Recurrent and de-novo disease in the liver allograft:

Management of the Liver Transplant Recipient: Approach to Allograft Dysfunction

Liver transplant (LT) recipients are living longer than ever today and many will experience some form of allograft dysfunction. The common causes of allograft dysfunction vary significantly depending on the timing since LT. Most allograft abnormalities are manageable with minimally invasive procedures, medications, and lifestyle modification. The most common differential diagnoses by time period after LT, and diagnostic and management considerations, are highlighted. Collaboration and comanagement of LT recipients between primary care and the transplant hepatologist is essential for optimizing recipient and allograft outcomes.

What is the long-term outcome of the liver allograft?

With improved long-term survival following liver transplantation (LT), issues relating to the assessment of the liver allograft in long-term survivors are becoming increasingly relevant. Histological abnormalities are commonly present in late post-transplant biopsies, including protocol biopsies from patients who appear to be well with good graft function. Recurrent disease is the commonest recognised cause of abnormal graft histology, but may be modified by the effects of immunosuppression or interactions with other graft complications, resulting in complex or atypical changes. Other abnormalities seen in late post-transplant biopsies include rejection (which often has different appearances to those seen in the post-transplant period), de novo disease, "idiopathic" post-transplant hepatitis (IPTH) and nodular regenerative hyperplasia. In many cases graft dysfunction has more than one cause and liver biopsy may help to identify the predominant cause of graft damage. Problems exist with the terminology used to describe less well understood patterns of graft injury, but there is emerging evidence to suggest that late rejection, de novo autoimmune hepatitis and IPTH may all be part of an overlapping spectrum of immune-mediated injury occurring in the late post-transplant liver allograft. Careful clinico-pathological correlation is very important and the wording of the biopsy report should take into account therapeutic implications, particularly whether changes in immunosuppression may be indicated. This article will provide an overview of the main histological changes occurring in long-term survivors post-LT, focusing on areas where the assessment of late post-transplant biopsies is most relevant clinically.

Cirrhosis after orthotopic liver transplantation in the absence of primary disease recurrence

Liver allograft cirrhosis is a relatively uncommon complication of liver transplantation. Most cases can be attributed to disease recurrence, particularly recurrent hepatitis C. Little is known about the frequency, etiology, and natural history of liver allograft cirrhosis occurring without evidence of recurrent disease. The aim of the present study was to review the clinicopathological features in this group of patients. We retrospectively reviewed data from all adult patients who were transplanted between 1982 and 2002 and survived >12 months after orthotopic liver transplantation (n = 1,287). Cases of histologically proven cirrhosis were identified from histopathological data entered into the Liver Unit Database. A total of 48 patients (3.7%) developed cirrhosis. In 29 of them, cirrhosis could be attributed to recurrent disease (hepatitis C, 11; hepatitis B, 4; autoimmune hepatitis, 4; primary biliary cirrhosis, 2; primary sclerosing cholangitis, 3; nonalcoholic steatohepatitis, 4; alcoholic liver disease, 1). In 9 of the 19 patients without evidence of disease recurrence, another cause of cirrhosis could be identified (de novo autoimmune hepatitis, 4; biliary complications, 4; acquired hepatitis B, 1). In the remaining 10 cases, the cause of cirrhosis remained unknown; their previous biopsies had shown features of chronic hepatitis of uncertain etiology. Three patients in this group died, and the remaining 7 are alive with good graft function 3-12 years after cirrhosis was first diagnosed. The prevalence of "cryptogenic" posttransplant cirrhosis was significantly higher in patients initially transplanted for fulminant seronegative hepatitis (6%) than in those transplanted for other diseases (0.3%). In conclusion, posttransplant cirrhosis without disease recurrence is uncommon, but it is more frequent in patients transplanted for fulminant seronegative hepatitis. Chronic hepatitis is the most frequent underlying pathological process in cases where the cause of cirrhosis remains uncertain.

Transplantation pathology

Histological assessments continue to have an important role in the diagnosis and management of graft complications following liver transplantation. For some conditions, such as liver allograft rejection, histology is regarded as the "gold standard" for diagnosis. In other cases, where a likely cause of graft dysfunction has been identified using other methods, liver biopsy provides important additional information (e.g., severity of necroinflammatory activity and fibrosis in recurrent hepatitis C infection) and may point to the presence of an additional or alternative cause for graft dysfunction. In cases where a dual pathology is suspected (eg, hepatitis C and rejection), histological findings can help to identify the main cause of graft dysfunction. This article will focus on the main patterns of damage that are seen in post-transplant liver biopsies and their differential diagnosis. As with the assessment of liver biopsies in the native liver, clinico-pathological correlation is very important. Consideration should also be given to the therapeutic implications of the biopsy report, in particular whether changes in immunosuppression are indicated.