Transcript Document

Progressive histological damage in liver allografts
following paediatric liver transplantation
Helen M Evans1, Deirdre A Kelly1, Patrick J McKiernan1 and Stefan G Hübscher2
1The
Liver Unit, Birmingham Children’s Hospital, United Kingdom and
2Department
of Pathology, University of Birmingham, United Kingdom
Background
1.
Histological Findings in Late (>12 months) Post-Transplant
Biopsies
2.
Chronic hepatitis in the liver allograft
3.
Specific issues relating to the paediatric liver allograft
recipient
Histological Findings in Late (>12 months) Post-Transplant Biopsies
(Nakhleh 1990, Hübscher1990, Hübscher 1993, Pappo 1995 Rosenthal 1997, Slapak 1997, Pessoa 1998,
Davison 1998,Sebagh 2003, Heneghan 2003, Rifai 2004, Nakhleh 2005)
•
Studies in adults suggest that the majority (70-90%) develop histological
abnormalities
•
Many seen in protocol biopsies obtained from people who are clinically well with
good graft function
•
Recurrent disease (particularly HCV) is the commonest aetiological factor.
•
Rejection relatively uncommon. May have different features to those seen in the
early post-transplant period.
•
Many biopsies have features of chronic hepatitis.
•
In a varying proportion of cases no obvious cause for chronic hepatitis can be
identified
Histological Findings in Late (>12 months) Post-Transplant Biopsies
(Nakhleh 1990, Hübscher1990, Hübscher 1993, Pappo 1995 Rosenthal 1997, Slapak 1997, Pessoa 1998,
Davison 1998,Sebagh 2003, Heneghan 2003, Rifai 2004, Nakhleh 2005)
Institution
Time of No of
biopsy biopsies
No (%)
Biopsies
with CH
Aetiology
Pittsburgh
(Pappo 1995)
> 5 yrs
65
19 (29)
9 HCV, 3 HBV, 1 AIH
6 (32%) cause unknown
Kings, London
(Slapak, 1997)
> 5 yrs
116
27 (23)
10 HCV, 2 HBV, 2 AIH
13 (48%) cause unknown
Paris
(Sebagh,
2003)
> 10 yrs
143
78 (54)
58 HCV, 10 HBV, 5 HBV+ HCV 4
AIH
1(1.3%) cause unknown
Birmingham
(Liver Unit
Database
1998-2003)
> 1 yr
1124
527 (47)
104 (20%) – recurrent disease
423 (80%) – other/unknown cause
Factors Influencing the Assessment of
Late Post-transplant biopsies
1.
Nature of original liver disease
2.
Indication for liver biopsy
(protocol or clinically indicated)
3.
Type/amount of immunosuppression used
4.
Recurrent disease versus other transplant complications
5.
Diagnostic criteria
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
5.
UNKNOWN (?REJECTION)
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
5.
UNKNOWN (?REJECTION)
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
In some cases histological features of “non-specific” chronic hepatitis may
precede development of more typical biochemical, serological or histological
changes
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
5.
UNKNOWN (?REJECTION)
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
5.
UNKNOWN (?REJECTION)
‘De Novo’ Autoimmune Hepatitis in the Liver Allograft
(Kerkar 1998, Jones 1999, Gupta 2001, Heneghan 2001, Salcedo 2002, Czaja 2002, Vergani 2002,
Mieli-Vergani 2004 ).
1.
Classical biochemical, serological and histological features of AIH may
develop in patients transplanted for other diseases
2.
Higher incidence in paediatric population (up to 5-10%)
3.
In adult population commonest underlying diseases are PBC and PSC.
4.
Most cases respond to increased immunosuppression. Occasional cases
have progressed to graft failure
‘De Novo’ Autoimmune Hepatitis in the Liver Allograft
Problems with Classification
•
Antibodies directed against graft antigens rather than self antigens
(alloimmune rather than autoimmune disease?)
•
Autoantibodies arising de novo following transplantation also described
transiently in association with episodes of rejection. (Lohse 1999, DuclosVallee 2000)
•
Acute rejection episodes have predictive value for development of de
novo AIH (D’Antiga 2002, Miyagawa-Hayashino 2004)
•
“De novo” AIH may represent a form of late cellular rejection
•
“Graft dysfunction mimicking autoimmune hepatitis“ may be a better
term (Heneghan et al Hepatology 2001 ;34 :464-70)
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
- chronic hepatitis not typical of immunosuppressive drug toxicity
- 7/31 cases of post-transplant hepatitis (patients at low risk for
disease recurrence) = probable drug toxicity (Nakhleh Transplant Proc. 2005
Mar;37(2):1240-2)
5.
UNKNOWN (?REJECTION)
Chronic Hepatitis in the Liver Allograft
Possible Causes
1.
VIRAL INFECTION (recurrent or acquired)
- hepatitis B
- hepatitis C
2.
RECURRENT AUTOIMMUNE DISEASE
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
3.
‘DE NOVO’ AUTOIMMUNE HEPATITIS
4.
DRUG TOXICITY
5.
UNKNOWN (?REJECTION)
Late Cellular Rejection
Different Histological Features
(Snover 1988, Kemnitz 1989, Cakaloglu 1995, Pappo 1995)
• Bile duct inflammation and venular endothelial inflammation less
conspicuous
• More prominent interface hepatitis
• More prominent lobular hepatitis with spotty necrosis
• Overall features resemble those seen in chronic hepatitis
(e.g. viral or autoimmune)
Late Post-Transplant Histology in the Paediatric Population
• Few studies have specifically assessed late post-transplant
biopsies in children undergoing liver transplantation
• Most of the diseases for which transplantation carried out in
children do not recur. Chronic hepatitis in the paediatric liver
allograft recipient not due to recurrent disease
• Children more susceptible than adults to develop ‘de novo’
autoimmune hepatitis
Methods
Patients & Biopsies
210 children transplanted between 1983 and 1996
158 alive with graft survival > 5 years
- age 0.0- 15.9 years (median 2.9, mean 4.7)
- 69 (44%) whole livers, 89 (56%) reduced size (81 cut down, 8 split)
Protocol biopsies at 1, 5 and 10 years post-transplant
Other investigations:
- standard LFTs (AST, bilirubin, Alk Phos)
- immunoglobulins A, G, M
- autoantibodies (ANA, SMA, AMA, LKM) - ≥ 1:25 = positive
- CMV and EBV serology
- HBV, HCV and HGV serology (if biopsy showed chronic hepatitis)
Indications for transplantation (158 cases)
•
•
•
•
•
Indication for transplantation
Number
%
Cholestatic disorders
Extra hepatic biliary atresia
Other
Fulminant hepatic failure
Non-A, non-B, non-C acute hepatitis
Viral hepatitis (HAV -3, Echovrus -1)
Drug-induced
Metabolic disorders
Alpha-1-antitrypsin deficiency
Tyrosinaemia type 1
Wilson’s disease
Other
Autoimmune diseases
Autoimmune hepatitis
Sclerosing cholangitis
Miscellaneous
Cryptogenic cirrhosis
Cystic fibrosis
Hepatoblastoma
Other
85
77
8
23
15
4
4
23
8
5
6
4
8
3
5
19
7
6
4
2
53.4
48.4
5.0
15.1
9.5
2.5
2.5
15.1
5.0
3.1
3.8
2.5
5.0
1.9
3.1
11.9
4.4
3.8
2.5
1.2
Methods
Histological Assessments
• Histological data recorded using a long-term biopsy proforma
(since 1989)
• Range of portal and parenchymal features assessed, some
semi-quantitatively graded
• Final diagnostic category assigned
• Statistical analyses
– Chi-squared test to demonstrate differences in frequencies of
observations at 1, 5 and 10 years
– Logistic regression to investigate factors associated with histological
abnormalities at 5 years (time at which most biopsies available)
Methods
Assessment of Inflammatory Activity and Fibrosis
(cases with chronic hepatitis)
Inflammatory Activity Grade
• Interface hepatitis (0-3)
• Lobular necro-inflammation (0-3)
• Overall inflammatory grade (0-3)
Fibrosis Stage
• 0 = none
• 1 = mild (fibrous expansion without bridging)
• 2 = moderate (bridging fibrosis)
• 3 = cirrhosis
Methods
Variables Assessed Statistically
Demographic variables
•
•
•
•
•
•
•
Underlying liver disease
Age (recipient and donor)
Sex (recipient and donor)
Blood group (recipient and donor)
CMV status (recipient and donor)
Cold ischaemic time
Type of allograft (whole, reduced or split)
Dynamic variables (at time of biopsy)
•
•
•
Transaminase levels (ALT and AST)
Immunoglobulin levels
Autoantibody positivity
Results
Biopsies at Different Time Points
1 year
•
113/158 (72%) biopsied
(10-17 months, mean 14 months)
No graft loss or death between 1-5 years
5 years
•
135/158 (85%) biopsied
(49-87 months, mean 62 months)
11 graft losses between 5-10 years
–
–
7 deaths (rec disease-4, bacterial sepsis-2, SAH-1)
4 retransplanted (biliary obstruction-2, chronic rejection-1, de novo AIH-1)
10 years
64/81 (79%) biopsied
(102-132 months, mean 117 months)
Configuration of patients similar at 3 time points (no drop-out bias)
Main Histological Findings at 1, 5 and 10 years
Histological Diagnosis
1 year
(n=113)
5 years
(n=135)
10 years
(n=64)
Normal/ near normal (1)
68.2%
45.2%
31.3%
Chronic hepatitis (2)
22.1%
43.0%
64.0%
Rejection (acute or chronic)
2.7%
2.2%
0
Biliary obstruction
6.2%
7.4%
1.6%
Recurrent Disease
0.9%
0.7%
1.6%
0
1.3%
1.6%
Other
(1) & (2)
p < 0.0001
Normal/near-normal biopsies
1 year
(n=77)
5 years
(n=61)
10 years
(n=20)
Normal
9%
16%
5%
Mild-non specific
changes
88%
75%
75%
Mild fibrosis
(all stage 1)
3%
9%
20%
Chronic Hepatitis 124 biopsies
25 – 1 year, 58 – 5 years, 41 – 10 years
Necroinflammatory Activity
None
Mild
Moderate
Severe
Interface hepatitis
6%
76%
16%
2%
Lobular
inflammation/
necrosis
49%
33%
15%
3%
Overall grade
0
59%
33%
8%
Chronic Hepatitis
Severity of Necro-inflammatory Activity at Different Times
80
70
60
50
% 40
30
20
10
0
mild
moderate
severe
1 year
5 years 10 years Overall
Time post-OLT
Chronic Hepatitis – Histological Findings
Inflammatory Changes
Chronic Hepatitis (mild)- Portal inflammation, mild interface hepatitis
Male, age 8, 1 year post-transplant for cryptogenic cirrhosis
Chronic Hepatitis (mild) – Portal lymphoid follicle
Female, age 6, 5 years post-transplant for acute liver failure (seronegative hepatitis)
Chronic Hepatitis (mild) - Spotty lobular inflammation (zone 3)
Female, age 44, 8 years post-transplant for PBC
Chronic Hepatitis (mild) - Zone 3 inflammation with dropout
Female, age 24, 1 year post-transplant for acute liver failure (seronegative hepatitis)
Chronic Hepatitis - Isolated zone 3 inflammation
Female, age 24, 1 year post-transplant for acute liver failure (seronegative hepatitis)
Chronic Hepatitis (moderate) – portal and lobular (zone 3) inflammation
Male, age 3, 2.5 years post-transplant for biliary atresia
Chronic Hepatitis (moderate) – Portal inflammtion with interface hepatitis
Male, age 3, 2.5 years post-transplant for biliary atresia
Chronic Hepatitis (moderate) – Zone 3 necro-inflammation
Male, age 3, 2.5 years post-transplant for biliary atresia
Normal Hepatic Vein
Chronic Hepatitis (moderate) - Portal plasma cells
Female,age 58, 1 year post-transplant for PBC (no other autoantibodies)
Chronic Hepatitis (severe) – Portal inflammation with interface hepatitis
Female, age 57, 12 years post-transplant for PBC
Chronic Hepatitis (severe) – bridging necrosis
Female, age 30, 3 years post-transplant for fibrolamellar HCC
Chronic Hepatitis (severe) – bridging necrosis
Female, age 30, 3 years post-transplant for fibrolamellar HCC
Chronic Hepatitis (severe) – panacinar necrosis
Female, age 30, 3 years post-transplant for fibrolamellar HCC
Chronic Hepatitis
versus
Late Cellular Rejection
Chronic Hepatitis (mild)
Female, age 28, 3 years post-transplant for acute liver failure (paracetamol)
Chronic hepatitis (mild) ? Cellular rejection - Bile duct inflammation
Female, age 28, 3 years post-transplant for acute liver failure (paracetamol)
Chronic hepatitis (mild) ? Cellular rejection – Portal venulitis
Female, age 28, 3 years post-transplant for acute liver failure (paracetamol)
Chronic hepatitis (mild) ? Cellular rejection – Bile duct loss
Female, age 28, 3 years post-transplant for acute liver failure (paracetamol)
Chronic Hepatitis – Histological Findings
Fibrosis
Chronic Hepatitis - Bridging Fibrosis
Female, age 53, 4 years post-transplant for acute liver failure (seronegative hepatitis)
Chronic Hepatitis – Cirrhosis
Male, age 21, 8 years post-transplant for cystic fibrosis
Chronic Hepatitis
Severity of Fibrosis at Different Times
50
45
40
35
30
% 25
20
15
10
5
0
none
mild
moderate
severe
1 year
5 years
10 years
Time post-OLT
(P<0.0001)
Correlation between AST levels and Histology
AST levels
Median (range)
Histology
1 year
5 years
10 years
Normal
43 (8 – 136)
44 (16 – 155)
38 (21 – 105)
Chronic hepatitis
52 (17 – 110)
63 (22 – 103)
48 (25 – 128)
Other histology
81 (24 – 138)
63 (28 – 248)
65 (16 – 142)
P < 0.005 Other histology vs normal/chronic hepatitis at 1 year
Correlation between Autoantibodies and Histology
Autoantibody positivity
(no positive/total number of biopsies)
Histology
5 years
10 years
Normal/near-normal
8/61 (13%)
2/20 (10%)
Chronic hepatitis
42/58 (72%)
33/41 (80%)
P< 0.0001 (normal vs CH)
4 children with chronic hepatitis and autoantibodies (1 at 5 years + 3 at 10 years)
had other features supporting a diagnosis of de novo AIH (AST>1.5xN, raised
immunoglobulins)
Correlation between Autoantibodies and Histology
Autoantibody positivity
(no positive/total number of biopsies)
Histology
Normal/near-normal
Chronic hepatitis
5 years
10 years
8/61 (13%)
2/20 (10%)
ANA 1 in 25 = 4
ANA 1 in 40 = 4
ANA 1 in 25 = 1
ANA 1 in 40 = 1
42/58 (72%)
33/41 (80%)
ANA 1 in 25 = 8
ANA 1 in 40 = 7
ANA 1 in 100 = 10
ANA 1 in 400 = 9
ANA 1 in 1600 = 4
SMA = 12
LKM = 2
Mixed Abs = 10
ANA 1 in 25 = 5
ANA 1 in 40 = 11
ANA 1 in 100 = 8
ANA 1 in 400 = 3
ANA 1 in 1600 = 3
SMA = 8
LKM = 2
Mixed Abs = 7
Chronic Hepatitis
Causes Identified
Possible cause
Number of cases
Time of diagnosis
Hepatitis C
2
1 year
De novo AIH
4
1 @ 5 years
3 @ 10 years
52/58 cases – no cause identified
Factors Correlating with Chronic Hepatitis
Univariate Analysis
• Autoantibody positivity
• Sex mismatch
• AST/ALT levels
Multivariate Analysis
• Autoantibody positivity
Late Biopsies from Paediatric Liver Allograft Recipients
Summary & Conclusions
• Histological abnormalities commonly present in biopsies taken > 1 year
post-transplant
• Many occur in children who are clinically well with normal LFTs
• Commonest histological diagnosis is chronic hepatitis:
– Prevalence increases with time (20% at 1 year, >60% at 10 years)
– Inflammatory activity typically mild, may increase with time
– Fibrosis increases with time (50% have bridging fibrosis or cirrhosis at 10
years)
• In the majority of cases (52/58) no definite cause for chronic hepatitis can
be identified.
• Many cases of chronic hepatitis are associated with autoantibodies, but
rarely fulfil other diagnostic criteria for de novo autoimmune hepatitis
• Potential clinical implications:
– Graft monitoring (autoantibody testing)
– Treatment ( to prevent development/progression of fibrosis)
Sunday May 15 2005, 4.19 pm
Sunday May 15 2005, 4.51 pm
Chronic Hepatitis
Severity of Necro-inflammatory Activity at Different Times
80
70
60
50
% 40
30
20
10
0
mild
moderate
severe
1 year
5 years 10 years Overall
Time post-OLT
Chronic Hepatitis
Severity of Necro-inflammatory Activity at Different Times
80
70
60
50
% 40
30
20
10
0
mild
moderate
severe
1 year
5 years 10 years Overall
Time post-OLT