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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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Matsukuma K, Yeh MM. Practical Guide, Challenges, and Pitfalls in Liver Fibrosis Staging. Surg Pathol Clin 2023; 16:457-472. [PMID: 37536882 DOI: 10.1016/j.path.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Liver fibrosis staging has many challenges, including the large number of proposed staging systems, the heterogeneity of the histopathologic changes of many primary liver diseases, and the potential for slight differences in histologic interpretation to significantly affect clinical management. This review focuses first on fibrosis regression. Following this, each of the major categories of liver disease is discussed in regard to (1) appropriate fibrosis staging systems, (2) emerging concepts, (3) current clinical indications for liver biopsy, (4) clinical decisions determined by fibrosis stage, and (5) histologic challenges and pitfalls related to staging.
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Affiliation(s)
- Karen Matsukuma
- University of California Davis, Pathology and Laboratory Medicine, 4400 V Street, Sacramento, CA 95817, USA.
| | - Matthew M Yeh
- University of Washington Medical Center - Montlake, Box 356100, 1959 NE Pacific Street, Seattle, WA 98195, USA
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3
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Quaglia A. Histopathology of Budd-Chiari Syndrome. Diagnostics (Basel) 2023; 13:2487. [PMID: 37568849 PMCID: PMC10417184 DOI: 10.3390/diagnostics13152487] [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: 05/27/2023] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/13/2023] Open
Abstract
The histopathological changes in Budd-Chiari syndrome (BCS) overlap with those of sinusoidal obstruction syndrome (SOS) and of cardiac or pericardiac disorders resulting in right cardiac failure. These conditions, however, are different on both clinical and pathological grounds and need to be differentiated from BCS. This review is centred on the three main aspects of BCS in diagnostic liver histopathology: (1) general histopathology of BCS; (2) implications for liver biopsy interpretation; and (3) BCS in the liver allograft. The histological features of BCS form a complex spectrum which is shaped differently in each individual case according to the topographical distribution and chronological evolution of the obliterative insult, its upstream effect of the hepatic vascularisation and the consequent parenchymal injury, scarring and remodelling. Sampling variation limits the use of liver biopsy for prognostication in patients with BCS.
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Affiliation(s)
- Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK;
- UCL Cancer Institute, London WC1E 6DD, UK
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Rushakoff JA, Kransdorf EP, Patel JK, Kobashigawa JA, Sundaram V, Guindi M. Heterogeneity of liver fibrosis in patients with congestive hepatopathy: A biopsy and explant comparison series. Ann Diagn Pathol 2021; 56:151876. [PMID: 34920382 DOI: 10.1016/j.anndiagpath.2021.151876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/19/2021] [Accepted: 12/09/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE Patients with end-stage heart failure and concomitant irreversible liver injury may be candidates for combined heart liver transplant (CHLT). Determining appropriate candidates for CHLT is essential given organ scarcity. Transjugular liver biopsy (TJLB) is used to evaluate the severity of parenchymal liver injury in transplant candidates. In patients with congestive hepatopathy (CH), the fibrosis pattern may be heterogenous. METHODS We reviewed all CHLT cases between 2007 and 2017, as well as lone-heart transplant cases with post-mortem autopsy. Pre-transplant TJLB was compared to explant to assess the performance of biopsy fibrosis staging. RESULTS 12 patients were included. Median age at time of transplant was 58 and the cohort was predominantly male (75%). Seven (64%) TJLB were predominantly stage 4 fibrosis and 4 (36%) were stage 1. Advanced fibrosis was the dominant pattern in 7 (70%) explants and 5 (50%) explants had heterogenous fibrosis. In 50% of CH cases, there was discordance between the TJLB and explant. In the autopsy cases, the TJLB and autopsy findings differed. CONCLUSIONS In this series of matched TJLB and explanted livers, we found variable performance of TJLB in predicting the predominant fibrosis stage present in the liver.
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Affiliation(s)
- Joshua A Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Maha Guindi
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Congestive Hepatopathy Secondary to Right Ventricular Hypertrophy Related to Monocrotaline-Induced Pulmonary Arterial Hypertension. Int J Mol Sci 2021; 22:ijms222111891. [PMID: 34769319 PMCID: PMC8585108 DOI: 10.3390/ijms222111891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 12/22/2022] Open
Abstract
Heart dysfunction and liver disease often coexist. Among the types of cardiohepatic syndrome, Type 2 is characterized by the chronic impairment of cardiac function, leading to chronic liver injury, referred to as congestive hepatopathy (CH). In this study, we aimed to establish a rat model of CH secondary to right ventricular hypertrophy (RVH) related to monocrotaline (MCT)-induced pulmonary arterial hypertension (PAH). Fifty male Wistar rats were divided into four groups and randomly assigned to control and experimental groups. Three experimental groups were submitted to intraperitoneal MCT inoculation (60 mg/kg) and were under its effect for 15, 30 and 37 days. The animals were then sacrificed, obtaining cardiac and hepatic tissues for anatomopathological and morphometric analysis. At macroscopic examination, the livers in the MCT groups presented a nutmeg-like appearance. PAH produced marked RVH and dilatation in the MCT groups, characterized by a significant increase in right ventricular free wall thickness (RVFWT) and chamber area. At histological evaluation, centrilobular congestion was the earliest manifestation, with preservation of the hepatocytes. Centrilobular hemorrhagic necrosis was observed in the groups exposed to prolonged MCT. Sinusoidal dilatation was markedly increased in the MCT groups, quantified by the Sinusoidal Lumen Ratio (SLR). The Congestive Hepatic Fibrosis Score and the Centrilobular Fibrosis Ratio (CFR) were also significantly increased in the MCT30 group. Hepatic atrophy, steatosis, apoptotic bodies and, rarely, hydropic swelling were also observed. SLR correlated strongly with CFR and RVFWT, and CFR correlated moderately with RVFWT. Our rat model was able to cause CH, related to monocrotaline-induced PAH and RVH; it was feasible, reproducible, and safe.
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Nickel NP, Galura GM, Zuckerman MJ, Hakim MN, Alkhateeb H, Mukherjee D, Austin ED, Heresi GA. Liver abnormalities in pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211054304. [PMID: 34707859 PMCID: PMC8544777 DOI: 10.1177/20458940211054304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/13/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a cardiopulmonary disease with high mortality. In recent years, it has been recognized that PAH is a multi-organ system disease, involving the systemic circulation, kidneys, skeletal muscles, and the central nervous system, among others. Right heart failure produces congestive hepatopathy, a disease state that has direct consequences on liver biochemistry, histology, and systemic glucose and lipid metabolism. This article aims to summarize the consequences of congestive hepatopathy with an emphasis on liver biochemistry, histology, and PAH-targeted therapy. Furthermore, PAH-specific changes in glucose and lipid metabolism will be discussed.
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Affiliation(s)
- Nils P. Nickel
- Division of Pulmonary and Critical Care Medicine, Texas Tech
University Health Sciences Center, El Paso, TX, USA
| | - Gian M. Galura
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - Marc J. Zuckerman
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - M. Nawar Hakim
- Department of Pathology, Texas Tech University Health Sciences
Center, El Paso, TX, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Eric D. Austin
- Division of Pediatric Pulmonary Medicine, Vanderbilt University,
Nashville, TN, USA
| | - Gustavo A. Heresi
- Division of Pulmonary and Critical Care Medicine, Cleveland
Clinic, OH, USA
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Sakellariou S, Michaelides C, Voulgaris T, Vlachogiannakos J, Manesis E, Tiniakos DG, Delladetsima I. Keratin 7 expression in hepatic cholestatic diseases. Virchows Arch 2021; 479:815-824. [PMID: 34312700 PMCID: PMC8516784 DOI: 10.1007/s00428-021-03152-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 11/21/2022]
Abstract
We evaluated keratin 7 (K7) hepatocellular expression in 92 patients with common types of acute and chronic cholestatic diseases caused by bile duct obstruction/destruction or parenchymal lesions [acute hepatitis (n=20), mixed/pure cholestasis (n=16), primary biliary cholangitis-PBC (n=35), primary sclerosing cholangitis-PSC (n=10), vanishing bile duct syndrome (n=3), complete large bile duct obstruction due to space-occupying lesions (n=8)]. K7 immunohistochemical hepatocellular expression and ductular reaction (DR) were semi-quantitatively assessed. Results were correlated with liver enzyme serum levels, cholestasis type, histological features, hepatocellular Ki67 labelling index (LI) and HepPar1 expression. Hepatocellular K7 expression was detected in 87% (81/92) cases and in all cholestatic disease types with lowest incidence in pure/mixed cholestasis and highest in incomplete bile duct obstruction (iBDO), reaching 100% in PSC. K7-positive hepatocytes had low Ki67 LI (0-5%) retaining HepPar1 expression, irrespective of disease type. PSC cases had high K7 hepatocellular expression even with intact bile ducts, a feature that may aid differential diagnosis of cholestatic syndromes. K7 hepatocellular expression significantly correlated with cholestasis type, bile duct loss and fibrosis stage. It was higher in milder acute cholestatic hepatitis showing inverse correlation with hepatocyte proliferation and serum transaminase levels. In iBDO, younger age independently correlated with high K7 expression, while serum GGT levels showed a nearly significant correlation. Correlation with DR findings implied that K7-positive hepatocytes may result through metaplasia. In conclusion, K7 hepatocellular expression is a sensitive though non-specific marker of cholestasis. It may represent a cytoprotective reaction of resting hepatocytes in cholestasis of longer duration especially in younger patients.
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Affiliation(s)
- S Sakellariou
- 1st Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias str, 11527, Athens, Greece
| | - C Michaelides
- 1st Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias str, 11527, Athens, Greece
| | - T Voulgaris
- Academic Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma str, 11527, Athens, Greece
| | - J Vlachogiannakos
- Academic Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma str, 11527, Athens, Greece
| | - E Manesis
- Liver Unit, Euroclinic, 7-9 Athanasiadou str, 11521, Athens, Greece
| | - D G Tiniakos
- Department of Pathology, Aretaieion Hospital, National and Kapodistrian University of Athens, 76 Vasilissis Sofias Ave, 11528, Athens, Greece. .,Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
| | - I Delladetsima
- 1st Department of Pathology, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 75 Mikras Asias str, 11527, Athens, Greece
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Bakshi N, Gulati N, Rastogi A, Chougule A, Bihari C, Jindal A. Nodular regenerative hyperplasia - An under-recognized vascular disorder of liver. Pathol Res Pract 2020; 216:152833. [PMID: 32164988 DOI: 10.1016/j.prp.2020.152833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/24/2019] [Accepted: 01/18/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Nodular regenerative hyperplasia (NRH) is a rare hepatic vascular disorder which is often associated with wide variety of systemic diseases. Intrahepatic microvascular injury and subsequent altered perfusion state leads to development of non-cirrhotic portal hypertension in many of these patients. Diagnosis of NRH often remains unsuspected clinically and liver biopsy is essential for the diagnosis and exclusion of fibrosis. We herein, present clinicopathological features of 22 NRH cases. In addition we assessed CK7 and CD34 expression in hepatocytes and sinusoidal endothelial cells respectively. RESULTS Most of the cases were associated with systemic disorders, predominantly immunological, inflammatory and drug-related injuries. Signs and symptoms of portal hypertension were found in 86.4 % patients. Majority of the patients showed a predominant mild cholestatic pattern of liver function tests. Nearly all the (21/22) cases showed CK7 positivity in centrizonal hepatocytes which ranged from <10 % cells to diffuse perivenular positivity extending into the midzonal areas. CD34 positivity in sinusoidal endothelial cells was seen in all the cases, which was prominent in periportal areas in all cases; while perivenular (n = 20) and midzonal (n = 14) areas also showed CD34 positive sinusoidal endothelial cells. CONCLUSION This study highlights the role of pathologist in the diagnosis of NRH and stresses upon the need for awareness of NRH as a cause of unexplained portal hypertension in patients with underlying systemic diseases. The altered perfusion state in NRH leads to phenotypic shift in centrizonal atrophic hepatocytes and sinusoidal endothelial cells (as depicted by IHC) which may be responsible for development of portal hypertension.
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Affiliation(s)
- Neha Bakshi
- Department of Pathology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India.
| | - Natasha Gulati
- Department of Pathology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India.
| | - Abhijit Chougule
- Department of Pathology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India.
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Heterogeneity of Fibrosis in Liver Biopsies of Patients With Heart Failure Undergoing Heart Transplant Evaluation. Am J Surg Pathol 2019; 42:1617-1624. [PMID: 30273196 DOI: 10.1097/pas.0000000000001163] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver biopsies are commonly performed in heart transplant candidates to confirm congestive hepatopathy (CH) and to assess the degree of fibrosis. Heterogeneity of fibrosis is frequent in CH, making it difficult to stage fibrosis. In this study, we evaluated the prevalence of heterogeneity of fibrosis and nodular regenerative hyperplasia (NRH) in liver biopsies with CH secondary to heart failure. Fifty liver biopsies with CH secondary to heart failure were reviewed. The fibrosis was scored on trichrome stain as follows: stage 0 for no fibrosis, stage 1 for zone 3 fibrosis, stage 2 for zone 3 and portal fibrosis, stage 3 for bridging fibrosis, and stage 4 for cirrhosis. Both stage 3 and stage 4 fibrosis were classified as advanced fibrosis. A predominant pattern of fibrosis and a secondary pattern of fibrosis, defined as a different stage of fibrosis seen in at least 10% of the biopsy material, if present, were recorded. A biopsy was considered to show heterogenous fibrosis if there was at least a 2 stage difference between the predominant and secondary patterns. Thirteen biopsies (26%) showed heterogenous fibrosis. Sixteen biopsies (32%) showed some evidence of advanced fibrosis: 5 had uniform advanced fibrosis, 4 had predominant pattern of advanced fibrosis, and advanced fibrosis was focal in 7 biopsies from 6 patients. NRH-type changes were seen in 9 of 50 biopsies (18%). In conclusion, our study showed heterogenous fibrosis in the liver biopsy of a quarter of patients with CH due to heart failure, highlighting the limitations of fibrosis assessment in the biopsies, and suggests that correlation with the complete clinical information is essential for management decisions.
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11
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Centrilobular ductular reaction correlates with fibrosis stage and fibrosis progression in non-alcoholic steatohepatitis. Mod Pathol 2018; 31:150-159. [PMID: 28862262 DOI: 10.1038/modpathol.2017.115] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 12/17/2022]
Abstract
There is increasing interest in the role of ductular reaction as part of the pathogenesis and characteristic histology of non-alcoholic steatohepatitis. However, earlier studies did not separately assess the contribution of periportal and centrilobular zone ductular reaction over the spectrum of non-alcoholic steatohepatitis, and their clinical significance remains unclear. We herein analyzed the character of ductular reaction in each hepatic zone in non-alcoholic steatohepatitis biopsies and for the first time evaluated the prognostic value of ductular reaction in baseline biopsies as a predictor of progression of fibrosis in subsequent biopsies. A total of 90 non-alcoholic steatohepatitis liver biopsies were included in the cohort. The relationships among ductular reaction, grade, stage, and other common histopathologic findings in non-alcoholic steatohepatitis were analyzed in a cross-sectional manner. Among these patients, a total of 47 patients underwent sequential liver biopsies in the absence of effective treatment. The frequency of ductular reaction and the other histopathologic parameters in the initial biopsies were analyzed as predictors of progression of fibrosis in the second biopsies in a longitudinal analysis. Centrilobular ductular reaction was identified in 90% of patients and 38% of centrilobular zones. The prevalence of centrilobular ductular reaction increased as non-alcoholic steatohepatitis grade increased (P=0.0002) and also as stage of fibrosis increased (P<0.0001) in the cross-sectional study. In the longitudinal study, the frequency of centrilobular ductular reaction in the initial biopsies was significantly higher in the group of progressors and correlated with the rate of fibrosis progression (P=0.02). Centrilobular ductular reaction is common in non-alcoholic steatohepatitis and its presence correlates significantly with increasing necroinflammatory activity and fibrosis stage. Development of centrilobular ductular reaction appears to predict progression of fibrosis in subsequent biopsies.
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12
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Zuo C, Chumbalkar V, Ells PF, Bonville DJ, Lee H. Prevalence of histological features of idiopathic noncirrhotic portal hypertension in general population: a retrospective study of incidental liver biopsies. Hepatol Int 2017; 11:452-460. [PMID: 28597108 DOI: 10.1007/s12072-017-9801-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Idiopathic noncirrhotic portal hypertension (INCPH) is associated with histologic changes secondary to obliterative portal venopathy without cirrhosis. We studied the prevalence of individual histological features of INCPH in liver biopsies obtained incidentally during unrelated elective procedures and in elective liver biopsies with the diagnosis of fatty liver disease. METHODS A total of 53 incidental liver biopsies obtained intraoperatively during unrelated elective procedures and an additional 28 elective biopsies with the diagnosis of fatty liver disease without portal hypertension and cirrhosis were studied. Various histologic features of INCPH were evaluated. RESULTS Shunt vessel (30%), phlebosclerosis (27%), increased number of portal vessels (19%) and incomplete septa (17%) were common in these liver biopsies after confounding factors such as co-existing fatty liver disease or fibrosis were excluded. At least one feature of INCPH was noted in 90% of the biopsies. Eight (10%) biopsies showed 5-6 features of INCPH. In total, 11 (14%) of 81 patients had risk factors associated with INCPH, including hypercoagulability, autoimmune disease, exposure to drugs, and infections. No patient had portal hypertension at the end of the follow-up. CONCLUSION The histologic features of INCPH are seen in incidental liver biopsies and fatty liver disease without portal hypertension. Ten percent of the biopsies show 5-6 features of INCPH without portal hypertension. Interpreting histologic features in the right clinical context is important for proper patient care.
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Affiliation(s)
- Chunlai Zuo
- Pathology and Laboratory Medicine, Albany Medical College, 47 New Scotland Ave., MC81, Albany, NY, 12208, USA
| | - Vaibhav Chumbalkar
- Pathology and Laboratory Medicine, Albany Medical College, 47 New Scotland Ave., MC81, Albany, NY, 12208, USA
| | - Peter F Ells
- Division of Gastroenterology, Albany Medical College, 47 New Scotland Ave., a405, Albany, NY, 12208, USA
| | - Daniel J Bonville
- General Surgery, Houston Methodist Hospital, 6550 Fannin St., Suite 1661, Houston, TX, 77030, USA
| | - Hwajeong Lee
- Pathology and Laboratory Medicine, Albany Medical College, 47 New Scotland Ave., MC81, Albany, NY, 12208, USA.
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Matsukuma S, Takeo H, Utsumi Y, Sato K. In hepatic venous outflow obstruction, alcoholic liver disease, and nonalcoholic fatty liver disease, centrilobular scars, CD34+ vessels, and keratin 7+ hepatocytes are in close proximity. Virchows Arch 2017; 470:411-420. [PMID: 28116521 DOI: 10.1007/s00428-017-2074-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/10/2016] [Accepted: 01/16/2017] [Indexed: 01/16/2023]
Abstract
For hepatic venous outflow obstruction, alcoholic liver injury, and nonalcoholic fatty liver disease, the term "centrizonal injury disease" (CID) is used, because injury patterns in all three entities are similar. To elucidate CID-related CD34+ vessels (sinusoids and/or microvessels) and keratin 7+ hepatocytes (K7+ Hs), we examined a series of 41 liver tissue specimens obtained at autopsy and surgery, consisting of 32 CID cases and 9 controls. Centrizonal scars were found in 21 CID cases, and these were associated with centrizonal CD34+ vessels (P = 0.009) and centrizonal K7+ Hs (P < 0.001). Centrizonal coexistence of CD34+ vessels and K7+ Hs was observed in 22 CID cases (P = 0.057). These findings suggest close centrizonal proximity of scar, CD34+ vessels, and K7+ Hs in CID. However, centrizonal K7+ Hs without CD34+ vessels were observed in 21 CID cases. CD34+ vessels were detectable in all control samples and may represent the normal vascular bed. In 29 CID cases, centrizonal CD34+ vessel density was higher than that in controls. However, most appeared to be continuous with periportal and/or interlobular CD34+ vessels, and those CD34+ vessels restricted to centrizonal regions were focal and limited in seven CID cases. Centrizonal CD34+ vessels were associated with venoportal adhesions (P = 0.027). Our findings suggest that CID induces both venoportal adhesion-related structural distortion and expansion of normally present CD34+ vessels, which may result in increased centrizonal CD34+ vessel density.
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Affiliation(s)
- Susumu Matsukuma
- Department of Pathology, Japan Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-ku, Tokyo, 154-8532, Japan.
- Health Care Center, Japan Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-ku, Tokyo, 154-8532, Japan.
| | - Hiroaki Takeo
- Department of Pathology, Japan Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-ku, Tokyo, 154-8532, Japan
| | - Yoshitaka Utsumi
- Department of Pathology, Japan Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-ku, Tokyo, 154-8532, Japan
| | - Kimiya Sato
- Department of Pathology, Japan Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-ku, Tokyo, 154-8532, Japan
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14
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Gonzalez RS, Gilger MA, Huh WJ, Washington MK. The Spectrum of Histologic Findings in Hepatic Outflow Obstruction. Arch Pathol Lab Med 2016; 141:98-103. [PMID: 27681331 DOI: 10.5858/arpa.2015-0388-oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Cardiac hepatopathy and Budd-Chiari syndrome are 2 forms of hepatic venous outflow obstruction with different pathophysiology but overlapping histologic findings, including sinusoidal dilation and centrilobular necrosis. OBJECTIVE -To determine whether a constellation of morphologic findings could help distinguish between the 2 and could suggest the diagnoses in previously undiagnosed patients. DESIGN -We identified 26 specimens with a diagnosis of cardiac hepatopathy and 23 with a diagnosis of Budd-Chiari syndrome. Slides stained with hematoxylin and eosin and with trichrome were evaluated for several distinctive histologic findings. RESULTS -Features common to both forms of hepatic outflow obstruction included sinusoidal dilation and portal tract changes of fibrosis, chronic inflammation, and bile ductular reaction. Histologic findings significantly more common in cardiac hepatopathy included pericellular/sinusoidal fibrosis and fibrosis around the central vein. Only centrilobular hepatocyte dropout/necrosis was significantly more common in Budd-Chiari, regardless of duration. CONCLUSIONS -The finding of pericellular/sinusoidal fibrosis in cardiac hepatopathy compared with Budd-Chiari is not unexpected, given the chronic nature of most cardiac hepatopathy. Portal tract changes are common in both forms of hepatic outflow obstruction and should not deter one from making the diagnosis of hepatic outflow obstruction. Fibrosis along sinusoids and around the central vein may be suggestive of cardiac hepatopathy in biopsies from patients without a prior diagnosis.
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Affiliation(s)
| | | | | | - Mary Kay Washington
- From the Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York (Dr Gonzalez); and the Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Drs Gilger, Huh, and Washington). Dr Gilger is currently at Colorado GI Pathology/Centennial Pathologists, Centennial
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15
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Surrey LF, Russo P, Rychik J, Goldberg DJ, Dodds K, O'Byrne ML, Glatz AC, Rand EB, Lin HC. Prevalence and characterization of fibrosis in surveillance liver biopsies of patients with Fontan circulation. Hum Pathol 2016; 57:106-115. [PMID: 27476041 DOI: 10.1016/j.humpath.2016.07.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/30/2016] [Accepted: 07/03/2016] [Indexed: 12/26/2022]
Abstract
The Fontan operation is a widely used palliative procedure in patients with single-ventricle anatomy that results in liver injury. As timely identification of liver fibrosis may result in management changes to Fontan patients, the aim of our study was to identify clinically meaningful semi quantitative/quantitative pathologic parameters for biopsy assessment. We performed a retrospective review of 74 liver needle biopsies from Fontan patients. Fibrosis was assessed using quantitative % collagen deposition by Sirius red image analysis, METAVIR, congestive hepatic fibrosis score, sinusoidal fibrosis score, and sinusoidal dilation score. Contemporaneous laboratory, hemodynamic, and ultrasound data were collected. Centrilobular and peri sinusoidal fibrosis was observed in all cases, with 39.2% high grade. Portal fibrosis was observed in 93.2%, with 36.2% high-grade (METAVIR F3-F4). Cirrhosis was observed in 5.4%. % Collagen deposition was increased over control tissue (P < .001) and correlated with time from Fontan (r = 0.3, P = .009) and prothrombin time (r = 0.25, P = .034). Mildly elevated prothrombin time/international normalized ratio was the only measure of liver function consistently associated with multiple high-grade fibrosis scores (METAVIR P = .046, sinusoidal fibrosis P = .018). Abnormal liver echotexture on ultrasound was associated with high-grade congestive hepatic fibrosis score (P = .03). Pathologic gradings and %CD correlated with each other (r = 0.48-0.8, P < .001). Hepatic fibrosis in Fontan patients in our study is universally present, appears to be time dependent, and correlates with few laboratory measurements of liver function. Careful assessment of needle liver biopsies lends a more meaningful measure of liver fibrosis in the Fontan patient than clinical and laboratory data, allowing for appropriate changes to patient management.
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Affiliation(s)
- Lea F Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104.
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Kathryn Dodds
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's National Medical Center, Washington, DC 20010
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Elizabeth B Rand
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Henry C Lin
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
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16
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Sato Y, Harada K, Sasaki M, Nakanuma Y. Altered intrahepatic microcirculation of idiopathic portal hypertension in relation to glutamine synthetase expression. Hepatol Res 2015; 45:1323-30. [PMID: 25692330 DOI: 10.1111/hepr.12506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 02/09/2015] [Accepted: 02/09/2015] [Indexed: 01/02/2023]
Abstract
AIM Alteration in intrahepatic microcirculation of idiopathic portal hypertension (IPH) has been poorly understood. This study aimed to characterize altered intrahepatic microcirculation of IPH focusing on the expression pattern of glutamine synthetase (GS). METHODS Immunohistochemical staining of GS was performed using liver sections of IPH (n = 28). Serial section analysis was performed to determine microcirculatory disturbances of IPH. RESULTS Paraportal shunt vessels were observed in 20 cases of IPH, and they were divided into two types according to the GS staining pattern; hepatocytes surrounding the vessels were negative for GS (type 1) and positive for GS (type 2). All 20 cases had one or more type 1 vessels within a section, and 10 cases were further associated with type 2 vessels. The cases with type 2 vessels showed infrequent symptoms of esophageal varices. Regarding the GS staining as an indicator of hepatic veins, some type 2 vessels were supposed to represent portovenous shunts. Isolated arteries in hepatic parenchyma were present in 21 cases, and they were located around terminal hepatic venules in six cases, corresponding to centrizonal arteries. Broad hepatocellular GS staining in hyperplastic lesions was noted in five cases, whereas nodular regenerative hyperplasia lacked GS expression. CONCLUSION GS immunostaining revealed microcirculatory disturbances of IPH that were associated with abnormalities in both venous and arterial vessels.
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Affiliation(s)
- Yasunori Sato
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Motoko Sasaki
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yasuni Nakanuma
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan.,Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
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17
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Louie CY, Pham MX, Daugherty TJ, Kambham N, Higgins JPT. The liver in heart failure: a biopsy and explant series of the histopathologic and laboratory findings with a particular focus on pre-cardiac transplant evaluation. Mod Pathol 2015; 28:932-43. [PMID: 25793895 DOI: 10.1038/modpathol.2015.40] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/30/2014] [Accepted: 12/31/2014] [Indexed: 11/09/2022]
Abstract
The pathologic liver changes in chronic heart failure have been characterized mostly based on autopsy series and include sinusoidal dilation and congestion progressing to pericellular fibrosis, bridging fibrosis, and ultimately to cardiac cirrhosis or sclerosis. Liver biopsies are commonly obtained as part of the work up before heart transplantation in patients with longstanding right heart failure, particularly if ascites, abnormal liver function tests or abnormal abdominal imaging are noted as part of the pre-transplant evaluation. In these cases, the liver biopsy findings may be used to further risk stratify patients for isolated heart or combined heart and liver transplantation. Thus, it is important to be able to correlate the histologic changes with post-transplant outcomes. We report the pathologic and clinical findings in liver explants from six patients who underwent combined heart-liver transplantation. We also report preoperative liver biopsy findings from 21 patients who underwent heart transplantation without simultaneous liver transplantation. We staged the changes related to chronic passive congestion as follows: stage 0-no fibrosis; stage I-pericellular fibrosis; stage II-bridging fibrosis; and stage III-regenerative nodules. Nineteen biopsies showed fibrosis with bridging fibrosis in 13 and regenerative nodules in 6. Fifteen patients were alive at 1 year post transplant. Only three patients had a post-operative course that was characterized by signs and symptoms of chronic liver disease. Pre-transplant liver biopsies from these patients all showed at least stage II fibrosis. These patients survived for 3, 6, and 10 months after cardiac transplant. The presence of bridging fibrosis was not significantly associated with post-operative survival (P=0.336) or post-operative liver failure (P=0.257). We conclude that patients with bridging fibrosis may still be considered viable candidates for isolated heart transplantation. Because the pattern of fibrosis due to passive congestion is highly variable throughout the liver, a diagnosis of cirrhosis, which implies fibrosis and regenerative nodules throughout the liver, should be made with great caution on biopsy.
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Affiliation(s)
- Christine Y Louie
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael X Pham
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Stanford, CA, USA
| | - Tami J Daugherty
- Department of Medicine (Hepatology), Stanford University School of Medicine, Stanford, CA, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - John P T Higgins
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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18
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Lee H, Ainechi S, Singh M, Ells PF, Sheehan CE, Lin J. Histological Spectrum of Idiopathic Noncirrhotic Portal Hypertension in Liver Biopsies From Dialysis Patients. Int J Surg Pathol 2015; 23:439-46. [DOI: 10.1177/1066896915582264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objectives. Liver biopsy is performed for various indications in dialysis patients. Being a less-common subset, the hepatic pathology in renal dialysis is not well documented. Idiopathic noncirrhotic portal hypertension (INCPH) is a clinical entity associated with unexplained portal hypertension and/or a spectrum of histopathological vascular changes in the liver. After encountering INCPH and vascular changes of INCPH in 2 renal dialysis patients, we sought to further investigate this noteworthy association. Materials and methods. A random search for patients on hemodialysis or peritoneal dialysis with liver biopsy was performed. Hematoxylin and eosin, reticulin, trichrome, and CK7 stains were performed on formalin-fixed, paraffin-embedded tissue sections. Histopathological features were reviewed, and the results were correlated with clinical findings. Results. In all, 13 liver biopsies were retrieved. The mean cumulative duration of dialysis was 50 months (range = 17 months to 11 years). All patients had multiple comorbidities. Indications for biopsy were a combination of abnormal liver function tests (6), portal hypertension (4), ascites (3), and possible cirrhosis (3). Two patients with portal hypertension underwent multiple liver biopsies for diagnostic purposes. All (100%) biopsies showed some histological features of INCPH, including narrowed portal venous lumen (9), increased portal vascular channels (8), shunt vessels (3), dilated sinusoids (9), regenerative nodule (5), and features of venous outflow obstruction (3). No cirrhosis was identified. Conclusion. Liver biopsies from patients on dialysis demonstrate histopathological vascular changes of INCPH. Some (31%) patients present with portal hypertension without cirrhosis. The histological changes may be reflective of underlying risk factors for INCPH in this group.
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Affiliation(s)
| | | | | | | | | | - Jingmei Lin
- Indiana University School of Medicine, Indianapolis, IN, USA
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19
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Central portalization correlates with fibrosis but not with risk factors for nonalcoholic steatohepatitis in steatotic chronic hepatitis C. Int J Hepatol 2014; 2014:329297. [PMID: 25525520 PMCID: PMC4265703 DOI: 10.1155/2014/329297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/10/2014] [Indexed: 12/23/2022] Open
Abstract
Concomitant steatosis in chronic hepatitis C is associated with fibrosis and unfavorable treatment outcome. Central zone injury in nonalcoholic steatohepatitis (NASH) manifests as central portalization, with centrizonal microvessels and ductular reaction. We investigated whether central portalization in steatotic HCV biopsies would identify patients with metabolic risk factors for NASH. Liver biopsies with chronic hepatitis C and >10% steatosis (n = 65) were evaluated for the degree of steatosis, zonation of steatosis, fibrosis, and nonalcoholic fatty liver disease (NAFLD) activity score. The presence of centrizonal microvessels, sinusoidal capillarization, ductular reaction, and CK7 positive intermediate-phenotype hepatocytes were evaluated by CD34 and CK7 immunostain. The degree of steatosis and fibrosis showed a positive correlation. Additional positive correlations were noted between centrizonal angiogenesis and NAFLD activity score and central portalization and fibrosis. However, neither central portalization nor zonation of steatosis identified patients with metabolic risk factors for NASH. Therefore, central portalization cannot be used as a surrogate marker to identify patients with metabolic risk factors for NASH in steatotic HCV biopsies. The mechanism of centrizonal injury in steatotic HCV hepatitis is not solely attributable to the metabolic risk factors for NASH.
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