 95% CI 1.45–19.28) was a risk factor for SMA positivity. Liver enzymes were not associated with ANA or SMA positivity. We did not observe an association of rejection activity index with ANA or SMA. However, the liver fibrosis score in follow-up biopsies was associated with ANA titer and donor age. In conclusion, this first multicenter study on AAB after pLTX showed high AAB prevalence and varied widely between centers. Longer CIT and prednisolone-free-IS were associated with AAB positivity, whereas AAB were not indicative of rejection, but instead were associated with graft fibrosis. The detection of AAB may be a marker of liver fibrosis and may be taken into consideration when indications for liver biopsy and immunosuppressive regimes, or reduction of immunosuppression in long-term follow-up, are being discussed. Prospective immunological profiling of pLTX patients, including AAB, is important to further improve our understanding of transplant immunology and silent graft fibrosis.
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Affiliation(s)
- Norman Junge
- Division for Pediatric Gastroenterology and Hepatology, Department of Peadiatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (C.L.); (E.-D.P.); (U.B.)
- Correspondence: ; Tel.: +49-511-532-3233; Fax: +49-511-532-3294
| | - Angelo Di Giorgio
- Department of Paediatric Hepatology, Gastroenterology and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, 24127 Bergamo, Italy; (A.D.G.); (L.D.)
| | - Muriel Girard
- Hépatologie Pédiatrique–Transplantation Hépatique, Hospital Necker Enfants-Malades, 75015 Paris, France; (M.G.); (Z.D.)
| | - Zeynep Demir
- Hépatologie Pédiatrique–Transplantation Hépatique, Hospital Necker Enfants-Malades, 75015 Paris, France; (M.G.); (Z.D.)
| | - Diana Kaminska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Maria Janowska
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Vaidotas Urbonas
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (V.U.); (D.V.)
| | - Dominykas Varnas
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (V.U.); (D.V.)
| | - Giuseppe Maggiore
- Gastrointestinal, Liver, Nutrition Disorders Unit, Liver Transplantation Center, IRCCS Pediatric Hospital Bambino Gesù, 00165 Rome, Italy; (G.M.); (T.A.)
| | - Tommaso Alterio
- Gastrointestinal, Liver, Nutrition Disorders Unit, Liver Transplantation Center, IRCCS Pediatric Hospital Bambino Gesù, 00165 Rome, Italy; (G.M.); (T.A.)
| | - Christoph Leiskau
- Division for Pediatric Gastroenterology and Hepatology, Department of Peadiatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (C.L.); (E.-D.P.); (U.B.)
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Georg August University, 37075 Göttingen, Germany
| | - Florian W. R. Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (F.W.R.V.); (N.R.)
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (F.W.R.V.); (N.R.)
| | - Lorenzo D’Antiga
- Department of Paediatric Hepatology, Gastroenterology and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, 24127 Bergamo, Italy; (A.D.G.); (L.D.)
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics, Interdisciplinary Center for Health Sciences, Medical Faculty of the Martin Luther University Halle-Wittenberg, 06112 Halle, Germany;
| | - Eva-Doreen Pfister
- Division for Pediatric Gastroenterology and Hepatology, Department of Peadiatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (C.L.); (E.-D.P.); (U.B.)
| | - Ulrich Baumann
- Division for Pediatric Gastroenterology and Hepatology, Department of Peadiatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (C.L.); (E.-D.P.); (U.B.)
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20
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Angelico R, Spada M, Liccardo D, Pedini D, Grimaldi C, Pietrobattista A, Basso MS, Della Corte C, Mosca A, Saffioti MC, Alaggio R, Maggiore G, Candusso M, Francalanci P. Allograft Fibrosis After Pediatric Liver Transplantation: Incidence, Risk Factors, and Evolution. Liver Transpl 2022; 28:280-293. [PMID: 34164907 DOI: 10.1002/lt.26218] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022]
Abstract
Allograft fibrosis (AF) after pediatric liver transplantation (pLT) is frequent, but its dynamics are unclear. Our aim was to assess the evolution and risk factors of AF after pLT. A retrospective single-center analysis of pLT patients with a follow-up of ≥5 years who underwent protocol liver biopsies at 6 months, 1 year, 2 years, 5 years, and 10 years was performed. Fibrosis was assessed using the METAVIR and Ishak systems and the liver allograft fibrosis score (LAFs). Of 219 pLTs performed from 2008 to 2018, 80 (36.5%) pLTs were included, and 320 biopsies were reviewed. At 6 months after pLT, fibrosis was found in 54 (67.5%) patients by the METAVIR/Ishak systems and in 59 (73.8%) by the LAFs (P = 0.65). By 5 years, AF was detected in 67 (83.8%), 69 (86.3%), and 72 (90%) specimens using the METAVIR, Ishak, and LAFs systems, respectively (P = 0.54); mild (METAVIR, 51 [63.8%]; Ishak, 60 [75%]; LAFs, 65 [81.2%]) and moderate (METAVIR, 16 [20%]; Ishak, 9 [11.9%]; LAFs, 7 [8.8%]) stages were detected, but severe fibrosis was not found (P = 0.09). In the LAFs, fibrosis involved the portal (85%), sinusoidal (15%), and centrolobular (12%) areas. Of 18 patients with 10-year protocol biopsies, AF was present in 16 (90%), including 1 (5.5%) with severe fibrosis. In all systems, 36.3% of patients showed fibrosis progression from 2 years to 5 years after LT, but they remained stable at the 10-year biopsies without clinical implications. In multivariate analysis, only donor age >40 years was a risk factor for moderate AF at 5 years after LT (odds ratio, 8.3; 95% confidence interval, 1.6-42.1, P = 0.01). Cold ischemia time (CIT) >8 hours was associated with portal (P < 0.001)/sinusoidal fibrosis (P = 0.04), donor age >40 years was associated with sinusoidal (P = 0.01)/centrilobular (P = 0.04) fibrosis, and low tacrolimus trough level within 1 year after LT was associated with centrilobular fibrosis (P = 0.02). AF has a high incidence after pLT, occurring early after transplantation. In most cases, AF is mild or moderate and remains stable in the long run without clinical implications. Donor selection, short CIT, and immunosuppression adherence are crucial to reducing the risk of advanced AF.
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Affiliation(s)
- Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy.,Department of Surgical Sciences, Hepatopancreatobiliary and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Daniela Liccardo
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Domiziana Pedini
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Pietrobattista
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Maria Sole Basso
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Claudia Della Corte
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Antonella Mosca
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Maria Cristina Saffioti
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Rita Alaggio
- Department of Pathology, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Giuseppe Maggiore
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Manila Candusso
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital Istituto di Ricerca e di Cura a Carattere Scientifico, Rome, Italy
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21
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Vannas M, Arola J, Nordin A, Isoniemi H. Value of posttransplant protocol biopsies in 2 biliary autoimmune liver diseases: A step toward personalized immunosuppressive treatment. Medicine (Baltimore) 2022; 101:e28509. [PMID: 35029206 PMCID: PMC8758011 DOI: 10.1097/md.0000000000028509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 12/17/2021] [Indexed: 01/05/2023] Open
Abstract
The value of protocol liver graft biopsies with good liver function was evaluated in patients with primary sclerosing cholangitis (PSC) or primary biliary cholangitis (PBC).A total of 250 protocol liver biopsy reports from 182 PSC and PBC patients were compared. Overall histopathological findings and those leading to changes in immunosuppression therapy were retrospectively analyzed.The mean time to first protocol biopsy after transplantation was 5.5 (±4.5) years for PSC patients and 9.3 (±6.6) years for PBC patients. More than 1 abnormal histopathological parameter was found in 43% and 62% of PSC and PBC patients, respectively. However, the histology was interpreted as normal by the pathologist in 78% of PSC and 60% of PBC patients. Immunosuppression therapy was reduced in 10% and increased in 6% patients due to protocol biopsy findings. Biopsies leading to increased immunosuppression therapy had more portal (P = .004), endothelial (P = .008), interphase (P = .021), and lobular (P = .000) inflammation.Mild histopathological findings were frequently found in the protocol biopsies despite the normal biochemistry. PBC patients had more histological abnormalities than those transplanted due to PSC; however, PBC patients had longer follow-up times. Immunosuppression therapy could be safely increased or decreased according to protocol biopsy findings after multidisciplinary meeting discussions.
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Affiliation(s)
- Marko Vannas
- Transplantation and Liver Surgery, Abdominal Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Arola
- Department of Pathology, HUH Diagnostic Centre, Helsinki University Hospital and University of Helsinki, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery, Abdominal Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Helena Isoniemi
- Transplantation and Liver Surgery, Abdominal Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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22
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Gu LH, Lv ZC, Wu HX, Hou YC, Gao RL, Xi ZF, Fang H, Feng H, Jiang LX, Xia Q. Two-Dimensional Shear Wave Elastography Evaluation of Post-transplantation Complications in Pediatric Receipt: A Retrospective Cohort. Front Pediatr 2022; 10:918145. [PMID: 35967551 PMCID: PMC9363609 DOI: 10.3389/fped.2022.918145] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The 20-year survival rate in pediatric patients after liver transplantation (LT) was no more than 70%. Hepatic fibrosis is one of the principal factors affecting the long-term prognosis. Imaging evaluation was the first-line examination for pediatric liver graft assessment. However, the sensitivity and specificity were insufficient. Thus, two-dimensional shear wave elastography (2D-SWE) was performed to evaluate liver graft stiffness and complication in post-transplant pediatric receipt. MATERIALS AND METHODS In this retrospective cohort, 343 pediatric recipients who underwent liver graft biopsy in our tertiary LT center were recruited between June 2018 and December 2020. The 2D-SWE evaluation, laboratory examination, routine post-transplant biopsy, and hepatic pathological assessment were performed. RESULTS Ninety-eight of the 343 pediatric patients were included according to the protocol. The Liver Stiffness Measurements (LSM) value of 2D-SWE was significantly elevated in post-transplant fibrosis (p < 0.0001). The LSM value of patients with post-transplant biliary complications (p < 0.0001) and biopsy-proven rejection (BPR, p = 0.0016) also rose compared to regular recovery patients. Concerning the sensitivity and specificity of 2D-SWE in diagnosing liver graft fibrosis, the area under the ROC curve (AUC) was 88%, and the optimal cutoff value was 10.3 kPa. CONCLUSION Pediatric LSM by 2D-SWE was efficient. Routine 2D-SWE evaluation could be optimal to predict significant liver graft fibrosis.
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Affiliation(s)
- Li-Hong Gu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zi-Cheng Lv
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hao-Xiang Wu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-Chen Hou
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Run-Lin Gao
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Feng Xi
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Fang
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Feng
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai, China.,Shanghai Institute of Transplantation, Shanghai, China
| | - Li-Xin Jiang
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Centre of Transplantation and Immunology, Shanghai, China.,Shanghai Institute of Transplantation, Shanghai, China
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23
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Vionnet J, Miquel R, Abraldes JG, Wall J, Kodela E, Lozano JJ, Ruiz P, Navasa M, Marshall A, Nevens F, Gelson W, Leithead J, Masson S, Jaeckel E, Taubert R, Tachtatzis P, Eurich D, Simpson KJ, Bonaccorsi-Riani E, Feng S, Bucuvalas J, Ferguson J, Quaglia A, Sidorova J, Elstad M, Douiri A, Sánchez-Fueyo A. Non-invasive alloimmune risk stratification of long-term liver transplant recipients. J Hepatol 2021; 75:1409-1419. [PMID: 34437910 DOI: 10.1016/j.jhep.2021.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Management of long-term immunosuppression following liver transplantation (LT) remains empirical. Surveillance liver biopsies in combination with transcriptional profiling could overcome this challenge by identifying recipients with active alloimmune-mediated liver damage despite normal liver tests, but this approach lacks applicability. Our aim was to investigate the utility of non-invasive tools for the stratification of stable long-term survivors of LT, according to their immunological risk and need for immunosuppression. METHODS We conducted a cross-sectional multicentre study of 190 adult LT recipients assessed to determine their eligibility to participate in an immunosuppression withdrawal trial. Patients had stable liver allograft function and had been transplanted for non-autoimmune non-replicative viral liver disease >3 years before inclusion. We performed histological, immunogenetic and serological studies and measured the intrahepatic transcript levels of an 11-gene classifier highly specific for T cell-mediated rejection (TCMR). RESULTS In this cohort, 35.8% of patients harboured clinically silent fibro-inflammatory liver lesions (13.7% had mild damage and 22.1% had moderate-to-severe damage). The severity of liver allograft damage was positively associated with TCMR-related transcripts, class II donor-specific antibodies (DSAs), ALT, AST, and liver stiffness measurement (LSM), and negatively correlated with serum creatinine and tacrolimus trough levels. Liver biopsies were stratified according to their TCMR transcript levels using a cut-off derived from biopsies with clinically significant TCMR. Two multivariable prediction models, integrating ALT+LSM or ALT+class II DSAs, had a high discriminative capacity for classifying patients with or without alloimmune damage. The latter model performed well in an independent cohort of 156 liver biopsies obtained from paediatric liver recipients with similar inclusion/exclusion criteria. CONCLUSION ALT, class II DSAs and LSM are valuable tools to non-invasively identify stable LT recipients without significant underlying alloimmunity who could benefit from minimisation of immunosuppression. LAY SUMMARY A large proportion of liver transplant patients with normal liver tests have inflammatory liver lesions, which in 17% of cases are molecularly indistinguishable from those seen at the time of rejection. ALT, class II donor-specific antibodies and liver stiffness are useful in identifying patients with this form of subclinical rejection. We propose these markers as a useful tool to help clinicians determine if the immunosuppression administered is adequate.
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Affiliation(s)
- Julien Vionnet
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom; Transplantation Center and Service of Gastroenterology and Hepatology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Rosa Miquel
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom; Liver Histopathology Laboratory, King's College Hospital, London, United Kingdom
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Jurate Wall
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom
| | - Elisavet Kodela
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom
| | - Juan-Jose Lozano
- Bioinformatic Platform, Biomedical Research Center in Hepatic and Digestive Diseases (CIBEREHD), Instituto de Salud Carlos III, Spain
| | | | | | | | | | - Will Gelson
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | - Steven Masson
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | | | | | | | | | | | | | - Sandy Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John Bucuvalas
- Mount Sinai Kravis Children's Hospital and Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, NY, USA
| | | | | | - Julia Sidorova
- Instituto de Tecnología del Conocimiento (ITC), Campus Somosaguas, Universidad Complutense, Madrid, Spain
| | - Maria Elstad
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Alberto Sánchez-Fueyo
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom.
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24
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Hirao H, Ito T, Kadono K, Kojima H, Naini BV, Nakamura K, Kageyama S, Busuttil RW, Kupiec‐Weglinski JW, Kaldas FM. Donor Hepatic Occult Collagen Deposition Predisposes to Peritransplant Stress and Impacts Human Liver Transplantation. Hepatology 2021; 74:2759-2773. [PMID: 34170562 PMCID: PMC9291051 DOI: 10.1002/hep.32030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/03/2021] [Accepted: 06/17/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Environmentally triggered chronic liver inflammation can cause collagen deposits, whereas early stages of fibrosis without any specific symptoms could hardly be detectable. We hypothesized that some of the human donor grafts in clinical liver transplantation (LT) might possess unrecognizable fibrosis, affecting their susceptibility to LT-induced stress and hepatocellular damage. This retrospective study aimed to assess the impact of occult hepatic fibrosis on clinical LT outcomes. APPROACH AND RESULTS Human (194) donor liver biopsies were stained for collagen with Sirius red, and positive areas (Sirius red-positive area; SRA) were measured. The body mass index, aspartate aminotransferase/alanine aminotransferase ratio, diabetes score was calculated using 962 cases of the donor data at the procurement. LT outcomes, including ischemia-reperfusion injury (IRI), early allograft dysfunction (EAD), and survival rates, were analyzed according to SRA and BARD scores. With the median SRA in 194 grafts of 9.4%, grafts were classified into low-SRA (<15%; n = 140) and high-SRA (≥15%; n = 54) groups. Grafts with high SRA suffered from higher rates of IRI and EAD (P < 0.05) as compared to those with low SRA. Interestingly, high SRA was identified as an independent risk factor for EAD and positively correlated with the donor BARD score. When comparing low-BARD (n = 692) with high-BARD (n = 270) grafts in the same period, those with high BARD showed significantly higher post-LT transaminase levels and higher rates of IRI and EAD. CONCLUSIONS These findings from the largest clinical study cohort to date document the essential role of occult collagen deposition in donor livers on LT outcomes. High-SRA and donor BARD scores correlated with an increased incidence of hepatic IRI and EAD in LT recipients. This study provides the rationale for in-depth and prospective assessment of occult fibrosis for refined personalized LT management.
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Affiliation(s)
- Hirofumi Hirao
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Takahiro Ito
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Kentaro Kadono
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Hidenobu Kojima
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Bita V. Naini
- Department of PathologyDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Kojiro Nakamura
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA,Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationDepartment of SurgeryKyoto UniversityKyotoJapan
| | - Shoichi Kageyama
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA,Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationDepartment of SurgeryKyoto UniversityKyotoJapan
| | - Ronald W. Busuttil
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Jerzy W. Kupiec‐Weglinski
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
| | - Fady M. Kaldas
- The Dumont‐UCLA Transplantation CenterDivision of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCA
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25
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Barbetta A, Butler C, Barhouma S, Hogen R, Rocque B, Goldbeck C, Schilperoort H, Meeberg G, Shapiro J, Kwon YK, Kohli R, Emamaullee J. Living Donor Versus Deceased Donor Pediatric Liver Transplantation: A Systematic Review and Meta-analysis. Transplant Direct 2021; 7:e767. [PMID: 34557584 PMCID: PMC8454909 DOI: 10.1097/txd.0000000000001219] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/19/2022] Open
Abstract
Reduced-size deceased donors and living donor liver transplantation (LDLT) can address the organ shortage for pediatric liver transplant candidates, but concerns regarding technical challenges and the risk of complications using these grafts have been raised. The aim of this study was to compare outcomes for pediatric LDLT and deceased donor liver transplantation (DDLT) via systematic review. METHODS A systematic literature search was performed to identify studies reporting outcomes of pediatric (<18 y) LDLT and DDLT published between 2005 and 2019. A meta-analysis was conducted to examine peri- and postoperative outcomes using fixed- and random-effects models. RESULTS Overall, 2518 abstracts were screened, and 10 studies met criteria for inclusion. In total, 1622 LDLT and 6326 DDLT pediatric patients from 4 continents were examined. LDLT resulted in superior patient survival when compared with DDLT at 1, 3, and 5 y post-LT (1-y hazard ratio: 0.58, 95% confidence interval [CI] 0.47-0.73, P < 0.0001). Similarly, LDLT resulted in superior graft survival at all time points post-LT when compared with DDLT (1-y hazard ratio: 0.56 [95% CI 0.46-0.68], P < 0.0001]. The OR for vascular complications was 0.73 (95% CI 0.39-1.39) and 1.31 (95% CI 0.92-1.86) for biliary complications in LDLT compared with DDLT, whereas LDLT was associated with lower rates of rejection (OR: 0.66 [95% CI 0.45-0.96], P = 0.03). CONCLUSIONS This meta-analysis demonstrates that LDLT may offer many advantages when compared with DDLT in children and suggests that LDLT should continue to be expanded to optimize outcomes for pediatric LT candidates.
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Affiliation(s)
- Arianna Barbetta
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Chanté Butler
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sarah Barhouma
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rachel Hogen
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Brittany Rocque
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Hannah Schilperoort
- Wilson Dental Library, USC Libraries, University of Southern California, Los Angeles, CA
| | - Glenda Meeberg
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Yong K. Kwon
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rohit Kohli
- Department of Pediatrics, University of Southern California, Los Angeles, CA
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, CA
- Division of Abdominal Transplantation, Children’s Hospital Los Angeles, Los Angeles, CA
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26
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Ewing CB, Soltys KA, Strauss KA, Sindhi R, Vockley J, McKiernan P, Squires RH, Bond G, Ganoza A, Khanna A, Mazariegos GV, Squires JE. Metabolic Control and "Ideal" Outcomes in Liver Transplantation for Maple Syrup Urine Disease. J Pediatr 2021; 237:59-64.e1. [PMID: 34153280 PMCID: PMC9795541 DOI: 10.1016/j.jpeds.2021.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/12/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess outcomes following liver transplantation for maple syrup urine disease by determining attainment and sustainability of metabolic control and apply an "ideal" outcome composite in long-term survivors. STUDY DESIGN A single center, retrospective review collected clinical data including branched-chain amino acid (leucine, isoleucine, and valine) levels following liver transplant and determined achievement of an ideal long-term outcome profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common transplant-related sequelae. RESULTS Of 77 patients meeting inclusion criteria identified, 23 were long-term (≥10-year) survivors and were additionally assessed for ideal outcome attainment. Patient and graft survival were 100% and 99%, respectively, and all patients were on an unrestricted protein intake diet. Although significant variation was noted in mean isoleucine (P < .01) and leucine (P < .05) levels postliver transplantation, no difference was seen in valine (P = .29) and overall clinical impact was likely negligible as metabolic stability was achieved and sustained beyond 3 years postliver transplantation and no metabolic crises were identified. Of 23 long-term survivors with available data, 9 (39%) achieved all composite metrics determined to define "ideal" outcomes in pediatric postliver transplantation populations. CONCLUSIONS Liver transplant enables long-term metabolic stability for patients with maple syrup urine disease. A combination of experience and improvement in both pre- and postliver transplantation care has enabled excellent survival and minimal comorbidities following transplant.
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Affiliation(s)
| | - Kyle A. Soltys
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | | | - Rakesh Sindhi
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Jerry Vockley
- Center for Rare Disease Therapy, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Geoffrey Bond
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Armando Ganoza
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Ajai Khanna
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - George V. Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
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27
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Iacob S, Cicinnati V, Kabar I, Hüsing-Kabar A, Radtke A, Iacob R, Baba H, Schmidt HH, Paul A, Beckebaum S. Prediction of late allograft dysfunction following liver transplantation by immunological blood biomarkers. Transpl Immunol 2021; 69:101448. [PMID: 34391882 DOI: 10.1016/j.trim.2021.101448] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND An accelerated course of hepatic fibrosis may occur in liver transplantation (LT) patients despite normal or slightly abnormal liver blood tests. AIM To identify screening tools based on blood biomarkers to predict late allograft dysfunction in LT recipients. METHODS 174 LT recipients were enrolled. Liver biopsy, liver functional tests, cytokine quantitation in serum, as well as soluble MHC class I polypeptide-related sequence A and B (sMICA/sMICB) and soluble UL16 binding protein 2 (sULBP2) were performed. RESULTS Patients with late graft dysfunction had a significantly higher donor age, lower albumin level, higher alanine (ALT) and aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), total bilirubin and alkaline phosphatase (ALP), higher sMICA, sULBP2, higher interleukin (IL) 6, interferon γ and lower IL10 in serum as compared to recipients without allograft dysfunction. In order to provide a better statistical accuracy for discriminating 5-year allograft dysfunction from other less progressive subtype of allograft injury, we established a predictive model, based on 7 parameters (serum ALP, ALT, AST, GGT, sMICA, IL6 and albumin) which provided an Area Under the Receiver Operating Characteristics (AUROC) curve of 0.905. CONCLUSIONS Blood-based biomarkers can significantly improve prediction of late liver allograft outcome in LT patients. The new developed score comprising serum parameters, with an excellent AUROC, can be reliably used for diagnosing late allograft dysfunction in transplanted patients.
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Affiliation(s)
- Speranta Iacob
- Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Vito Cicinnati
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Iyad Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Anna Hüsing-Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Arnold Radtke
- Department of General, Visceral and Transplant Surgery, Comprehensive Cancer Center, University of Tübingen, 72076 Tübingen, Germany
| | - Razvan Iacob
- Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Hideo Baba
- Institute for Pathology, University Hospital Essen, 45147 Essen, Germany
| | - Hartmut H Schmidt
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, 45147 Essen, Germany
| | - Susanne Beckebaum
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
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Liver Histopathology in Late Protocol Biopsies after Pediatric Liver Transplantation. CHILDREN-BASEL 2021; 8:children8080671. [PMID: 34438562 PMCID: PMC8392008 DOI: 10.3390/children8080671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 12/04/2022]
Abstract
Liver transplantation has become a routine treatment for children with end stage liver failure. Recently, the long term survival of pediatric patients after liver transplantation has improved, with a life expectancy much longer than that of adult recipients, but also with longer exposition of the graft to various injuries, including immunological, inflammatory and others. Biochemical tests, although important, do not always reflect graft injury. The aim of our study was to analyze the histopathology of the graft in late protocol biopsies and correlate it with the clinical and biochemical status of these patients. We analyzed 61 protocol liver biopsies taken from 61 patients. Biopsies were taken 9.03–17.09 years (mean 12.68, median 11.74 years) after transplantation. Liver specimens were examined particularly for the presence and stage of liver fibrosis, inflammation, steatosis, and acute or chronic cellular and humoral rejection. We did not find any abnormalities in 26 (42.6%) liver specimens. None of the patients had signs of cellular or antibody mediated rejection or chronic rejection. In 23 liver biopsies (37.7%), we found non-specific lymphoid infiltrates. Another problem was fibrosis (equal to or more than three on the Ishak scale)—we found it in 17 patients, including seven liver specimens (11.5%) with severe fibrosis (Ishak 5–6). Conclusions: Various pathomorphological abnormalities were found in more than half of patients with a median 11.74 years post-transplant follow-up. Most of them presented normal laboratory liver tests at the same time, suggesting a slow subclinical process leading to pathomorphological abnormalities. No single factor for the development of these abnormalities was found, but our study supports the need for protocol liver biopsies even in patients with normal/almost normal biochemical liver tests.
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Vo HD, Radio SJ, Reyes-Santiago EM, Mauch TJ. Post-transplant hepatic fibrosis in pediatric liver-small bowel transplant recipients: A single-center, retrospective, observational study. Pediatr Transplant 2021; 25:e13965. [PMID: 33378567 DOI: 10.1111/petr.13965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/02/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about the prevalence of hepatic graft fibrosis in combined LSBT children. We aimed to determine the prevalence of and identify potential predictors for hepatic graft fibrosis in LSBT children and to compare them with those in LT children. METHODS We retrospectively included children younger than 19 years who had received a primary LT/LSBT between 2000 and 2018 and had a liver biopsy performed at least 6 months post-transplant. A Cox proportional hazards regression model was used to determine predictors associated with significant hepatic graft fibrosis (≥F2) in LSBT vs LT children. RESULTS Ninety-six children (47 LSBT, 54 females) were included. The median post-transplant follow-up (years) was 12.8 in LT vs 10.5 in LSBT patients (P = .06). Hepatic graft fibrosis was found in 81.6% of LT vs 70.2% of LSBT children (P = .19), after a median time of 2.5 years and 2.6 years, respectively. On multivariate analyses, having post-transplant biliary complications was found to be associated with significant graft fibrosis in LT children, whereas AST/ALT ratio was found to predict significant hepatic graft fibrosis in LSBT children. The use of parenteral nutrition after transplant was not associated with significant hepatic graft fibrosis. CONCLUSIONS The prevalence of hepatic graft fibrosis in LSBT children did not significantly differ from that in LT children, but the predictors may differ. Future studies should investigate the role of post-transplant autoimmune antibodies and donor-specific antibodies in the development and progression of hepatic graft fibrosis in LSBT children.
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Affiliation(s)
- Hanh D Vo
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stanley J Radio
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Emille M Reyes-Santiago
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Teri J Mauch
- Pediatric Nephrology, University of Nebraska Medical Center, Omaha, NE, USA
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Voutilainen SH, Kosola SK, Lohi J, Jahnukainen T, Pakarinen MP, Jalanko H. Expression of fibrosis-related genes in liver allografts: Association with histology and long-term outcome after pediatric liver transplantation. Clin Transplant 2021; 35:e14373. [PMID: 34043847 DOI: 10.1111/ctr.14373] [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: 11/21/2020] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unexplained graft fibrosis and inflammation are common after pediatric liver transplantation (LT). OBJECTIVE We investigated the graft expression of fibrogenic genes and correlated the findings with transplant histopathology and outcome. METHODS Liver biopsies from 29 recipients were obtained at a median of 13.1 (IQR: 5.0-18.4) years after pediatric LT. Control samples were from six liver-healthy subjects. Hepatic expression of 40 fibrosis-related genes was correlated to histological findings: normal histology, fibrosis with no inflammation, and fibrosis with inflammation. Liver function was evaluated after a subsequent follow-up of 9.0 years (IQR: 8.0-9.4). RESULTS Patients with fibrosis and no inflammation had significantly increased gene expression of profibrotic TGF-β3 (1.17 vs. 1.02 p = .005), CTGF (1.64 vs. 0.66 p = .014), PDGF-α (1.79 vs. 0.98 p = .049), PDGF -β (0.99 vs. 0.76 p = .006), integrin-subunit-β1 (1.19 vs. 1.02 p = .045), α-SMA (1.12 vs. 0.58 p = .013), type I collagen (0.82 vs. 0.53 p = .005) and antifibrotic decorin (1.15 vs. 0.99 p = .045) compared to patients with normal histology. mRNA expression of VEGF A (0.84 vs. 1.06 p = .049) was lower. Only a few of the studied genes were upregulated in patients with both fibrosis and inflammation. The gene expression levels showed no association with later graft outcome. CONCLUSIONS Altered hepatic expression of fibrosis-related genes is associated with graft fibrosis without concurrent inflammation.
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Affiliation(s)
- Silja H Voutilainen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University, Hospital and University of Helsinki, Helsinki, Finland
| | - Silja K Kosola
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University, Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Qiu C, Sha T, Yin T, Zhang W, Chen X, Miao X, Zheng R, Shuai X, Ren J. VEGFR2-targeted ultrasound molecular imaging of angiogenesis to evaluate liver allograft fibrosis. Biomater Sci 2021; 9:5802-5811. [PMID: 34008615 DOI: 10.1039/d1bm00100k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Liver allograft fibrosis (LAF) is a common challenge threatening patient survival after liver transplantation, making a potent imaging technique vital for clinical management. To date, ultrasound (US) elastography has been regarded as one of the most promising techniques for LAF monitoring. However, it is susceptible to inflammation and also insensitive to early-stage pathological changes, which affects its diagnostic accuracy of LAF. Herein, based on a thorough comparison with US elastography at multiple disease stages, VEGF receptor-2 (VEGFR2) targeted US molecular imaging (USMI) was validated to be highly potent for LAF early diagnosis and staging. The VEGFR2-targeted microbubbles (MBs) were fabricated as a specific probe for angiogenesis. Then, VEGFR2-targeted USMI and US elastography were compared in terms of evaluating the LAF progress in a rodent model. The quantitative USMI result displayed a much higher linear correlation with histological standards including the Metavir fibrosis score (R2 = 0.77 vs. 0.35) and VEGFR2 semi-quantitative counting (R2 = 0.78 vs. 0.49) than US elastography, which demonstrated a greatly improved diagnostic accuracy. The study not only revealed the mechanism of employing angiogenesis to describe LAF but also overcame the intrinsic limitations of US elastography, thus highlighting the potential of VEGFR2-targeted USMI as an effective monitoring tool for LAF surveilling.
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Affiliation(s)
- Chen Qiu
- Department of Medical Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) imaging, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Autoantibodies and Donor-specific Antibodies are Associated With Graft Dysfunction in Pediatric Liver Transplantation. J Pediatr Gastroenterol Nutr 2021; 72:661-666. [PMID: 32810036 DOI: 10.1097/mpg.0000000000002913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Autoantibodies (AAb) and donor-specific HLA antibodies (DSA) are frequently present in pediatric liver transplant (LT) recipients. Their clinical significance remains incompletely understood. We aimed to investigate the prevalence of serum AAb and DSA in pediatric LT recipients and its correlation with patient characteristics and histological and biochemical parameters. METHODS We retrospectively reviewed the data from 62 pediatric LT patients in follow-up at Ghent University Hospital between January 2007 and February 2018. Blood samples with AAb measurement were taken systematically, liver biopsies (LB) were performed on clinical indication. RESULTS AAb were detected in 27 (43.3%) patients, with antinuclear antibodies (ANA) being the most frequently (24%) encountered AAb. There was an association between AAb positivity and female gender (P = 0,032) and deceased donor LT (P = 0,006). Patients with positive AAb underwent a higher number of LB during their follow-up (P < 0,001), and an association was found with the presence of nonspecific histologic alterations (P = 0,032) in the absence of de novo autoimmune hepatitis. Positive AAb were also associated with higher alkaline phosphatase (P < 0,001), ALT (P < 0,001), AST (P < 0,001), γ-GT (P = 0,001), IgG (P = 0,011) and lower albumin (P = 0,029). Fourteen out of 50 (28%) patients were DSA-positive, mostly anti-HLA class II. DSA positivity was associated with T-cell-mediated rejection (P = 0,019), higher total (P = 0,033), and direct (P = 0,012) bilirubin and γ-GT (P < 0,001). CONCLUSIONS The presence of AAb and DSA is associated with histological and biochemical parameters of graft dysfunction. Larger prospective studies are warranted to investigate the causal relationships between AAb and DSA development and outcome parameters post pediatric LT.
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Abstract
PURPOSE OF REVIEW Achieving operational tolerance remains a priority in liver transplantation. Although several biomarkers of tolerance and rejection have been identified, few have been reproducible and validated across centers, and therefore have yet to reach clinical practice. Here we summarize findings from prior seminal studies and review current developments in profiling the liver allograft. RECENT FINDINGS Substantial efforts and progress have been made in the recent years towards the discovery of reliable biomarkers that can predict and guide successful immunosuppression withdrawal. Recent studies have also investigated the transcriptomic signatures underlying not only acute rejection but also subclinical inflammation and chronic allograft injury. SUMMARY As new genomic and sequencing technologies continue to develop, clinical trials are underway to validate biomarkers of tolerance, as well as better understand the mechanisms of both acute and subclinical rejection, with the goal of maximizing allograft survival. Altogether, this will hopefully enable the implementation of immunosuppression withdrawal protocols into clinical practice and make operational tolerance reliably attainable in the near future.
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Affiliation(s)
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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34
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Evaluation of Graft Fibrosis, Inflammation and Donor-specific Antibodies at Protocol Liver Biopsies in Pediatric Liver Transplant Patients: a Single Center Experience. Transplantation 2021; 106:85-95. [PMID: 33496554 DOI: 10.1097/tp.0000000000003649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The impact of graft fibrosis and inflammation on the natural history of pediatric liver transplants (LT) is still debated. Our objectives were to evaluate the evolution of posttransplant fibrosis and inflammation over time at protocol liver biopsies (PLBs), risk factors for fibrosis, presence of donor-specific antibodies (DSAs) and/or their correlation with graft and recipient factors. METHODS A single-center, retrospective (2000-2019) cross-sectional study on pediatric LT recipients who had at least one PLB, followed by a longitudinal evaluation in those who had at least two PLBs, was conducted. Fibrosis was assessed by the Liver Allograft Fibrosis Semiquantitative score, inflammation by the Rejection Activity Index, DSAs by Luminex®. RESULTS A total of 134 PLBs from 94 patients were included. Fibrosis was detected in 87% (30% mild, 45% moderate, 12% severe), 80% in the portal tracts. There was an increase in fibrosis between the 1-3 and the 4-6 year group (p=0.01), then it was stable. Inflammation was observed in 44% (30% mild, 13% moderate, 1% severe), 90% in the portal tracts. Anti-HLA II (IgG) DSAs were detected in 14/40 (35%). Portal fibrosis was associated with portal inflammation in the 1-3 year group (p=0.04). Low immunosuppression levels were correlated with sinusoidal fibrosis (p=0.04) and DSA positivity (p-value=0.006). There was no statistically significant correlation between DSA positivity and the presence of graft fibrosis or inflammation. CONCLUSIONS This study corroborates the concept of an early evolution of silent graft fibrosis. Suboptimal immunosuppression may play a role in the development of fibrosis and DSAs.
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Gu C, Shi X, Dang X, Chen J, Chen C, Chen Y, Pan X, Huang T. Identification of Common Genes and Pathways in Eight Fibrosis Diseases. Front Genet 2021; 11:627396. [PMID: 33519923 PMCID: PMC7844395 DOI: 10.3389/fgene.2020.627396] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/15/2020] [Indexed: 01/05/2023] Open
Abstract
Acute and chronic inflammation often leads to fibrosis, which is also the common and final pathological outcome of chronic inflammatory diseases. To explore the common genes and pathogenic pathways among different fibrotic diseases, we collected all the reported genes of the eight fibrotic diseases: eye fibrosis, heart fibrosis, hepatic fibrosis, intestinal fibrosis, lung fibrosis, pancreas fibrosis, renal fibrosis, and skin fibrosis. We calculated the Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) enrichment scores of all fibrotic disease genes. Each gene was encoded using KEGG and GO enrichment scores, which reflected how much a gene can affect this function. For each fibrotic disease, by comparing the KEGG and GO enrichment scores between reported disease genes and other genes using the Monte Carlo feature selection (MCFS) method, the key KEGG and GO features were identified. We compared the gene overlaps among eight fibrotic diseases and connective tissue growth factor (CTGF) was finally identified as the common key molecule. The key KEGG and GO features of the eight fibrotic diseases were all screened by MCFS method. Moreover, we interestingly found overlaps of pathways between renal fibrosis and skin fibrosis, such as GO:1901890-positive regulation of cell junction assembly, as well as common regulatory genes, such as CTGF, which is the key molecule regulating fibrogenesis. We hope to offer a new insight into the cellular and molecular mechanisms underlying fibrosis and therefore help leading to the development of new drugs, which specifically delay or even improve the symptoms of fibrosis.
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Affiliation(s)
- Chang Gu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Shi
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuening Dang
- Department of Colorectal and Anal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Colorectal Cancer Research Center, Shanghai, China
| | - Jiafei Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yumei Chen
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xufeng Pan
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tao Huang
- Bio-Med Big Data Center, CAS Key Laboratory of Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute of Nutrition and Health, Chinese Academy of Sciences, Shanghai, China
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Issa F, Strober S, Leventhal JR, Kawai T, Kaufman DB, Levitsky J, Sykes M, Mas V, Wood KJ, Bridges N, Welniak LA, Chandran S, Madsen JC, Nickerson P, Demetris AJ, Lakkis FG, Thomson AW. The Fourth International Workshop on Clinical Transplant Tolerance. Am J Transplant 2021; 21:21-31. [PMID: 32529725 DOI: 10.1111/ajt.16139] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/20/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
The International Workshop on Clinical Transplant Tolerance is a biennial meeting that aims to provide an update on the progress of studies of immunosuppression minimization or withdrawal in solid organ transplantation. The Fourth International Workshop on Clinical Tolerance was held in Pittsburgh, Pennsylvania, September 5-6, 2019. This report is a summary of presentations on the status of clinical trials designed to minimize or withdraw immunosuppressive drugs in kidney, liver, and lung transplantation without subsequent evidence of rejection. All protocols had in common the use of donor or recipient cell therapy combined with organ transplantation. The workshop also included presentations of mechanistic studies designed to improve understanding of the cellular and molecular basis of tolerance and to identify potential predictors/biomarkers of tolerance. Strategies to enhance the safety of hematopoietic cell transplantation and to improve patient selection/risk stratification for clinical trials were also discussed.
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Affiliation(s)
- Fadi Issa
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Samuel Strober
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Joseph R Leventhal
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tatsuo Kawai
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dixon B Kaufman
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Josh Levitsky
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Microbiology & Immunology, Columbia University, New York, New York, USA
| | - Valeria Mas
- Transplant Research Institute, James D. Eason Transplant Institute, School of Medicine, The University of Tennessee Health Care Science, Memphis, Tennessee, USA
| | - Kathryn J Wood
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Nancy Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisbeth A Welniak
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sindhu Chandran
- Department of Medicine, University of California, San Francisco, California, USA
| | - Joren C Madsen
- MGH Transplant Center and Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Nickerson
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anthony J Demetris
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fadi G Lakkis
- Department of Surgery, Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Angus W Thomson
- Department of Surgery, Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Bosma PJ, Wits M, Oude-Elferink RPJ. Gene Therapy for Progressive Familial Intrahepatic Cholestasis: Current Progress and Future Prospects. Int J Mol Sci 2020; 22:ijms22010273. [PMID: 33383947 PMCID: PMC7796371 DOI: 10.3390/ijms22010273] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023] Open
Abstract
Progressive Familial Intrahepatic Cholestasis (PFIC) are inherited severe liver disorders presenting early in life, with high serum bile salt and bilirubin levels. Six types have been reported, two of these are caused by deficiency of an ABC transporter; ABCB11 (bile salt export pump) in type 2; ABCB4 (phosphatidylcholine floppase) in type 3. In addition, ABCB11 function is affected in 3 other types of PFIC. A lack of effective treatment makes a liver transplantation necessary in most patients. In view of long-term adverse effects, for instance due to life-long immune suppression needed to prevent organ rejection, gene therapy could be a preferable approach, as supported by proof of concept in animal models for PFIC3. This review discusses the feasibility of gene therapy as an alternative for liver transplantation for all forms of PFIC based on their pathological mechanism. Conclusion: Using presently available gene therapy vectors, major hurdles need to be overcome to make gene therapy for all types of PFIC a reality.
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Ruth N, Sharif K, Legarda M, Smith M, Lewis P, Lloyd C, Mirza D, Kelly D. What is the long-term outlook for young people following liver transplant? A single-centre retrospective analysis of physical and psychosocial outcomes. Pediatr Transplant 2020; 24:e13782. [PMID: 32678500 DOI: 10.1111/petr.13782] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 03/17/2020] [Accepted: 06/10/2020] [Indexed: 11/29/2022]
Abstract
LT is a successful treatment for end-stage liver disease. The long-term outcome of patients transplanted in childhood has not previously been widely reported. This project assessed the long-term impact of transplantation in patients surviving >15 years. Retrospective data on growth, end-organ damage and psychosocial development were collected in young people transplanted from 1985 to 2000 in a single centre. Clinical notes were reviewed, and patients interviewed at clinic follow-up. 224 patients were transplanted between 1985 and 2000. 143 recipients (63.8%) survived >15 years with a median survival of 19.52 years. The majority were well, and only 10% had abnormal graft function (biochemical/synthetic), the main cause of which was chronic hepatitis (6%). Renal dysfunction and the necessity for renal transplant were identified in 32.8%, of whom 16.7% of patients had a cGFR <70 mL/min/1.73 m2 and 6% of patients had either undergone or awaiting renal transplant. This cohort was healthier than the average age-matched UK population in terms of body mass index (9% obese), smoking and alcohol consumption. 92% of patients had completed or were in education (93/123 had completed education and 20/123 remained in school). 63.7% of patients had been transitioned into adult services, and 46.3% of these patients were employed. 67.5% were in a relationship, one patient was divorced, and 10.6% of patients had one or more children. 11 patients had symptoms that corresponded to a DSM IV diagnosis of depression. Four patients had anorexia nervosa. Developmental delay was identified in 9 out of 99 patients. The development of malignancy, including PTLD, occurred in 10/143 (7%) patients at a median time post-transplant of 2.76 years (range 0.76-9.06 years). Epstein-Barr infection was implicated in 75% of these malignancies. We conclude the long-term outcome of LT in childhood is good with 63.8% surviving into adulthood and over 60% transferring into adult services. Graft dysfunction and end organ damage are minimal. Our cohort is healthier than the general population, and the majority have completed education, sought employment and formed relationships with peers, contributing well to society.
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Affiliation(s)
- Nicola Ruth
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Khalid Sharif
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Maria Legarda
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,Gastroenterologica, Hepatologica y Nutricion pediatricas, Hospital Universitano Cruces, Barakaldo, Spain
| | - Monica Smith
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, Birmingham, UK
| | - Philipa Lewis
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, Birmingham, UK
| | - Carla Lloyd
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Darius Mirza
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK.,Queen Elizabeth Hospital, Birmingham, UK
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
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Stormon MO, Hardikar W, Evans HM, Hodgkinson P. Paediatric liver transplantation in Australia and New Zealand: 1985-2018. J Paediatr Child Health 2020; 56:1739-1746. [PMID: 32649047 DOI: 10.1111/jpc.14969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/09/2023]
Abstract
Liver transplantation has become the standard of care for children with end-stage liver disease. In Australia and New Zealand, there are four paediatric liver transplant units, in Sydney, Melbourne, Brisbane and Auckland. Over the past 30 years, there have been significant changes to indications for transplant, as well as medical and surgical advances. In this paper, using retrospective data from the Australia and New Zealand Liver Transplant Registry, we review 977 children (less than 16 years of age) who underwent liver transplant from 1985 to 2018. The most common indication was biliary atresia (54%), although there has been an increase in other indications, including inborn errors of metabolism, fulminant hepatic failure and malignant liver tumours. Over the past 3 decades, areas of change and innovation include: the use of 'split grafts' to enable an adult and a child to receive the same donor liver, live donation, improvements in immunosuppressive regimens and infectious prophylaxis protocols and innovative surgical techniques allowing transplantation in smaller infants. The outcomes for children who undergo liver transplant in ANZ are excellent, with current 10-year patient survival rates of 95%, comparable to other larger centres around the world.
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Affiliation(s)
- Michael O Stormon
- Department of Gastroenterology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Helen M Evans
- Department of Gastroenterology, Starship Children's Hospital Auckland, Auckland, New Zealand
| | - Peter Hodgkinson
- Queensland Liver Transplant Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Wu Y, Huang M, Sun H, Zhou X, Zhou R, Gu G, Xia Q. Role of Innate Immunity in Pediatric Post-transplant Idiopathic Liver Fibrosis. Front Immunol 2020; 11:2111. [PMID: 33193293 PMCID: PMC7642407 DOI: 10.3389/fimmu.2020.02111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/04/2020] [Indexed: 01/22/2023] Open
Abstract
Pediatric post-transplant idiopathic liver fibrosis is an unexplained graft fibrosis that occurs in symptom-free children without acute rejection and surgical complications. Despite a lack of consensus on the subject, the development of pediatric post-transplant idiopathic liver fibrosis is believed to be the result of multiple potential factors, including ischemia-reperfusion injury, allogeneic acute and chronic rejection, viral hepatitis recurrence, opportunistic infection, and drug-induced liver damage. Among them, there is growing evidence that innate immunity may also have a unique role in this progression. This study reviews the features of pediatric post-transplant idiopathic liver fibrosis and discusses current studies illustrating the potential mechanisms of liver allograft tolerance induced by intrahepatic innate immunity, the role of components including Toll-like receptors (TLRs), interferons (IFN), dendritic cells (DC), natural killer cells (NK cells), NKT cells, neutrophils, and Kupffer cells, as well as their possibly relevant role in the development of pediatric post-transplant idiopathic liver fibrosis.
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Affiliation(s)
- Yue Wu
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingzhu Huang
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haojie Sun
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiying Zhou
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruoqiao Zhou
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guangxiang Gu
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Voutilainen SH, Kosola SK, Lohi J, Mutka A, Jahnukainen T, Pakarinen M, Jalanko H. Expression of 6 Biomarkers in Liver Grafts After Pediatric Liver Transplantation: Correlations with Histology, Biochemistry, and Outcome. Ann Transplant 2020; 25:e925980. [PMID: 33060556 PMCID: PMC7574360 DOI: 10.12659/aot.925980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Subclinical graft inflammation and fibrosis after pediatric liver transplantation (LT) are common. Biomarkers are needed that precede and are associated with these changes and graft outcome. Material/Methods We evaluated immunohistochemical expression of 6 biomarkers [α-smooth muscle actin (α-SMA), collagen I, decorin, vimentin, P-selectin glycoprotein ligand-1 (PSGL-1), and CD34] in biopsies taken intraoperatively at LT (baseline) (n=29) and at 11.3 years after LT (first follow-up) (n=51). Liver biochemistry and graft histology were assessed at the first follow-up and at final assessment (19.6 years after LT) (n=48). Second follow-up biopsies for histology were available from 24 patients. The immunostainings were correlated with liver histology, biochemistry, and outcome at these time-points. Results Baseline levels of the biomarkers were unrelated to presence of fibrosis at follow-up. Increased α-SMA, collagen I levels, decorin, and vimentin were associated with simultaneous fibrosis at the first follow-up (p=0.001–0.027). Increased SMA, collagen I, decorin, vimentin, PSGL-1, and CD34 expression at first follow-up were associated with simultaneous portal inflammation (p=0.001–0.025). α-SMA, decorin, and vimentin expression were increased in patients without fibrosis at the first follow-up but who developed fibrosis in second follow-up (p=0.014 p=0.024 and p=0.024). Significant fibrosis (F2) and markedly increased α-SMA, collagen I, decorin, and vimentin levels at first follow-up were associated with suboptimal liver status at the final assessment (p=0.002–0.042). Conclusions The expression of the biomarkers at LT was unrelated to later development of graft fibrosis. α-SMA, decorin, and vimentin were associated with later graft fibrosis and suboptimal liver status.
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Affiliation(s)
- Silja H Voutilainen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Silja K Kosola
- Pediatric Research Center, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aino Mutka
- Department of Pathology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Pakarinen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Qin T, Fu J, Verkade HJ. The role of the gut microbiome in graft fibrosis after pediatric liver transplantation. Hum Genet 2020; 140:709-724. [PMID: 32920649 PMCID: PMC8052232 DOI: 10.1007/s00439-020-02221-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022]
Abstract
Liver transplantation (LT) is a life-saving option for children with end-stage liver disease. However, about 50% of patients develop graft fibrosis in 1 year after LT, with normal liver function. Graft fibrosis may progress to cirrhosis, resulting in graft dysfunction and ultimately the need for re-transplantation. Previous studies have identified various risk factors for the post-LT fibrogenesis, however, to date, neither of the factors seems to fully explain the cause of graft fibrosis. Recently, evidence has accumulated on the important role of the gut microbiome in outcomes after solid organ transplantation. As an altered microbiome is present in pediatric patients with end-stage liver diseases, we hypothesize that the persisting alterations in microbial composition or function contribute to the development of graft fibrosis, for example by bacteria translocation due to increased intestinal permeability, imbalanced bile acids metabolism, and/or decreased production of short-chain fatty acids (SCFAs). Subsequently, an immune response can be activated in the graft, together with the stimulation of fibrogenesis. Here we review current knowledge about the potential mechanisms by which alterations in microbial composition or function may lead to graft fibrosis in pediatric LT and we provide prospective views on the efficacy of gut microbiome manipulation as a therapeutic target to alleviate the graft fibrosis and to improve long-term survival after LT.
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Affiliation(s)
- Tian Qin
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Jingyuan Fu
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.,Department of Genetics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Henkjan J Verkade
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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Lee CK, Nastasio S, Mitchell PD, Fawaz R, Elisofon SA, Vakili K, Kim HB, Nguyen D, Jonas MM. Transient elastography assessment of liver allograft fibrosis in pediatric transplant recipients. Pediatr Transplant 2020; 24:e13736. [PMID: 32432836 DOI: 10.1111/petr.13736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/12/2020] [Accepted: 04/17/2020] [Indexed: 01/06/2023]
Abstract
TE measures liver stiffness to assess fibrosis. Its use in post-transplant patients was reported in few small pediatric studies. We evaluated TE ability to predict liver graft fibrosis in a large cohort while comparing it to the performance of APRI and FIB-4. We also investigated the effect of graft type on LSMs. Patients at Boston Children's Hospital who underwent LT and LSM ≤ 1 year from biopsy (2007-2018) were eligible. Ninety-four patients (45%M) aged 1-21 years (89% < 18 years; 13% < 2 years) were eligible. Median time between transplant/biopsy and LSM was 5.1 years and 52 days, respectively. Thirty-nine percent received whole-liver grafts, 54% TV grafts, and 6% as part of MV. At LSM, median ALT was 25 [IQR 16-33] IU/L. Twenty-one percent had METAVIR ≥ F2. LSM was statistically higher among those with significant fibrosis (METAVIR ≥ F2) compared to those with METAVIR F0/F1 (median [IQR] 7.5 [4.6, 13.6] vs 5.1 [4.0, 6.4] kPa, respectively) (P = .005 by Wilcoxon rank-sum test). APRI and FIB-4 distributions were not different across METAVIR stages. The AUROC for LSM was 0.71 (95% CI 0.56-0.85) with an optimal cut-point of 6.5 kPa. Graft type had no influence on the AUROC for LSM. TE is useful for assessing significant graft fibrosis in children and young adult LT recipients and performs better than APRI and FIB-4. TV grafts demonstrate similar correlation with histology as whole-liver grafts.
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Affiliation(s)
- Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Silvia Nastasio
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Rima Fawaz
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Denis Nguyen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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Cousin VL, Rougemont AL, Rubbia-Brandt L, Wildhaber BE, Villard J, Ferrari-Lacraz S, McLin VA. Peripheral Donor-specific Antibodies Are Associated With Histology and Cellular Subtypes in Protocol Liver Biopsies of Pediatric Recipients. Transplantation 2020; 104:1633-1643. [PMID: 32732841 DOI: 10.1097/tp.0000000000003099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The cellular infiltrate in protocol liver biopsies (PB) following pediatric liver transplantation remains mostly uncharacterized, yet there is increasing concern about the role of inflammation and fibrosis in long-term liver allografts. We aimed to define cell types in PB and to analyze their relationship with donor-specific antibodies (DSA) and histological phenotype. METHODS PB were performed at least 1 year after transplantation. We identified 4 phenotypes: normal, fibrosis, inflammation, inflammation with fibrosis. Cell types were counted after immunostaining for CD3, CD4, CD8, CD68, CD20, MUM1, and FoxP3. RESULTS Forty-four patients underwent 1 PB between 2000 and 2015. Eleven percent (5/44) of PB displayed normal histology, 13.6% (6/44) fibrosis, 34.1% (15/44) inflammation, and 40.9% (18/44) inflammation and fibrosis. The main cell types in the portal tracts and lobules were CD3+ and CD68+ cells. Frequency of de novo DSA was 63% (27/44). The presence of CD8+ cells in the lobules was associated with fibrosis. Inflammation and fibrosis in PB were associated with the presence of circulating de novo DSA, number of de novo DSA, and C1q binding activity when compared to other phenotypes. CONCLUSIONS T cells (CD3+) and macrophages (CD68+) were the most prevalent cell-types in PB. In the presence of inflammation, portal tracts were enriched in CD3+, CD20+ but displayed fewer CD68+. This coincided with the presence and number of de novo DSA. How these cellular and humoral actors interact is unclear, but peripheral DSA may be a marker of immune cellular activity in the seemingly quiescent allograft.
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Affiliation(s)
- Vladimir L Cousin
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Anne-Laure Rougemont
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - Laura Rubbia-Brandt
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - Barbara E Wildhaber
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
- Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Jean Villard
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Valérie A McLin
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
- Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
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45
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Vo HD, Harp KA, Mauch TJ. Diagnostic performance of non-invasive tests for evaluation of hepatic graft fibrosis in pediatric liver transplantation: A scoping review. Transplant Rev (Orlando) 2020; 34:100568. [PMID: 32713759 DOI: 10.1016/j.trre.2020.100568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatic graft fibrosis is a common histologic finding of pediatric liver transplant (LT) that might affect long-term graft outcome. However, its diagnosis and staging require an invasive liver biopsy. AIM To review the published literature on the diagnostic accuracy of elastography and serum-based fibrosis markers for assessing hepatic graft fibrosis in pediatric LT recipients. METHODS A scoping review was conducted using a systematic search of published literature in PubMed (MEDLINE), EMBASE, SCOPUS, and Cochrane Library between 2002 and 2019. We included all English conference abstracts or full-text articles that examined the diagnostic accuracy of the non-invasive test(s) to assess hepatic fibrosis in LT children, using liver biopsy as the reference test. RESULTS Eight studies were included, of which 6 examined transient elastography (TE), one investigated acoustic radiation force impulse elastography, and 5 examined serum-based fibrosis markers (AST/ALT ratio, AST-to-platelet ratio index, FibroTest, enhanced liver fibrosis test). TE reportedly had a good AUROC (range: 0.82-0.92) to distinguish children with hepatic graft fibrosis (≥F1) from those with no fibrosis. However, there was considerable overlap of liver stiffness cutoffs in the mild to significant fibrosis groups (≥F1 and ≥F2). Current serum-based fibrosis markers reportedly had an unsatisfactory diagnostic accuracy. CONCLUSIONS TE in LT children has similar diagnostic value and limitations as in the non-transplant setting. Prospective studies are warranted to validate an optimal liver stiffness cutoff for predicting significant hepatic graft fibrosis (≥F2) and to determine if a meaningful change in liver stiffness from baseline could identify patients at risk for fibrosis progression.
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Affiliation(s)
- Hanh D Vo
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, NE, United States.
| | - Kimberly A Harp
- Education and Research Services, McGoogan Library of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Teri J Mauch
- Pediatric Nephrology, University of Nebraska Medical Center, Omaha, NE, United States
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Berumen J, Baglieri J, Kisseleva T, Mekeel K. Liver fibrosis: Pathophysiology and clinical implications. WIREs Mech Dis 2020; 13:e1499. [PMID: 32713091 DOI: 10.1002/wsbm.1499] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023]
Abstract
Liver fibrosis is a clinically significant finding that has major impacts on patient morbidity and mortality. The mechanism of fibrosis involves many different cellular pathways, but the major cell type involved appears to be hepatic stellate cells. Many liver diseases, including Hepatitis B, C, and fatty liver disease cause ongoing hepatocellular damage leading to liver fibrosis. No matter the cause of liver disease, liver-related mortality increases exponentially with increasing fibrosis. The progression to cirrhosis brings more dramatic mortality and higher incidence of hepatocellular carcinoma. Fibrosis can also affect outcomes following liver transplantation in adult and pediatric patients and require retransplantation. Drugs exist to treat Hepatitis B and C that reverse fibrosis in patients with those viral diseases, but there are currently no therapies to directly treat liver fibrosis. Several mouse models of chronic liver diseases have been successfully reversed using novel drug targets with current therapies focusing mostly on prevention of myofibroblast activation. Further research in these areas could lead to development of drugs to treat fibrosis, which will have invaluable impact on patient survival. This article is categorized under: Metabolic Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Jennifer Berumen
- Department of Surgery, University of California, San Diego, California, USA
| | - Jacopo Baglieri
- Department of Surgery, University of California, San Diego, California, USA.,Department of Medicine, University of California, San Diego, California, USA
| | - Tatiana Kisseleva
- Department of Surgery, University of California, San Diego, California, USA
| | - Kristin Mekeel
- Department of Surgery, University of California, San Diego, California, USA
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Influence of Preformed Antibodies in Liver Transplantation. J Clin Med 2020; 9:jcm9030708. [PMID: 32151032 PMCID: PMC7141359 DOI: 10.3390/jcm9030708] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/02/2020] [Indexed: 12/12/2022] Open
Abstract
The significance of human leukocyte antigen (HLA) matching and preformed donor-specific antibodies (DSAs) in liver transplantation remains unclear. The aim of this study was to analyze the presence of DSAs in a large cohort of 810 liver recipients undergoing liver transplant to determine the influence on acute (AR) or chronic liver rejection (CR), graft loss and allograft survival. DSAs were identified using complement dependent cytotoxicity crossmatch (CDC-CM) and multiplexed solid-phase-based flow cytometry assay (Luminex). CDC-CM showed that a 3.2% of liver transplants were positive (+CDC-CM) with an AR frequency of 19.2% which was not different from that observed in negative patients (-CDC-CM, 22.3%). Only two patients transplanted with +CDC-CM (7.6%) developed CR and suffered re-transplant. +CDC-CM patients showed a significantly lower survival rate compared to -CDC-CM patients (23.1% vs. 59.1%, p = 0.0003), developing allograft failure within the first three months (p < 0.00001). In conclusion, we have demonstrated a relationship between the presence of preformed DSAs and the low graft liver survival, indicating the important role and the potential interest of performing this analysis before liver transplantation. Our results could help to detect patients with an increased risk of graft loss, a better choice of liver receptors as well as the establishment of individualized immunosuppressive regimens.
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48
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Veraldi S, Pietrobattista A, Liccardo D, Basso MS, Mosca A, Alterio T, Cardile S, Benedetti S, Della Corte C, Candusso M. Fat soluble vitamins deficiency in pediatric chronic liver disease: The impact of liver transplantation. Dig Liver Dis 2020; 52:308-313. [PMID: 31734113 DOI: 10.1016/j.dld.2019.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Children affected with chronic liver disease are at risk for fat-soluble vitamins (FSV) deficiency, in this scenario the role of liver transplant has been only partially explored. AIMS This study aimed to evaluate the prevalence of FSV deficiency in a cohort of paediatric patients awaiting liver transplant, analyze relationships between plasma vitamin concentrations and risk of acute rejections and liver fibrosis and assess the impact of the transplant on vitamin status. METHODS 166 children candidates for liver transplant were retrospectively evaluated. Vitamin concentrations were measured before and 12 months after transplantation. RESULTS Before transplant vitamin A, vitamin E and vitamin D deficiency was found in 66.6%, 40.6% and 36.3% of patients, respectively. 12 months after surgery, the prevalence of deficiency decreased to 29,5% and 2,6% for vitamin A and E while remained the same for vitamin D (36.3%). No association was found between vitamin status and the risk of acute rejections or the severity of liver fibrosis. CONCLUSION Liver transplant was effective to improve vitamin A and E, but it did not affect vitamin D. A consensus is needed to define optimal nutritional management of these patients in order to prevent deficiencies.
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Affiliation(s)
- Silvio Veraldi
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Sapienza University of Rome, Department of Pediatrics, Rome, Italy.
| | - Andrea Pietrobattista
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Daniela Liccardo
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Sole Basso
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonella Mosca
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Tommaso Alterio
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sabrina Cardile
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sabina Benedetti
- Biochemistry Laboratory, Department of Specialist Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudia Della Corte
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manila Candusso
- Department of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Cernigliaro V, Peluso R, Zedda B, Silengo L, Tolosano E, Pellicano R, Altruda F, Fagoonee S. Evolving Cell-Based and Cell-Free Clinical Strategies for Treating Severe Human Liver Diseases. Cells 2020; 9:cells9020386. [PMID: 32046114 PMCID: PMC7072646 DOI: 10.3390/cells9020386] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 02/07/2023] Open
Abstract
Liver diseases represent a major global health issue, and currently, liver transplantation is the only viable alternative to reduce mortality rates in patients with end-stage liver diseases. However, scarcity of donor organs and risk of recidivism requiring a re-transplantation remain major obstacles. Hence, much hope has turned towards cell-based therapy. Hepatocyte-like cells obtained from embryonic stem cells or adult stem cells bearing multipotent or pluripotent characteristics, as well as cell-based systems, such as organoids, bio-artificial liver devices, bioscaffolds and organ printing are indeed promising. New approaches based on extracellular vesicles are also being investigated as cell substitutes. Extracellular vesicles, through the transfer of bioactive molecules, can modulate liver regeneration and restore hepatic function. This review provides an update on the current state-of-art cell-based and cell-free strategies as alternatives to liver transplantation for patients with end-stage liver diseases.
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Affiliation(s)
- Viviana Cernigliaro
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (V.C.); (R.P.); (B.Z.)
- Maria Pia Hospital, 10126 Turin, Italy
| | - Rossella Peluso
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (V.C.); (R.P.); (B.Z.)
- Maria Pia Hospital, 10126 Turin, Italy
| | - Beatrice Zedda
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (V.C.); (R.P.); (B.Z.)
- Maria Pia Hospital, 10126 Turin, Italy
| | - Lorenzo Silengo
- Molecular Biotechnology Center, Departmet of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (L.S.); (E.T.)
| | - Emanuela Tolosano
- Molecular Biotechnology Center, Departmet of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (L.S.); (E.T.)
| | | | - Fiorella Altruda
- Molecular Biotechnology Center, Departmet of Molecular Biotechnology and Health Sciences, University of Turin, Via Nizza 52, 10126 Turin, Italy; (L.S.); (E.T.)
- Correspondence: (F.A.); (S.F.)
| | - Sharmila Fagoonee
- Institute of Biostructure and Bioimaging, National Research Council, Molecular Biotechnology Center, Via Nizza 52, 10126 Turin, Italy
- Correspondence: (F.A.); (S.F.)
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Performance of B-mode ratio and 2D shear wave elastography for the detection and quantification of hepatic steatosis and fibrosis after liver transplantation. Eur J Gastroenterol Hepatol 2020; 32:222-230. [PMID: 31464783 DOI: 10.1097/meg.0000000000001500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the diagnostic performance of B-mode ratio and shear wave elastography (SWE) for the assessment of steatosis and liver fibrosis after liver transplantation. MATERIALS AND METHODS Patients hospitalized for a systematic check-up after liver transplantation underwent the same day hepatic ultrasound with B-mode ratio and SWE, followed by liver biopsy and biological examinations. Steatosis was measured using hepatorenal sonographic index of B-mode ratio and liver stiffness using SWE. Liver biopsy, used as gold standard, graded steatosis S0(<5%), S1(5-<33%), S2(33-<66%), or S3(≥66%) and liver fibrosis according to the Metavir score. The results were tested against two external validation cohorts. RESULTS Fifty-eight patients were included. Mean B-ratio value was significantly higher in patients with steatosis (0.95 ± 0.13 versus 1.39 ± 0.41, P < 0.001). A B-mode ratio cutoff values at least 0.985 was found optimal for steatosis' detection [area under the receiver operating characteristic curve (AUROC) 0.902 ± 0.05, sensitivity 95%, specificity 79%]. A B-mode ratio value below 0.9 ruled out steatosis and above 1.12 ruled in steatosis. Mean SWE value for patients without significant fibrosis (≤F1) was 15.90 ± 9.2 versus 19.27 ± 7.7 kPa for patients with fibrosis (P = 0.185). A 2D-SWE value below 7.85 kPa ruled out significant fibrosis and above 26.35 kPa ruled it in. CONCLUSION The B-mode ratio is an efficient and accurate tool for the noninvasive diagnostic of steatosis in postliver transplantation patients. Yet, because liver stiffness is higher in postliver transplantation patients, 2D-SWE is not reliable in the diagnosis of significant fibrosis after liver transplantation.
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