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Lerut J, Lai Q. Comments on: Induction Immunosuppression Does Not Worsen Tumor Recurrence After Liver Transplantation for Hepatocellular Carcinoma. Transplantation 2023; 107:1434-1435. [PMID: 36706072 DOI: 10.1097/tp.0000000000004488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Jan Lerut
- Institut de Recherche Clinique et Expérimental, Université Catholique de Louvain, Brussels, Belgium
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of General and Specialistic Surgery, Sapienza University of Rome, AOU Policlinico Umberto I of Rome, Rome, Italy
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2
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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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3
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Leonard NB, Hale GL, Boylan KE, Ou Z, Zhang C, Kim R, Chandna S, Dong ZM, Evason KJ. Histologic features of allograft livers in patients treated for rejection before biopsy. Hum Pathol 2023; 135:11-21. [PMID: 36804507 PMCID: PMC10121875 DOI: 10.1016/j.humpath.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/04/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Abstract
Liver biopsy is essential for management in liver transplant patients with clinical features suspicious for acute cellular rejection (ACR). As more patients are transplanted for noninfectious indications, it has become increasingly common for them to receive treatment for presumed ACR before biopsy. The effect of pretreatment on the classic histologic triad of ACR's mixed portal inflammation, endothelialitis, and bile duct damage is not well described. Here we report a retrospective study of 70 liver transplant biopsies performed on 53 patients for suspected ACR between 2018 and 2021. Thirty-seven biopsies had a clinical diagnosis of ACR after biopsy. Pretreatment with steroids, antithymocyte globulin, or other increased immunosuppression was given before biopsy in 17 of 37 cases; 20 not-pretreated cases acted as controls. A representative hematoxylin and eosin-stained slide from each biopsy was reviewed independently in a blinded fashion by 3 hepatic pathologists, graded according to the Banff system, assigned a Rejection Activity Index (RAI), and assessed for other histologic features. We found that pretreated biopsies had significantly less portal inflammation (P < .001), less endothelialitis (P < .001), lower RAI (P < .001), and less prominent eosinophils (P = .048) compared to not-pretreated biopsies. There was no significant difference for the other examined variables, including bile duct inflammation/damage (P = .32). Our findings suggest that portal inflammation and endothelialitis become less prominent with pretreatment, whereas bile duct inflammation/damage may take longer to resolve. When evaluating biopsies for suspected ACR, the finding of bile duct inflammation/damage should raise the possibility of partially treated ACR, even in the absence of endothelialitis and portal inflammation.
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Affiliation(s)
- Nicole B Leonard
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112, USA
| | - Gillian L Hale
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112, USA
| | - Katherine E Boylan
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - Robin Kim
- Department of Surgery, University of Utah, Salt Lake City, UT, 84132, USA
| | - Shaun Chandna
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, And Nutrition, University of Utah, Salt Lake City, UT, 84132, USA
| | - Zachary M Dong
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112, USA
| | - Kimberley J Evason
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112, USA; Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, 84112, USA.
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4
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Narita S, Miuma S, Okudaira S, Koga Y, Fukushima M, Sasaki R, Haraguchi M, Soyama A, Hidaka M, Miyaaki H, Futakuchi M, Nagai K, Ichikawa T, Eguchi S, Nakao K. Regular protocol liver biopsy is useful to adjust immunosuppressant dose after adult liver transplantation. Clin Transplant 2023; 37:e14873. [PMID: 36443801 DOI: 10.1111/ctr.14873] [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: 03/01/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adjusting immunosuppression to minimal levels post-adult liver transplantation (LT) is critical; however, graft rejection has been reported in LT recipients with normal liver function evaluated by liver biopsy (LBx). Continual protocol liver biopsy (PLB) is performed regularly in LT recipients with normal liver function in some centers; however, its usefulness remains inadequately evaluated. This study aimed to assess retrospectively the usefulness of late PLB after adult LT. METHODS LBx evaluations of LT recipients with normal liver function and hepatitis B and C virus seronegativity were defined as PLB. The cases requiring immunosuppressive therapy for rejection findings based on Banff criteria were extracted from the PLBs, and pathological data collected before and after immunosuppressive dosage adjustment (based on modified histological activity index [HAI] score) were compared. RESULTS Among 548 LBx cases, 213 LBx in 110 recipients fulfilled the inclusion criteria for PLB. Immunosuppressive therapy after PLB was intensified in 14 LBx (6.6%) recipients (12.7%); of these, nine had late-onset acute rejection, three had isolated perivenular inflammation, one had plasma cell-rich rejection, and one had early chronic rejection. Follow-up LBx after immunosuppressive dose adjustment showed improvement in the modified HAI score grading in 10 of 14 cases (71.4%). No clinical background and blood examination data, including those from the post-LT period, immunosuppressant trough level, or examination for de novo DSA, predicted rejection in PLB. Complications of PLB were found in only three cases. CONCLUSION PLB is useful in the management of seemingly stable LT recipients, to discover subclinical rejection and allow for appropriate immunosuppressant dose adjustment.
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Affiliation(s)
- Shohei Narita
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sadayuki Okudaira
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshito Koga
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Masanori Fukushima
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masafumi Haraguchi
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuru Futakuchi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuki Ichikawa
- Nagasaki Harbor Medical Center, Department of Gastroenterology, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
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5
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Oberkofler CE, Raptis DA, Müller PC, Sousa da Silva RX, Lehmann K, Ito T, Owen T, Pollok J, Parente A, Schlegel A, Peralta P, Winter E, Selzner M, Fodor M, Maglione M, Jaklitsch M, Marques HP, Chavez‐Villa M, Contreras A, Kron P, Lodge P, Alford S, Rana A, Magistri P, Di Benedetto F, Johnson B, Kirchner V, Bauldrick F, Halazun KJ, Ghamarnedjad O, Mehrabi A, Basto ST, Fernandes ESM, Paladini J, de Santibañes M, Florman S, Tabrizian P, Dutkowski P, Clavien P, Busuttil RW, Kaldas FM, Petrowsky H. Low-dose aspirin confers protection against acute cellular allograft rejection after primary liver transplantation. Liver Transpl 2022; 28:1888-1898. [PMID: 35735232 PMCID: PMC9804747 DOI: 10.1002/lt.26534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/06/2022] [Accepted: 05/18/2022] [Indexed: 01/09/2023]
Abstract
This study investigated the effect of low-dose aspirin in primary adult liver transplantation (LT) on acute cellular rejection (ACR) as well as arterial patency rates. The use of low-dose aspirin after LT is practiced by many transplant centers to minimize the risk of hepatic artery thrombosis (HAT), although solid recommendations do not exist. However, aspirin also possesses potent anti-inflammatory properties and might mitigate inflammatory processes after LT, such as rejection. Therefore, we hypothesized that the use of aspirin after LT has a protective effect against ACR. This is an international, multicenter cohort study of primary adult deceased donor LT. The study included 17 high-volume LT centers and covered the 3-year period from 2013 to 2015 to allow a minimum 5-year follow-up. In this cohort of 2365 patients, prophylactic antiplatelet therapy with low-dose aspirin was administered in 1436 recipients (61%). The 1-year rejection-free survival rate was 89% in the aspirin group versus 82% in the no-aspirin group (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.63-0.94; p = 0.01). The 1-year primary arterial patency rates were 99% in the aspirin group and 96% in the no-aspirin group with an HR of 0.23 (95% CI, 0.13-0.40; p < 0.001). Low-dose aspirin was associated with a lower risk of ACR and HAT after LT, especially in the first vulnerable year after transplantation. Therefore, low-dose aspirin use after primary LT should be evaluated to protect the liver graft from ACR and to maintain arterial patency.
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Affiliation(s)
- Christian E. Oberkofler
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Dimitri A. Raptis
- Department of Hepato Pancreatico Biliary Surgery and Liver TransplantationRoyal Free HospitalLondonUK,Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | - Philip C. Müller
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Richard X. Sousa da Silva
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Kuno Lehmann
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Takahiro Ito
- Dumont‐University California Los Angeles Transplant CenterDavid Geffen School of Medicine at University California Los AngelesLos AngelesCaliforniaUSA
| | - Timothy Owen
- Department of Hepato Pancreatico Biliary Surgery and Liver TransplantationRoyal Free HospitalLondonUK
| | - Joerg‐Matthias Pollok
- Department of Hepato Pancreatico Biliary Surgery and Liver TransplantationRoyal Free HospitalLondonUK,Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | | | - Andrea Schlegel
- The Liver UnitQueen Elizabeth Hospital BirminghamBirminghamUK
| | - Peregrina Peralta
- Multi‐Organ Transplant Program, Department of SurgeryToronto General HospitalTorontoOntarioCanada
| | - Erin Winter
- Multi‐Organ Transplant Program, Department of SurgeryToronto General HospitalTorontoOntarioCanada
| | - Markus Selzner
- Multi‐Organ Transplant Program, Department of SurgeryToronto General HospitalTorontoOntarioCanada
| | - Margot Fodor
- Department of Visceral, Transplant, and Thoracic SurgeryMedical University InnsbruckInnsbruckAustria
| | - Manuel Maglione
- Department of Visceral, Transplant, and Thoracic SurgeryMedical University InnsbruckInnsbruckAustria
| | - Manuel Jaklitsch
- Hepato‐Biliary‐Pancreatic and Transplantation Center, Curry Cabral HospitalLisbon's Central Hospitals and University Center, Nova Medical SchoolLisbonPortugal
| | - Hugo P. Marques
- Hepato‐Biliary‐Pancreatic and Transplantation Center, Curry Cabral HospitalLisbon's Central Hospitals and University Center, Nova Medical SchoolLisbonPortugal
| | - Mariana Chavez‐Villa
- Department of SurgeryInstituto Nacional De Ciencias Médicas Y Nutrición Salvador ZubiránTlalpanMexico
| | - Alan Contreras
- Department of SurgeryInstituto Nacional De Ciencias Médicas Y Nutrición Salvador ZubiránTlalpanMexico
| | - Philipp Kron
- Leeds Teaching HospitalNHS Trust, Hepato Pancreatico Biliary SurgeryLeedsUK
| | - Peter Lodge
- Leeds Teaching HospitalNHS Trust, Hepato Pancreatico Biliary SurgeryLeedsUK
| | - Scott Alford
- Michael E. Debakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Abbas Rana
- Michael E. Debakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Paolo Magistri
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Fabrizio Di Benedetto
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Bethany Johnson
- Department of SurgeryUniversity of Minnesota Masonic Children's HospitalMinneapolisMinnesotaUSA
| | - Varvara Kirchner
- Department of SurgeryUniversity of Minnesota Masonic Children's HospitalMinneapolisMinnesotaUSA
| | - Francis Bauldrick
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of SurgeryWeill Cornell MedicineNew YorkNew YorkUSA
| | - Karim J. Halazun
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of SurgeryWeill Cornell MedicineNew YorkNew YorkUSA
| | - Omid Ghamarnedjad
- Department of General, Visceral and Transplantation SurgeryUniversity HeidelbergHeidelbergGermany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation SurgeryUniversity HeidelbergHeidelbergGermany
| | - Samanta Teixeira Basto
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of MedicineUniversidade Federal Do Rio De JaneiroRio De JaneiroBrazil
| | - Eduardo S. M. Fernandes
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of MedicineUniversidade Federal Do Rio De JaneiroRio De JaneiroBrazil
| | - Jose Paladini
- Department of Surgery, Division of Hepato Pancreatico Biliary Surgery, Liver Transplant UnitHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Martin de Santibañes
- Department of Surgery, Division of Hepato Pancreatico Biliary Surgery, Liver Transplant UnitHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Sander Florman
- Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Parissa Tabrizian
- Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Philipp Dutkowski
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Pierre‐Alain Clavien
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
| | - Ronald W. Busuttil
- Dumont‐University California Los Angeles Transplant CenterDavid Geffen School of Medicine at University California Los AngelesLos AngelesCaliforniaUSA
| | - Fady M. Kaldas
- Dumont‐University California Los Angeles Transplant CenterDavid Geffen School of Medicine at University California Los AngelesLos AngelesCaliforniaUSA
| | - Henrik Petrowsky
- Swiss Hepato Pancreatico Biliary and Transplant Center Zurich, Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
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Panackel C, Mathew JF, Fawas N M, Jacob M. Immunosuppressive Drugs in Liver Transplant: An Insight. J Clin Exp Hepatol 2022; 12:1557-1571. [PMID: 36340316 PMCID: PMC9630030 DOI: 10.1016/j.jceh.2022.06.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/16/2022] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) is the standard of care for end-stage liver failure and hepatocellular carcinoma. Over the years, immunosuppression regimens have improved, resulting in enhanced graft and patient survival. At present, the side effects of immunosuppressive agents are a significant threat to post-LT quality of life and long-term outcome. The role of personalized immunosuppression is to reach a delicate balance between optimal immunosuppression and minimal side effects. Today, immunosuppression in LT is more of an art than a science. There are no validated markers for overimmunosuppression and underimmunosuppression, only a few drugs have therapeutic drug monitoring and immunosuppression regimens vary from center to center. The immunosuppressive agents are broadly classified into biological agents and pharmacological agents. Most regimens use multiple agents with different modes of action to reduce the dosage and minimize the toxicities. The calcineurin inhibitor (CNI)-related toxicities are reduced by antibody induction or using mTOR inhibitor/antimetabolites as CNI sparing or CNI minimization strategies. Post-liver transplant immunosuppression has an intensive phase in the first three months when alloreactivity is high, followed by a maintenance phase when immunosuppression minimization protocols are implemented. Over time some patients achieve "tolerance," defined as the successful stopping of immunosuppression with good graft function and no indication of rejection. Cell-based therapy using immune cells with tolerogenic potential is the future and may permit complete withdrawal of immunosuppressive agents.
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Key Words
- AMR, Antibody-mediated rejection
- APCs, Antigen-presenting cells
- ATG, Anti-thymocyte globulin
- CNI, Calcineurin inhibitors
- CsA, Cyclosporine A
- EVR, Everolimus
- IL-2R, Interleukin 2 Receptor
- LT, Liver transplantation
- MMF, Mycophenolate mofetil
- MPA, Mycophenolic acid
- SRL, Sirolimus
- TAC, Tacrolimus
- TCMR, T-cell-mediated rejection
- antimetabolites
- basiliximab
- calcineurin inhibitors
- cyclosporine
- everolimus
- immunosuppression
- liver transplantation
- mTORi, mammalian targets of rapamycin inhibitor
- mycophenolate mofetil
- tacrolimus
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Affiliation(s)
- Charles Panackel
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Joe F Mathew
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Mohamed Fawas N
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
| | - Mathew Jacob
- Aster Integrated Liver Care, Aster Medcity, Kochi, Kerala, 682027, India
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7
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Osawa I, Ide K, Sakamoto S, Uchida H, Fukuda A, Nishimura N, Haga C, Yoshioka T, Nosaka S, Nakagawa S, Kasahara M. Hematological and biochemical characteristics and diagnostic imaging results in acute T cell-mediated rejection after pediatric liver transplantation. Pediatr Transplant 2022; 26:e14161. [PMID: 34617637 DOI: 10.1111/petr.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/24/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Liver biopsy is the gold standard for diagnosing TCMR after LT. However, complications caused by liver biopsy may occur especially during the immediate post-transplantation period and other effective methods for predicting TCMR have not been established. Thus, we investigated whether hematological and biochemical characteristics and Doppler ultrasonography findings are associated with acute TCMR. METHODS A multiple logistic regression analysis was performed to identify the prognostic factors of acute TCMR, defined as a RAI ≥4. Then, a ROC curve analysis was conducted to evaluate for diagnostic performance. The relationship between prognostic factors and each histological category of RAI was investigated. RESULTS Eighty-nine liver biopsies were performed on 85 patients between January 2012 and December 2019. The RAI of 62 (69.7%) liver biopsies was ≥4. AEC (×104 /μl), direct bilirubin level (mg/dl), and MHVV (cm/s) were found to be associated with acute TCMR (OR: 4.96, 95% CI: 1.44-17.0, p = .011; OR: 1.41, 95% CI: 1.04-1.91, p = .025; OR: 1.05, 95% CI: 1.02-1.08, p < .001, respectively). The area under the ROC curves for predicting acute TCMR was 0.86 (95% CI: 0.78-0.94). There was a correlation between AEC, direct bilirubin level, and MHVV as well as the severity of RAI. CONCLUSIONS AEC, direct bilirubin level, and MHVV were the independent risk factors for acute TCMR. This study could provide information regarding the identification of patients requiring liver biopsy.
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Affiliation(s)
- Ichiro Osawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chizuko Haga
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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8
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Angelico R, Sensi B, Manzia TM, Tisone G, Grassi G, Signorello A, Milana M, Lenci I, Baiocchi L. Chronic rejection after liver transplantation: Opening the Pandora’s box. World J Gastroenterol 2021; 27:7771-7783. [PMID: 34963740 PMCID: PMC8661381 DOI: 10.3748/wjg.v27.i45.7771] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/25/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic rejection (CR) of liver allografts causes damage to intrahepatic vessels and bile ducts and may lead to graft failure after liver transplantation. Although its prevalence has declined steadily with the introduction of potent immunosuppressive therapy, CR still represents an important cause of graft injury, which might be irreversible, leading to graft loss requiring re-transplantation. To date, we still do not fully appreciate the mechanisms underlying this process. In addition to T cell-mediated CR, which was initially the only recognized type of CR, recently a new form of liver allograft CR, antibody-mediated CR, has been identified. This has indeed opened an era of thriving research and renewed interest in the field. Liver biopsy is needed for a definitive diagnosis of CR, but current research is aiming to identify new non-invasive tools for predicting patients at risk for CR after liver transplantation. Moreover, the minimization or withdrawal of immunosuppressive therapy might influence the establishment of subclinical CR-related injury, which should not be disregarded. Therapies for CR may only be effective in the “early” phases, and a tailored management of the immunosuppression regimen is essential for preventing irreversible liver damage. Herein, we provide an overview of the current knowledge and research on CR, focusing on early detection, identification of non-invasive biomarkers, immunosuppressive management, re-transplantation and future perspectives of CR.
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Affiliation(s)
- Roberta Angelico
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Bruno Sensi
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Tommaso M Manzia
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Tisone
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
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9
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Immunosuppression in liver and intestinal transplantation. Best Pract Res Clin Gastroenterol 2021; 54-55:101767. [PMID: 34874848 DOI: 10.1016/j.bpg.2021.101767] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 02/07/2023]
Abstract
Immunosuppression handling plays a key role in the early and long-term results of transplantation. The development of multiple immunosuppressive drugs led to numerous clincial trials searching to reach the ideal regimen. Due to heterogeneity of the studied patient cohorts and flaws in many, even randomized controlled, study designs, the answer still stands out. Nowadays triple-drug immunosuppression containing a calcineurin inhibitor (preferentially tacrolimus), an antimetabolite (using mycophenolate moffettil or Azathioprine) and short-term steroids with or without induction therapy (using anti-IL2 receptor blocker or anti-lymphocytic serum) is the preferred option in both liver and intestinal transplantation. This chapter aims, based on a critical review of the definitions of rejection, corticoresistant rejection and standard immunosuppression to give some reflections on how to reach an optimal immunosuppressive status and to conduct trials allowing to draw solid conclusions. Endpoints of future trials should not anymore focus on biopsy proven, acute and chronic, rejection but also on graft and patient survival. Correlation between early- and long-term biologic, immunologic and histopathologic findings will be fundamental to reach in much more patients the status of operational tolerance.
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10
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Toti L, Manzia TM, Sensi B, Blasi F, Baiocchi L, Lenci I, Angelico R, Tisone G. Towards tolerance in liver transplantation. Best Pract Res Clin Gastroenterol 2021; 54-55:101770. [PMID: 34874844 DOI: 10.1016/j.bpg.2021.101770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023]
Abstract
Life-long immunosuppression has always been considered the key in managing liver graft protection from recipient rejection. However, it is associated with severe adverse effects that lead to increased morbidity and mortality, including infections, cardiovascular diseases, kidney failure, metabolic disorders and de novo malignancies. This explains the great interest that has developed in the concept of tolerance in recent years. The liver, thanks to its marked tolerogenicity, is to be considered a privileged organ: up to 60% of selected patients undergoing liver transplantation could safely withdraw immunosuppression.
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Affiliation(s)
- L Toti
- Hepato-Pancreato-Biliary and Transplant Unit, Fondazione Policlinico Tor Vergata, Rome, Italy.
| | - T M Manzia
- University of Rome Tor Vergata, Department of Surgical Science, Italy
| | - B Sensi
- University of Rome Tor Vergata, Department of Surgical Science, Italy
| | - F Blasi
- University of Rome Tor Vergata, Department of Surgical Science, Italy
| | - L Baiocchi
- University of Rome Tor Vergata, Department of Surgical Science, Italy
| | - I Lenci
- Hepatology and Liver Transplant Unit, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - R Angelico
- University of Rome Tor Vergata, Department of Surgical Science, Italy
| | - G Tisone
- University of Rome Tor Vergata, Department of Surgical Science, Italy
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Abstract
Die Lebertransplantation ist in den letzten beinahe 40 Jahren zu einer etablierten Therapie der fortgeschrittenen Leberzirrhose, des akuten Leberversagens sowie gewisser auf die Leber beschränkter Tumorerkrankungen geworden und stellt somit für viele unserer Patientinnen und Patienten eine lebensrettende Behandlungsmöglichkeit dar. Leider jedoch ist der Zugang zu einer Lebertransplantation dadurch limitiert, dass nicht für alle Patientinnen und Patienten ausreichend Spenderorgane zur Verfügung stehen. Der folgende Artikel fasst die wichtigsten Punkte zur Indikation, Abklärung vor Transplantation sowie zum Management nach der Transplantation zusammen.
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Affiliation(s)
- Katharina Staufer
- Universitätsklinik für Viszerale Chirurgie und Medizin, Inselspital, Universitätsspital Bern, Freiburgstrasse, 3010 Bern, Schweiz
| | - Antonio Galante
- Servizio di Gastroenterologia e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Schweiz
| | - Andrea De Gottardi
- Servizio di Gastroenterologia e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Schweiz
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12
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Thomson AW, Vionnet J, Sanchez-Fueyo A. Understanding, predicting and achieving liver transplant tolerance: from bench to bedside. Nat Rev Gastroenterol Hepatol 2020; 17:719-739. [PMID: 32759983 DOI: 10.1038/s41575-020-0334-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
Abstract
In the past 40 years, liver transplantation has evolved from a high-risk procedure to one that offers high success rates for reversal of liver dysfunction and excellent patient and graft survival. The liver is the most tolerogenic of transplanted organs; indeed, immunosuppressive therapy can be completely withdrawn without rejection of the graft in carefully selected, stable long-term liver recipients. However, in other recipients, chronic allograft injury, late graft failure and the adverse effects of anti-rejection therapy remain important obstacles to improved success. The liver has a unique composition of parenchymal and immune cells that regulate innate and adaptive immunity and that can promote antigen-specific tolerance. Although the mechanisms underlying liver transplant tolerance are not well understood, important insights have been gained into how the local microenvironment, hepatic immune cells and specific molecular pathways can promote donor-specific tolerance. These insights provide a basis for the identification of potential clinical biomarkers that might correlate with tolerance or rejection and for the development of novel therapeutic targets. Innovative approaches aimed at promoting immunosuppressive drug minimization or withdrawal include the adoptive transfer of donor-derived or recipient-derived regulatory immune cells to promote liver transplant tolerance. In this Review, we summarize and discuss these developments and their implications for liver transplantation.
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Affiliation(s)
- Angus W Thomson
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Julien Vionnet
- Institute of Liver Studies, Medical Research Council (MRC) Centre for Transplantation, School of Immunology and Infectious Diseases, King's College London University, King's College Hospital, London, UK.,Transplantation Center, University Hospital of Lausanne, Lausanne, Switzerland.,Service of Gastroenterology and Hepatology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, Medical Research Council (MRC) Centre for Transplantation, School of Immunology and Infectious Diseases, King's College London University, King's College Hospital, London, UK
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13
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Negrey JD, Thompson ME, Langergraber KE, Machanda ZP, Mitani JC, Muller MN, Otali E, Owens LA, Wrangham RW, Goldberg TL. Demography, life-history trade-offs, and the gastrointestinal virome of wild chimpanzees. Philos Trans R Soc Lond B Biol Sci 2020; 375:20190613. [PMID: 32951554 PMCID: PMC7540950 DOI: 10.1098/rstb.2019.0613] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2020] [Indexed: 12/11/2022] Open
Abstract
In humans, senescence increases susceptibility to viral infection. However, comparative data on viral infection in free-living non-human primates-even in our closest living relatives, chimpanzees and bonobos (Pan troglodytes and P. paniscus)-are relatively scarce, thereby constraining an evolutionary understanding of age-related patterns of viral infection. We investigated a population of wild eastern chimpanzees (P. t. schweinfurthii), using metagenomics to characterize viromes (full viral communities) in the faeces of 42 sexually mature chimpanzees (22 males, 20 females) from the Kanyawara and Ngogo communities of Kibale National Park, Uganda. We identified 12 viruses from at least four viral families possessing genomes of both single-stranded RNA and single-stranded DNA. Faecal viromes of both sexes varied with chimpanzee age, but viral richness increased with age only in males. This effect was largely due to three viruses, salivirus, porprismacovirus and chimpanzee stool-associated RNA virus (chisavirus), which occurred most frequently in samples from older males. This finding is consistent with the hypothesis that selection on males for early-life reproduction compromises investment in somatic maintenance, which has delayed consequences for health later in life, in this case reflected in viral infection and/or shedding. Faecal viromes are therefore useful for studying processes related to the divergent reproductive strategies of males and females, ageing, and sex differences in longevity. This article is part of the theme issue 'Evolution of the primate ageing process'.
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Affiliation(s)
| | | | | | | | | | | | | | - Leah A. Owens
- University of Wisconsin-Madison, Madison, WI 53706, USA
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14
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Ruiz P, Millán O, Ríos J, Díaz A, Sastre L, Colmenero J, Crespo G, Brunet M, Navasa M. MicroRNAs 155-5p, 122-5p, and 181a-5p Identify Patients With Graft Dysfunction Due to T Cell-Mediated Rejection After Liver Transplantation. Liver Transpl 2020; 26:1275-1286. [PMID: 32615025 DOI: 10.1002/lt.25842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/05/2020] [Accepted: 06/14/2020] [Indexed: 12/11/2022]
Abstract
MicroRNAs (miRNAs) are small noncoding RNAs that can be detected in plasma and whose expression is associated with pathological processes. The role of miRNAs in the noninvasive diagnosis of T cell-mediated rejection (TCMR) after liver transplantation (LT) is unclear. Thus, we aimed to assess the effectiveness of a panel of 4 miRNAs (155-5p, 122-5p, 181a-5p, and 148-3p) in diagnosing TCMR in LT recipients with graft dysfunction (GD), and we compared its accuracy with previously published tests for diagnosing TCMR based on routine laboratory parameters. From a prospective cohort of 145 patients followed during the first year after transplant, 49 developed GD and underwent a liver biopsy and plasma collection for miRNA analysis using quantitative real-time polymerase chain reaction. Patients with GD due to TCMR (n = 21) exhibited significantly higher (P < 0.001) expression of miRNA 155-5p (2.05 versus 0.07), 122-5p (19.36 versus 1.66), and 181a-5p (1.33 versus 0.37) compared with those with GD from other causes (n = 28). The area under the receiver operating characteristic curve of miRNAs 155-5p, 122-5p, and 181a-5p for the diagnosis of TCMR was 0.87, 0.91, and 0.89, respectively, significantly higher than those of the other noninvasive tests (P < 0.001). Furthermore, miRNA 155-5p identified all patients who presented TCMR during the first 2 weeks after transplant. miRNA plasmatic expression differentiates TCMR from other causes of GD in patients who have undergone LT and may be a useful tool in clinical practice.
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Affiliation(s)
- Pablo Ruiz
- Liver Transplant Unit, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Olga Millán
- Pharmacology and Toxicology, Biochemistry and Molecular Genetics, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Jose Ríos
- Pathology Department, Biochemical Diagnostic Centre, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Díaz
- Medical Statistics Core Facility, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Lydia Sastre
- Liver Transplant Unit, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Mercè Brunet
- Pharmacology and Toxicology, Biochemistry and Molecular Genetics, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Liver Transplant Unit, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
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15
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von Platen A, D'Souza MA, Rooyackers O, Nowak G. Intrahepatic Microdialysis for Monitoring of Metabolic Markers to Detect Rejection Early After Liver Transplantation. Transplant Proc 2020; 53:130-135. [PMID: 32631580 DOI: 10.1016/j.transproceed.2020.02.157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/07/2020] [Accepted: 02/15/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The clinical and biochemical manifestations of acute rejection after liver transplantation are nonspecific, and a liver biopsy is often needed to verify the diagnosis. This may delay treatment. The aim of this study was to evaluate whether monitoring of intrahepatic glucose, lactate, pyruvate, and glycerol by microdialysis can be used to predict rejection early after liver transplantation. METHODS Seventy-one patients undergoing liver transplantation were included in the study. The patients were monitored using microdialysis for up to 6 days postoperatively. Patients who developed acute rejection within 1 month were identified according to standard protocol. Area under the curve (AUC) was calculated for 12-hour intervals for glucose, lactate, pyruvate, glycerol, and lactate/pyruvate ratio. Patients with and without rejection were compared with respect to these parameters, as well as standard liver blood investigations and time-zero biopsies. RESULTS The lactate/pyruvate ratio was higher at 0 to 12 hours in the group with rejection as compared to the group without rejection. Glucose was lower in the group with rejection at 24 to 48 hours. Also, the intrahepatic lactate levels at 48 to 72 hours and pyruvate levels at 60 to 72 hours after liver transplantation, were higher in the rejection group. The lactate/pyruvate ratio at 0 to 12 hours and lactate at 60 to 72 hours were two independent risk factors for rejection within the first month after liver transplantation. No significant differences in glycerol levels could be detected between the two patient groups. CONCLUSIONS Microdialysis monitoring following liver transplantation may be useful in the detection of the metabolic events that precede rejection. The metabolic patterns detected by microdialysis early after transplantation indicate a possible relation between primary ischemia-reperfusion injury and the development of rejection. Identifying these patterns may help to identify patients at risk for the development of acute rejection and may help select those who may benefit from higher dose of immunosuppression early after liver transplantation.
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Affiliation(s)
- Anna von Platen
- Division of Transplant Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Melroy A D'Souza
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesiology and Intensive Care, Department for Clinical Science, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Division of Transplant Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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16
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International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients. Transplantation 2019; 102:727-743. [PMID: 29485508 DOI: 10.1097/tp.0000000000002147] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.
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17
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Kumar S, Mohapatra N, Borle DP, Choudhury A, Sarin S, Gupta E. Non invasive diagnosis of acute cellular rejection after liver transplantation - Current opinion. Transpl Immunol 2018; 47:1-9. [PMID: 29452168 DOI: 10.1016/j.trim.2018.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/31/2018] [Accepted: 02/05/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Senthil Kumar
- Dept of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi 70, India.
| | - Nihar Mohapatra
- Dept of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi 70, India
| | | | - Ashok Choudhury
- Dept of Transplantation Hepatology, Institute of Liver and Biliary Sciences, New Delhi 70, India
| | - Shashwat Sarin
- Dept of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi 70, India
| | - Ekta Gupta
- Dept of Virology, Institute of Liver and Biliary Sciences, New Delhi 70, India
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18
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Heinze G, Dunkler D. Five myths about variable selection. Transpl Int 2017; 30:6-10. [PMID: 27896874 DOI: 10.1111/tri.12895] [Citation(s) in RCA: 315] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/14/2016] [Accepted: 11/25/2016] [Indexed: 01/15/2023]
Abstract
Multivariable regression models are often used in transplantation research to identify or to confirm baseline variables which have an independent association, causally or only evidenced by statistical correlation, with transplantation outcome. Although sound theory is lacking, variable selection is a popular statistical method which seemingly reduces the complexity of such models. However, in fact, variable selection often complicates analysis as it invalidates common tools of statistical inference such as P-values and confidence intervals. This is a particular problem in transplantation research where sample sizes are often only small to moderate. Furthermore, variable selection requires computer-intensive stability investigations and a particularly cautious interpretation of results. We discuss how five common misconceptions often lead to inappropriate application of variable selection. We emphasize that variable selection and all problems related with it can often be avoided by the use of expert knowledge.
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Affiliation(s)
- Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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19
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Rodríguez-Perálvarez M, De Luca L, Crespo G, Rubin Á, Marín S, Benlloch S, Colmenero J, Berenguer M, Navasa M, Tsochatzis E, De la Mata M. An objective definition for clinical suspicion of T-cell-mediated rejection after liver transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation; Reina Sofía University Hospital; IMIBIC; CIBERehd; Córdoba Spain
| | - Laura De Luca
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit; Royal Free Hospital and UCL; London UK
| | - Gonzalo Crespo
- Liver Transplant Unit; Hospital Clinic; IDIBAPS; CIBERehd; Barcelona Spain
| | - Ángel Rubin
- Hepatology and Liver Transplantation Unit; La Fe University Hospital; CIBERehd; Valencia Spain
| | - Sandra Marín
- Department of Hepatology and Liver Transplantation; Reina Sofía University Hospital; IMIBIC; CIBERehd; Córdoba Spain
| | - Salvador Benlloch
- Hepatology and Liver Transplantation Unit; La Fe University Hospital; CIBERehd; Valencia Spain
| | - Jordi Colmenero
- Liver Transplant Unit; Hospital Clinic; IDIBAPS; CIBERehd; Barcelona Spain
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit; La Fe University Hospital; CIBERehd; Valencia Spain
| | - Miguel Navasa
- Liver Transplant Unit; Hospital Clinic; IDIBAPS; CIBERehd; Barcelona Spain
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit; Royal Free Hospital and UCL; London UK
| | - Manuel De la Mata
- Department of Hepatology and Liver Transplantation; Reina Sofía University Hospital; IMIBIC; CIBERehd; Córdoba Spain
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20
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Shaked A, Chang BL, Barnes MR, Sayre P, Li YR, Asare S, DesMarais M, Holmes MV, Guettouche T, Keating BJ. An ectopically expressed serum miRNA signature is prognostic, diagnostic, and biologically related to liver allograft rejection. Hepatology 2017; 65:269-280. [PMID: 27533743 DOI: 10.1002/hep.28786] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 08/02/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED The ability to noninvasively diagnose acute cellular rejection (ACR) with high specificity and sensitivity would significantly advance personalized liver transplant recipient care and management of immunosuppression. We performed microRNA (miRNA) profiling in 318 serum samples from 69 liver transplant recipients enrolled in the Immune Tolerance Network immunosuppression withdrawal (ITN030ST) and Clinical Trials in Organ Transplantation (CTOT-03) studies. We quantified serum miRNA at clinically indicated and/or protocol biopsy events (n = 130). The trajectory of ACR diagnostic miRNAs during immunosuppression withdrawal were also evaluated in sera taken at predetermined intervals during immunosuppression minimization before and at clinically indicated liver biopsy (n = 119). Levels of 31 miRNAs were significantly associated with ACR diagnosis with two miRNAs differentiating ACR from non-ACR (area under the receiver operating characteristic curve = 90%, 95% confidence interval = 82%-96%) and predicted ACR events up to 40 days before biopsy-proven rejection. The most differentially expressed miRNAs were low or absent in the blood of healthy individuals but highly expressed in liver tissue, indicating an ectopic origin from the liver allograft. Pathway analyses of rejection-associated miRNAs and their target messenger RNAs (mRNAs) showed induction of proinflammatory and cell death-related pathways. Integration of differentially expressed serum miRNA with concordant liver biopsy mRNA demonstrates interaction between molecules with a known role in transplant rejection. CONCLUSION Distinct miRNA levels profiled from sera at the time of clinical allograft dysfunction can be used to noninvasively diagnose ACR. Predictive trajectories of the same profile during supervised immunosuppression minimization diagnosed rejection up to 40 days prior to clinical expression. The rejection-associated miRNAs in sera appear to be ectopically expressed liver and specific immune cell miRNAs that are biologically related, and the consequences of immune-mediated damage to the allograft. (Hepatology 2017;65:269-280).
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Affiliation(s)
- Abraham Shaked
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bao-Li Chang
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael R Barnes
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Peter Sayre
- Immune Tolerance Network, University of California, San Francisco, CA
| | - Yun R Li
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Michele DesMarais
- Immune Tolerance Network, University of California, San Francisco, CA.,Immune Tolerance Network, Bethesda, MD
| | - Michael V Holmes
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Toumy Guettouche
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brendan J Keating
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
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21
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Crespo G, Castro-Narro G, García-Juárez I, Benítez C, Ruiz P, Sastre L, Colmenero J, Miquel R, Sánchez-Fueyo A, Forns X, Navasa M. Usefulness of liver stiffness measurement during acute cellular rejection in liver transplantation. Liver Transpl 2016; 22:298-304. [PMID: 26609794 DOI: 10.1002/lt.24376] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/19/2015] [Accepted: 10/22/2015] [Indexed: 12/11/2022]
Abstract
Liver stiffness measurement (LSM) is a useful method to estimate liver fibrosis and portal hypertension. The inflammatory process that takes place in post-liver transplant acute cellular rejection (ACR) may also increase liver stiffness. We aimed to explore the association between liver stiffness and the severity of ACR, as well as to assess the relationship between liver stiffness and response to rejection treatment in a prospective study that included 27 liver recipients with biopsy-proven ACR, 30 stable recipients with normal liver tests, and 30 hepatitis C virus (HCV)-infected LT recipients with histologically diagnosed HCV recurrence. Patients with rejection were stratified into 2 groups (mild and moderate/severe) according to the severity of rejection evaluated with the Banff score. Routine biomarkers and LSM with FibroScan were performed at the time of liver biopsy (baseline) and at 7, 30, and 90 days in patients with rejection and at baseline in control patients. Median baseline liver stiffness was 5.9 kPa in the mild rejection group, 11 kPa in the moderate/severe group (P = 0.001), 4.2 kPa in stable recipients (P = 0.02 versus mild rejection), and 13.6 kPa in patients with recurrent HCV (P = 0.17 versus moderate/severe rejection). The area under the receiver operator characteristic curve of LSM to discriminate mild versus moderate/severe ACR was 0.924, and a LSM value of 8.5 kPa yielded a positive predictive value of 100% to diagnose moderate/severe rejection. Liver stiffness improved in 7%, 21%, and 64% of patients with moderate/severe rejection at 7, 30, and 90 days. In conclusion, according to the results of this exploratory study, LSM is associated with the severity of ACR in liver transplantation and thus may be of help in its assessment.
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Affiliation(s)
| | - Graciela Castro-Narro
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico DF, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico DF, Mexico
| | - Carlos Benítez
- Liver Transplant Unit, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Pablo Ruiz
- Liver Unit, University of Barcelona, Barcelona, Spain
| | - Lydia Sastre
- Liver Unit, University of Barcelona, Barcelona, Spain
| | | | - Rosa Miquel
- Pathology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | | | - Xavier Forns
- Liver Unit, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Liver Unit, University of Barcelona, Barcelona, Spain
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Rodríguez-Perálvarez M, Rico-Juri JM, Tsochatzis E, Burra P, De la Mata M, Lerut J. Biopsy-proven acute cellular rejection as an efficacy endpoint of randomized trials in liver transplantation: a systematic review and critical appraisal. Transpl Int 2016; 29:961-73. [DOI: 10.1111/tri.12737] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 09/18/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation; Reina Sofía University Hospital; IMIBIC; CIBERehd; Córdoba Spain
| | - Jose M. Rico-Juri
- Starzl Unit of Abdominal Transplantation; Cliniques Universitaires Saint Luc; Université Catholique de Louvain (UCL); Brussels Belgium
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit; Royal Free Hospital and UCL; London UK
| | - Patrizia Burra
- Multivisceral Transplant Unit Gastroenterology; Padova University Hospital; Padova Italy
| | - Manuel De la Mata
- Department of Hepatology and Liver Transplantation; Reina Sofía University Hospital; IMIBIC; CIBERehd; Córdoba Spain
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation; Cliniques Universitaires Saint Luc; Université Catholique de Louvain (UCL); Brussels Belgium
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Ascha MS, Ascha ML, Hanouneh IA. Management of immunosuppressant agents following liver transplantation: Less is more. World J Hepatol 2016; 8:148-161. [PMID: 26839639 PMCID: PMC4724578 DOI: 10.4254/wjh.v8.i3.148] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/12/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Immunosuppression in organ transplantation was revolutionary for its time, but technological and population changes cast new light on its use. First, metabolic syndrome (MS) is increasing as a public health issue, concomitantly increasing as an issue for post-orthotopic liver transplantation patients; yet the medications regularly used for immunosuppression contribute to dysfunctional metabolism. Current mainstay immunosuppression involves the use of calcineurin inhibitors; these are potent, but nonspecifically disrupt intracellular signaling in such a way as to exacerbate the impact of MS on the liver. Second, the impacts of acute cellular rejection and malignancy are reviewed in terms of their severity and possible interactions with immunosuppressive medications. Finally, immunosuppressive agents must be considered in terms of new developments in hepatitis C virus treatment, which undercut what used to be inevitable viral recurrence. Overall, while traditional immunosuppressive agents remain the most used, the specific side-effect profiles of all immunosuppressants must be weighed in light of the individual patient.
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