Initial two-year results of the Oregon Liver Transplantation Program

Acute cellular rejection after liver transplantation: variability, morbidity, and mortality

Acute cellular rejection of the allograft is a potentially serious complication after liver transplantation, yet its true incidence is unknown. We therefore investigated the frequency of acute cellular rejection reported by transplant centers and its impact on morbidity and mortality. Morbidity was defined as duration of hospitalization. Of 200 articles screened, 18 were selected for inclusion in the study database, in which there was a total of 1,437 patients who received transplants. All contained more than 20 patients and invariably used histopathology for diagnosis of acute cellular rejection. These reports included all transplant patients within a fixed period and sufficient data to determine the incidence of acute cellular rejection. Morbidity data were obtained from our previous series. The mean incidence of acute cellular rejection in all centers was 49.8% (range between centers, 24% to 80%). Two immunosuppressive cohorts were identified: high-dose cyclosporine induction (> or = 5 mg/kg/d) and low-dose cyclosporine induction (< or = 4 mg/kg/d). Acute cellular rejection was reported in 27.0% of the high-dose group and 63.6% of the low-dose group, P = .0001. Strict adherence to Snover's histological criteria for acute cellular rejection did not alter the reported mean incidence. Frequency of acute cellular rejection was 45.2% (range between centers, 24% to 80%) in 8 studies that used Snover's criteria, and 51.6% (range between centers, 37% to 80%) in 10 studies that did not. There was no correlation between mortality and incidence of acute cellular rejection in the 9 studies that reported survival (R2 = .105). Morbidity data showed that the average length of initial hospitalization after transplantation for patients with acute cellular rejection was 52.4 +/- 8.3 (range, 14 to 124) days, in contrast to 28.3 +/- 2.3 (range, 9 to 87) days for patients with no rejection. P = .0008. The total number of hospital days in the first 6 months for patients with acute cellular rejection was 55.6 +/- 8.6 (range, 14 to 124) days and with no rejection, was 37.7 +/- 3.1 (range, 9 to 99) days. P = .0232. The incidence of acute cellular rejection varies widely among transplant centers, regardless of the use of Snover's criteria. Acute cellular rejection appeared to be less frequent in programs using high-dose cyclosporine induction regimens. The presence of acute cellular rejection seemed to have no correlation with mortality but significantly increased morbidity and therefore the cost of transplantation.

Biliary tract reconstruction: comparison of different techniques after 187 paediatric liver transplantations

Biliary complications after liver transplantation are common and cause significant morbidity and mortality. In order to evaluate the complications related to different sorts of biliary reconstruction, from January 1984 to July 1992 we retrospectively analysed 187 consecutive liver transplants in 136 paediatric patients at Addenbrooke's Hospital, Cambridge. There were 51 (27.2%) retransplantations. Biliary reconstruction consisted of: type 1-common bile duct-Roux loop (CBD-RL); n = 90 (48.1%); type 2-gallbladder conduit-Roux loop (GC-RL), n = 51 (27.2%); type 3-gallbladder conduit-common bile duct (GC-CBD), n = 20 (10.6%); type 4-common bile duct-common bile duct (CBD-CBD), n = 18 (9.6%); and type 5-common bile duct-common bile duct+gallbladder drainage (CBD-CBD+GB), n = 8 (4.2%). There were, in all 26 biliary complications (14%). Of these 26 complications, biliary stricture was the most common (17/26; 65.3%) and 6 out of these 17 (35.2%) were associated with chronic rejection. Hepatic artery thrombosis was directly related to biliary leakage in 6 out of 26 (23.1%) biliary tract complications. This series demonstrated that type 1 and type 4 reconstructions were related to fewer biliary complications (9/90, 10% and 2/18; 11%, respectively) than the other techniques: 8/51 (16%) for GC-RL 5/20 (25%) for GC-CBD and 2/8 (25%) for CBD-CBD+GB (P = 0.09).

Fibrosing cytolytic liver failure secondary to recurrent hepatitis B after liver transplantation

Four patients who underwent transplantation for hepatitis B virus-related liver disease developed rapidly progressive liver failure attributable to recurrent hepatitis B disease typified by hyperbilirubinemia and distinctive hepatocyte ballooning and progressive fibrosis consistent with recently reported fibrosing cholestatic hepatitis. Among these four patients, the mean interval from transplantation to redocumentation of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) was 5 months, to development of malaise and jaundice 6 months, to histological diagnosis 7 months, and to graft failure 8 months. The only patient who underwent retransplantation had accelerated recurrence of the same syndrome with biopsy documentation 1 month later and graft failure 2 months later. Distinctive histological features included confluent hepatocellular ballooning and progressive periportal fibrosis followed by lobular collapse over 4-6 weeks without significant inflammation. Immunohistochemical staining showed marked HBsAg and hepatitis B core antigen (HBcAg) immunoreactivity. The rapid development of cytolytic hepatocellular necrosis and lobular collapse with prominent HBcAg immunoreactivity without significant inflammation suggests a cytolytic rather than immune pathogenesis for this unique and devastating form of recurrent hepatitis B that might better be termed "fibrosing cytolytic hepatitis."

Management of biliary complications after liver transplantation

Biliary tract complications after liver transplantation are common, and the evaluation of newer treatment options compared with standard surgical treatment is important. In 62 liver transplants performed in 55 adult patients, the biliary tract was reconstructed with choledochocholedochostomy (CC) in 52 (84%) and Roux-en-Y choledochojejunostomy (RYCJ) in 10 (16%). Seventeen biliary tract complications occurred in 16 patients (29%). The incidence of complications was the same after CC and RYCJ. Eight complications (47%) occurred within the first month and nine (53%) thereafter. Only 6 of 17 (35%) biliary tract complications required operation. One patient died of a biliary tract complication. No other allografts were lost due to biliary tract complications. Four patients transplanted at other centers were also treated, for a total of 21 biliary tract complications. Overall, there were nine bile leaks, eight bile duct strictures, two Roux loop hemorrhages, one choledocholithiasis, and one ampullary dyskinesia. Temporary or permanent stents were used successfully in seven of eight strictures. Five bile leaks were managed without operation. Nonsurgical management is appropriate for a selected majority of patients with late bile leaks, biliary tract strictures, or choledocholithiasis after liver transplantation.