Graft failure from severe recurrent primary sclerosing cholangitis following orthotopic liver transplantation

Seeking beyond rejection: an update on the differential diagnosis and a practical approach to liver allograft biopsy interpretation

Pathologic evaluation of liver allograft biopsies plays an integral role in the management of patients after liver transplantation. This review summarizes the clinical context and classical histology of different types of allograft rejection and also the common entities that enter the differential diagnosis of allograft rejection, and provides practical approaches to liver allograft biopsy interpretation. In addition, some of the new developments in the field of liver transplant pathology are updated. The purpose of this review is to provide guidance for pathologists interpreting liver allograft biopsies, particularly those interested in developing expertise in the field of liver transplant pathology.

Transplantation in autoimmune liver diseases

Liver transplantation remains an effective treatment for those with end-stage disease and with intractable liver-related symptoms. The shortage of organs for transplantation has resulted in the need for rationing. A variety of approaches to selection and allocation have been developed and vary from country to country. The shortage of donors has meant that new approaches have to be adopted to make maximal use of the available organs; these include splitting grafts, use of extended criteria livers, livers from non-heart-beating donors and from living donors. Post transplantation, most patients will need life-long immunosuppression, although a small proportion can have immunosuppression successfully withdrawn. Newer immunosuppressive drugs and different strategies may allow a more targeted approach with a reduction in side-effects and so improve the patient and graft survival. For autoimmune diseases, transplantation is associated with significant improvement in the quality and length of life. Disease may recur after transplantation and may affect patient and graft survival.

Risk factors for recurrence of primary sclerosing cholangitis after liver transplantation

Orthotopic liver transplantation (OLT) is the only effective treatment for end-stage liver disease due to primary sclerosing cholangitis (PSC). Recurrence of PSC has recently emerged as a leading cause of allograft failure in the long term. There is limited data on risk factors for recurrence of PSC. We performed a retrospective analysis of 69 consecutive patients who underwent a first OLT for PSC over a 14-year period. Baseline characteristics and clinical and laboratory test results post-LT were recorded. Cholangiograms and liver histopathology were reviewed in a blinded manner by an experienced radiologist and hepatopathologist. Recurrent PSC was diagnosed using previously published Mayo Clinic cholangiographic or histologic criteria. Of 69 patients, 7 (10%) developed recurrent PSC at a median of 68 months (range, 24-134 months) post-LT. The following variables were associated with recurrent PSC in our cohort: presence of human leukocyte antigen (HLA)-DRB1*08 (29% versus 2%; P= 0.026; odds ratio [OR], 24.4; 95% confidence interval [CI], 1.8-318.1), acute cellular rejection (ACR) (71% versus 22%; P= 0.015; OR, 8.7; 95% CI, 1.5-49.9), and steroid-resistant ACR (29% versus 0%; P= 0.012). Despite the strong linkage disequilibrium between DRB1*08 and DQB1*04, DRB1*08-positive subjects with recurrence were negative for DQB1*04, whereas the single DRB1*08-positive subject without recurrent PSC was positive for DQB1*04. A history of ACR and presence of HLA-DRB1*08 are associated with increased risk of recurrent PSC, suggesting an immunologic mechanism for this syndrome. Further studies are required to confirm these observations and to understand the underlying mechanisms.

A difficult case of primary sclerosing cholangitis

1. The immediate postoperative concerns in a patient with primary sclerosing cholangitis. 2. Recognize the difficulties in assessing biliary health in patients that have had complicated postoperative biliary concerns. 3. Recognize the difficulty in ascertaining the presence of chronic rejection vs. recurrent primary sclerosing cholangitis.

Primary sclerosing cholangitis: summary of a workshop

Primary sclerosing cholangitis (PSC) is a rare but important liver disease that leads to cirrhosis and need for liver transplantation in a high proportion of cases. The disease occurs in approximately 1 per 100,000 population per year, usually presents in adulthood, and affects men more often than women. Typical serum biochemical results, autoantibodies and liver biopsy are suggestive but not diagnostic of PSC, the diagnosis requiring cholangiographic demonstration of stricturing and dilatation of the intra- and/or extra-hepatic bile ducts. The natural history of PSC is variable, the average survival being 12 to 17 years. The cause of PSC is still unknown. Although considered an autoimmune disease, PSC has several atypical features and a strong genetic component. The therapy of PSC is unsatisfactory. Standard doses of ursodeoxycholic acid (UDCA) lead to improvements in biochemical abnormalities but not in histology, cholangiographic appearance or survival. Several innovative therapies have been tried in PSC, but with scant evidence of benefit. For patients with high grade strictures, endoscopic dilatation is beneficial. Liver transplantation is successful for end-stage liver disease due to PSC and improves survival. PSC may recur after transplantation but is rarely progressive. The most dreaded complication of PSC is cholangiocarcinoma. Diagnosis of this highly malignant tumor is difficult, and there are no biomarkers for its early detection. Liver transplantation for cholangiocarcinoma has an exceedingly poor outcome, although transplantation with neoadjuvant chemoirradiation holds promise in selected patients. Thus, significant opportunities remain for basic and clinical research into the cause, natural history, and therapy of PSC.

Diagnosis and management of allograft failure

The article focuses on diagnosis and management of allograft failure in four main categories: (1) ischemic-reperfusion injury (primary nonfunction), (2) technical complications (hepatic artery and portal vein thrombosis), (3) chronic rejection, and (4) recurrent disease. It also discusses the complex problems involved in retransplantation for allograft failure.

Review article: current management of primary sclerosing cholangitis

The management of primary sclerosing cholangitis (PSC) is hindered by incomplete understanding of the pathogenesis of the disease and the lack of good prognostic models. Few large randomized controlled trials of drug therapy have been published. Best practice in the management of PSC is currently based therefore on careful interpretation of the available evidence, close observation of individual patients and clinical experience of the disease. Drug therapy is useful for alleviating symptoms. Ursodeoxycholic acid may slow progression of the disease and reduce the frequency of complications. Consensus is emerging on the issues of screening for the malignant complications of PSC and the indications for liver transplantation are becoming broader and encompassing the earliest stages of cholangiocarcinoma. In view of the rarity of the disease in the general population, large international collaborations to study PSC are necessary to provide clearer answers in areas of uncertainty, and these are now beginning to emerge.

Endoscopic Management of Biliary Complications After Orthotopic Liver Transplantation

After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.