Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 28  |  Issue : 3  |  Page : 702--711

Impact of clinicopathological parameters in differentiation between acute rejection and recurrent hepatitis C after liver transplantation


Nancy Y Assad1, Nermine A Ehsan2, Asmaa G Abdou1, Sheren F Younis1, Asmaa A Gomaa3, Walaa G El-Gendy2,  
1 Pathology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Pathology Department, Liver Institute, Menoufia University, Menoufia, Egypt
3 Hepatology Department, Liver Institute, Menoufia University, Menoufia, Egypt

Correspondence Address:
Walaa G El-Gendy
Liver Institute, Menoufia University, Yassin Abd El Ghaffar Street, Shebin El Kom, 32511 El Menoufia
Egypt

Abstract

Objective The aim of the study was to investigate the impact of clinical and histopathological changes in the liver tissue of acute rejection and recurrent hepatitis C patients after liver transplantation and determine whether they could differentiate between them. Background Hepatitis C virus (HCV) is considered the most common cause of chronic liver disease and may require liver transplantation in advanced stages. Liver transplantation is today a well-established procedure for curative treatment of various inherited and acquired liver diseases, and in many conditions it is the only possible therapeutic strategy. Acute rejection and recurrent HCV infection are the major causes of graft failure in liver transplant patients and differentiation between them is necessary because of different treatment strategies. Patients and methods This retrospective study included liver biopsies from 51 post-transplant patients (25 acute rejection and 26 recurrent hepatitis C patients). Post-transplanted liver biopsies were histopathologically evaluated for portal tract inflammation as regards the extent and nature of the infiltrate, bile duct injury, venous injury, interface hepatitis, and lobular inflammation (spotty necrosis and confluent necrosis). Other pathological findings were also addressed. Demographic, laboratory, and histopathological results were subjected to statistical analysis. Results Clinically, high model for end-stage liver disease score (P < 0.01) and high viremia (P < 0.01) were in favor of recurrent hepatitis C compared with acute rejection. Histopathologically, the two groups differed with regard to the extent and nature of the inflammatory infiltrate, whereas dense infiltrate (grade II and III) was in favor of recurrent hepatitis C (P = 0.02). With regard to the nature of infiltrate, the mean number of eosinophils (P < 0.01), neutrophils (P < 0.05), macrophages (P < 0.01), and immunoblasts (P < 0.01) was higher in acute rejection compared with recurrent hepatitis C. Presence of bile duct injury(P = 0.001), vascular injury (P = 0.001), and perivenular necrosis(P = 0.001) was in favor of acute rejection, whereas the presence of interface hepatitis (P = 0.001), fibrosis (P = 0.001), and steatosis (P = 0.001) was in favor of recurrent hepatitis C. Conclusion The current study demonstrated that discrimination between acute rejection and recurrent hepatitis C in the setting of post-liver-transplantation could be possible on the basis of clinical data (the value of model for end-stage liver disease score and the degree of HCV viremia) and several histopathological parameters.



How to cite this article:
Assad NY, Ehsan NA, Abdou AG, Younis SF, Gomaa AA, El-Gendy WG. Impact of clinicopathological parameters in differentiation between acute rejection and recurrent hepatitis C after liver transplantation.Menoufia Med J 2015;28:702-711


How to cite this URL:
Assad NY, Ehsan NA, Abdou AG, Younis SF, Gomaa AA, El-Gendy WG. Impact of clinicopathological parameters in differentiation between acute rejection and recurrent hepatitis C after liver transplantation. Menoufia Med J [serial online] 2015 [cited 2020 Mar 28 ];28:702-711
Available from: http://www.mmj.eg.net/text.asp?2015/28/3/702/165831


Full Text

 Introduction



The population in Egypt has a heavy burden of chronic liver disease, mostly because of chronic infection with the hepatitis C virus (HCV) [1]. Liver transplantation (LT) is the chosen treatment for patients with advanced liver disease and cirrhosis. End-stage liver disease associated with HCV infection constitutes the leading indication for orthotopic LT [2]. Although the impact of HCV infection on allograft varies substantially, allograft failure secondary to recurrence of HCV is the most common cause of death and retransplantation among recipients with HCV [1]. Unfortunately, reinfection of the graft is a universal phenomenon after LT. The majority of patients with virological recurrence will develop histological graft injury, with about one-third of patients developing cirrhosis at 5 years of follow-up [3],[7]. In addition, the time interval from HCV cirrhosis to decompensation is significantly shorter in orthotropic LT recipients than in nontransplant patients [3],[7]. Not surprisingly, HCV is associated with decreased patient and graft survival when compared with other indications of orthotopic LT [3],[7].

Factors associated with accelerated HCV recurrence after LT include high viremia, donor age (>55 years), prolonged cold ischemia time, coinfection with cytomegalovirus, and immunosuppressant protocols [2].

Acute cellular rejection (ACR) after LT is common and remains an important cause of morbidity and late graft failure in the liver transplant recipient. The rate of ACR varies between 18 and 30% [8]. This tendency may be explained by the introduction of new and more potent immunosuppressant drugs in the last decade, capable of reducing the risk for ACR [8],[9].

ACR rate after LT is especially controversial in HCV-positive recipients because of the overlapping of clinical and histological features with HCV recurrence. Both acute rejection and hepatitis C reinfection often display the same clinical picture with rising serum transaminases, elevated bilirubin levels, and deterioration of productive liver function in the absence of perfusion deficit [10].

Reports suggest that the incidence of ACR may be in the range of 40-49% in HCV-positive recipients 6 months after LT [9]. The high discrepancy of ACR incidence in HCV patients is explained by the difficulty on the differential diagnoses, which represents one of the most critical challenges in the liver transplant community. Furthermore, accurate diagnosis remains a critical issue, as associated therapy may lead to worse graft and affect patient survival [8],[9],[11],[12]. It is well documented that pulse intravenous corticosteroid bolus treatment for ACR exacerbates HCV infection, inducing transient from 1-log to 2-log increased HCV RNA levels and thus increasing the incidence of mortality and graft loss [9],[11],[13],[14]. Many authors advocate a very restricted use of steroid-pulse treatment even in cases of validated rejection in HCV-positive patients to avoid activation of virus replication [12],[15],[16],[17].

Liver biopsy represents the gold standard for diagnosis of both acute rejection and HCV reinfection; nevertheless, discrimination can be highly difficult because of quite similar display of alterations in the liver specimen [15],[18],[19],[20]. Therefore, we decided to report the histopathological differences between acute rejection and recurrent hepatitis C to improve differential and diagnostic tools between them.

 Patients and methods



This retrospective study included 51 consecutive post-transplant patients (46 male and five female) who were recruited from the Pathology Department, National Liver Institute (NLI), Menoufia University, during the period from 2006 to 2013. All patients underwent LT and follow-up at the NLI, Menoufia University.

Exclusion criteria

Patients with chronic hepatitis B viral infection were excluded from this study. Patients were classified into two groups:

(1) Group A: patients who developed acute rejection.

(2) Group B: patients who developed recurrent hepatitis C infection.

The following clinical data were collected from patients' medical records:

Donor and recipient age, donor and recipient sex, model for end-stage liver disease (MELD) score [MELD = 10 {0.957 log (serum creatinine) + 0.378 log (total bilirubin) + 1.12log (INR) + 0.643}] as described by Varma et al. [21], level of HCV viremia, pretransplantation hepatocellular carcinoma, history of schistosomiasis (assessed by antischistosomal antibody detection in serum using ELISA), and liver function tests (alanine aminotransferase, aspartate aminotransferase, and total bilirubin).

Hematoxylin and eosin-stained slides of cases of acute rejection and recurrent hepatitis C were retrieved from the Archive of Pathology Department, NLI, Menoufia University, for further evaluation.

Histopathological evaluation

The histopathological evaluation of cases included the following parameters:

Portal tract inflammation as regards the extent and nature of infiltrate (plasma cells, eosinophils, neutrophils, macrophages, and immunoblasts), bile duct injury, venous injury, hepatic artery injury, interface hepatitis, lobular inflammation (spotty and confluent necrosis), perivenular necrosis, degree of fibrosis, extent of steatosis, and other associated pathological findings [22].

The Banff schema was established in 1997 for histopathological diagnosis of acute rejection and for grading it using the rejection activity index. Diagnosis of acute rejection was made on the basis of these criteria [Table 1].{Table 1}

Statistical analyses

Data were collected, tabulated, and statistically analyzed using a personal computer with statistical package for the social sciences (SPSS, version 21; SPSS Inc., Chicago, Illinois, USA) program. The X2 and Fischer's exact tests were used to compare between qualitative variables. The Mann-Whitney and Kruskal-Wallis tests were used to compare between quantitative variables. P-value less than 0.05 was considered significant.

 Results



The clinical and pathological characteristics of patients with acute rejection and recurrent hepatitis C are presented in [Table 2] and [Table 3], respectively.

Differences between acute rejection and recurrent hepatitis C with respect to the clinicopathological parameters are presented in [Table 4] and [Table 5].

Clinically, both groups differed with regard to the MELD score and degree of HCV viremia, as high MELD score (P < 0.01) and high viremia (P < 0.01) were in favor of recurrent hepatitis C compared with acute rejection.{Table 2}{Table 3}{Table 4}{Table 5}

Histopathologically, they differed with regard to the extent and nature of inflammatory infiltrate, whereas dense infiltrate (grade II and III) was in favor of recurrent hepatitis C. With regard to the nature of infiltrate, the mean number of eosinophils (P < 0.01), neutrophils (P < 0.05), macrophages (P < 0.01), and immunoblasts (P < 0.01) was higher in acute rejection compared with recurrent hepatitis C. Conversely, the mean number of plasma cells did not differ between the two groups (P > 0.05). Furthermore, presence of bile duct injury (P = 0.001), vascular injury (P = 0.001), and perivenular necrosis (P = 0.001) was in favor of acute rejection, whereas presence of interface hepatitis (P = 0.001), fibrosis (P = 0.001), and steatosis (P = 0.001) was in favor of recurrent hepatitis C [Figure 1],[Figure 2],[Figure 3] and [Figure 4].{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



The current study showed that age and history of schistosomiasis did not discriminate between acute rejection and recurrent hepatitis C, agreeing with the study by Osman et al. [1] and Samonakis et al. [20]. In contrast, Wiesner et al. [23] reported that advanced donor age was associated with higher degree of HCV recurrence. Féray [24] and Krawczynski et al. [25] added that older donor age leads to faster progression of hepatitis C reinfection, perhaps because older patients are less able to mount an effective immune response against viral recurrence.

In this study, there was a high statistical difference between the two groups (acute rejection and recurrent hepatitis C) with regard to HCV viremia level favoring the diagnosis of recurrent HCV in patients with high pretransplantation viremic level than in those with low viremic levels. Osman et al. [1] and Berenguer et al. [12] agreed with our results as they reported that high pretransplantation viral load is likely to be associated with more severe post-living donor LT HCV recurrence and poor outcome. In contrast, Gruener et al. [26] reported that pretransplantation viremia titer was not correlated with HCV histological recurrence.

Moreover, this study showed that severity of pretransplantation liver pathology represented by MELD score [21] has high significant impact on post-living donor LT HCV recurrence. This did not agree with the results of Osman et al. [1], who found that the severity of pretransplantation liver pathology has no impact on HCV recurrence after transplantation, as evidenced by the absence of significant role of MELD score in their study.

Our study showed that bile duct injury and venous injury were highly significant predictors of acute rejection, which was believed to be compatible with the Banff criteria for diagnosis of acute rejection [27]. This agreed with the study by Wietzke-Braun et al. [17], who mentioned that bile ducts are specific targets of damage in acute rejection. This is because biliary epithelial cells and the basement membrane of bile ducts normally express immunologically active antigen and participate in immune responses. The classic triad for recognizing acute rejection defined by Snover et al. [28] is mixed portal tract inflammation, bile duct damage, and venular endothelitis. Also, previous reports [29] demonstrated that bile duct injury was shown to be an essential part of the histopathological changes in all grades of acute rejection in the liver allograft, the grade of severity of bile duct injury correlating to a certain extent with the grade of severity of acute rejection.

The number of eosinophils (P < 0.01), macrophages (P < 0.01), and immunoblasts (P < 0.01) was statistically higher in acute rejection compared with recurrent hepatitis C. This agreed with the results of Nagral et al. [30], who proved that eosinophils have a role in various allergic and inflammatory disease processes and participate in the process of acute rejection in solid organ allografts. Initial studies [3] have described the diagnostic value of eosinophils in renal allograft rejection. Graft eosinophilia is a sensitive and specific marker of acute rejection in liver allografts and has been incorporated as one of the diagnostic criteria of acute rejection by the Royal Free Hospital scoring system according to Portmann and Koukoulis [31] and Jones and Ferrell [32]. Eosinophils probably act through chemokines such as interleukin-5 and RANTES and factors such as basic cytotoxic proteins (eosinophil cationic protein and major basic protein), with their effective role in acute rejection as described by Portmann and Koukoulis [31]. Successful treatment of acute rejection with corticosteroids has been associated with a decrease in graft and blood eosinophil counts; they also act as prognostic markers of acute rejection [17].

For macrophages, Yang et al. [33] demonstrated that early activation of macrophages as a result of graft injury might play an important role in the accelerated acute rejection process. Saiman and Friedman [34] linked injury to chemokines whose expression is upregulated in nearly all forms of injury in all tissues. Survival days were not prolonged by elimination of Kupffer cells of the graft or by depletion of migrated macrophages of the recipient alone [35]. In addition, in the administration group, in which both Kupffer cells of the graft and migrated macrophages of the recipient were eliminated together, graft survival was prolonged significantly.

The present study showed that presence of perivenular necrosis was in favor of acute rejection, which is in agreement with the results of other studies [36],[37],[38],[39]. The susceptibility of perivenular regions to immune-mediated injury is probably because these areas contain potent donor antigen-presenting cells, which can trigger an alloimmune response [38].

The number of neutrophils was found to be statistically higher in acute rejection according to our results, in agreement with the study by Adams et al. [40] who showed that neutrophil activation occurs during acute liver allograft rejection, possibly in response to lymphokine secretion, and suggests an important, and unrecognized, mechanism of graft damage during rejection.

In contrast, presence of fibrosis, interface hepatitis, and steatosis was significantly in favor of recurrent hepatitis C rather than in favor of acute rejection, agreeing with previous studies, which attributed these factors to viral infection, which causes necroinflammatory changes with subsequent stellate cell activation and fibrosis formation [9],[35],[36],[40],[41],[42],[43],[44],[45]. Steatosis is one of the histopathological landmarks of hepatitis C reinfection [42],[43].

In conclusion, the current study demonstrated that discrimination between acute rejection and recurrent hepatitis C in the setting of post-LT could be possible depending on clinical data (the value of MELD score and the degree of HCV viremia) as well as several histopathological parameters.

 Acknowledgements



The authors thank all patients in the study and their families.

Conflicts of interest

None declared.

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