Aya Miyagawa-Hayashino

Allograft steatohepatitis in progressive familial intrahepatic cholestasis type 1 after living donor liver transplantation

We studied histological features and long‐term outcomes in patients with progressive familial intrahepatic cholestasis type 1 (PFIC1) after liver transplantation (LT). Histological findings were correlated with the post‐LT course and treatment in 11 recipients with PFIC1. Ages at LT varied from 1 to 18 years (median, 4 years). Macrovesicular steatosis was observed in 8 patients at a median of 60 days post‐LT (range, 21‐191 days). Severe steatosis progressed to steatohepatitis in 7 patients at a median of 161 days (range, 116‐932 days). The patients were followed up for a median of 7.3 years (range, 2.3‐16.1 years). Six showed bridging fibrosis, with 2 progressing to cirrhosis. One patient with cirrhosis died because of the rupture of a splenic artery aneurysm 13.6 years post‐LT. Post‐LT refractory diarrhea was present in all 8 having steatosis. Three without post‐LT diarrhea showed no allograft steatosis. Bile adsorptive resin therapy reduced the diarrhea and steatosis. Patients with posttransplant steatosis typically had more severe mutations of the ATPase class I type 8B member 1 (ATP8B1) gene and were more likely to have systemic complications such as pancreatitis. In conclusion, allograft steatosis was present in patients with PFIC1, progressing to steatohepatitis and cirrhosis. Because expression of the familial intrahepatic cholestasis 1 gene occurs in several organs, including the small intestine, pancreas, and liver, and it is involved in enterohepatic bile acid circulation, post‐LT steatosis may be due to a malfunction of the ATP8B1 product. Liver Transpl 15:610–618, 2009.

Does a positive lymphocyte cross-match contraindicate living-donor liver transplantation?

BACKGROUNDnThere is still no consensus on the importance of lymphocyte cross-matching (LCM) in the field of living-donor liver transplantation (LDLT).nnnMETHODSnLCM examinations are routinely performed before LDLT, and the results of complement-dependent cytotoxicity were used in this study. A total of 1157 LDLT cases were evaluated. The recipients were divided into four groups based on the LCM and ABO compatibilities: (1) negative LCM and identical/compatible ABO; (2) negative LCM and incompatible ABO; (3) positive LCM and identical/compatible ABO; and (4) positive LCM and incompatible ABO. The diagnosis of antibody-mediated rejection (AMR) was made based on the clinical course, immunological assays and histopathological findings. C4d immunostaining was added if AMR was suspected.nnnRESULTSnThe LCM-positive LDLT recipients showed significantly poorer outcomes than the LCM-negative recipients. Among the LCM-positive recipients, 44.1% of recipients eventually died and 85.2% of recipients revealed positive C4d findings. The survival rate of LCM-positive and ABO-incompatible group was 0.50. The survival days were compared with the LCM-negative and ABO-identical/compatible group, and the LCM-positive and ABO-identical/compatible group clearly showed early death after LDLT, although the ABO-incompatible groups did not show significant. The factors of age, disease, pre-transplant scores, LCM, ABO compatibility and graft-recipient weight ratio showed statistical significance in multivariate analysis for important factors of LDLT outcomes. However, the LCM and ABO compatibilities had no synergetic effects on the LDLT survival.nnnCONCLUSIONnHLA antigens are more widely expressed than ABO antigens, and advanced immunological strategies must be established for LCM-positive LDLT as well as for ABO-incompatible LDLT.

Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left‐sided lobe grafts: Kyoto university experience

The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left‐sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left‐sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient‐to‐donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor‐recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long‐term patency of stents and stent‐related complications. New stenting devices, such as drug‐eluting and biodegradable stents, may be promising for the management of HVOO. Liver Transpl 16:1207–1214, 2010.

Non‐inflammatory centrilobular sinusoidal fibrosis in pediatric liver transplant recipients under tacrolimus withdrawal

Aim:u2002 We hypothesized that non‐inflammatory central sinusoidal fibrosis (NICSF) is a sign of inadequate immunosuppression in children after living‐donor liver transplantation.

Treatment of Pulmonary Epithelioid Hemangioendothelioma with Bevacizumab

To the Editor: We read the article by Belmont et al.1 with great interest. In the article, the author reported that a patient with pulmonary epithelioid hemangioendothelioma (PEH) showed a good partial response to combination chemotherapy of carboplatin, paclitaxel, and bevacizumab. That was the first report of bevacizumab for PEH, and the antitumor activity shown was striking. Recently, we also treated a patient with PEH using the same regimen. A 44-year-old woman, who had been followed-up for bilateral pulmonary nodules for 15 years, was referred to our hospital because of increased size of the nodules. Bronchofiberscopic examination and computed tomography-guided needle biopsy were performed; however, no definite diagnosis was obtained. Finally, video-assisted thoracoscopic surgery was performed. Histologically, the nodules consisted of short, single-file cords, nests, or single cells embedded in the myxohyaline matrix. Intracytoplasmic vacuoles were present (Figure 1A), and the alveolar septa were well preserved. Prominent necrosis was present in the central area of the nodule. The peripheral portion of the tumor was more cellular than the central portion. The tumor cells spread into the bronchioles, vessels, and lymphatics. Immunohistochemical study demonstrated that tumor cells were positive for endothelial markers, CD31, CD34, and factor VIII, and negative for keratin and thyroid transcription factor-1 (Figure 1B). A diagnosis of epithelioid hemangioendothelioma was made. The tumor contained areas of more nuclear atypia and mitoses at the periphery of the nodule (Figure 1C), suggesting more aggressive behavior of the tumor than typical epithelioid hemangioendothelioma. At the time of diagnosis, she already had liver and bone metastases and complained of lumbago arising from the metastasis to the sacrum. After radiotherapy (39 Gy) to the sacrum, she was followed-up without chemotherapy, taking into account the following two aspects: (1) PEH progresses slowly in general; and (2) there is no standard chemotherapy for PEH; however, her disease gradually progressed and she started chemotherapy 2 years after the diagnosis. She started combination chemotherapy of carboplatin and paclitaxel concurrent with zoledronic acid for three cycles; however, her tumor increased in size. Thereafter, she received another two cycles of chemotherapy with carboplatin, paclitaxel, and bevacizumab (15 mg/kg). Although there were no distinct toxicities from bevacizumab, her disease progressed and the treatment was terminated. Epithelioid hemangioendothelioma, formerly known as intravascular bronchoalveolar tumor, is a rare vascular tumor of borderline or low-grade malignancy and can arise from various organs, including lung, liver, and bone.2 The biologic behavior is generally indolent; however, it is highly variable. Surgical resection is selected when the PEH lesion is solitary or when the number of lesions is limited. Although there are isolated case reports suggesting the effectiveness of chemotherapy, no standard chemotherapy has been established because of the rarity of this disease.3 In the article by Belmont et al., a patient with PEH was treated with carboplatin, paclitaxel, and bevacizumab after the failure of chemotherapy with cisplatin and etoposide, and a marked response was observed. In addition, Mascarenhas et al.4 reported the effectiveness of thalidomide, a drug with antiangiogenic properties, for PEH. Although no tumor response was observed in our case, the second using bevacizumab for PEH, treatment with an antiangiogenic agent seems to be quite reasonable considering that PEH is a tumor of vascular origin. Further studies of bevacizumab are needed to treat this rare but fatal disease.

Idiopathic post‐transplantation hepatitis following living donor liver transplantation, and significance of autoantibody titre for outcome

Idiopathic post‐transplantation hepatitis (IPTH) is a common histology occurring late after liver transplantation. Its natural history and the effect of treatment have not been determined. This study is a matched case–control study that evaluates predictors, outcome and response to treatment for IPTH. Patients were divided by autoantibodies into high‐titre (≥1:160) and low‐titre (<1:160) groups, so as to evaluate clinicopathological differences between the two groups. IPTH was identified in 42 of 944 recipients (4.4%) with tacrolimus‐based immunosuppression. They comprised 10 males and 32 females, having median age 6.0 (0–50) years. IPTH presented at a median duration of 5.2 (0.7–10.8) years after transplantation. Particular risk of IPTH was associated with acute rejection, late‐onset acute rejection occurring later than 6u2003month post‐transplant, and autoantibody positivity. IPTH was associated with dependence on steroids and frequent adverse outcomes: retransplantation in five (12%); relapse in four (9.5%); and progression of fibrosis in eight (19%). The high‐titre group and low‐titre group did not differ in their clinicopathological features, response to treatment or outcome. To prevent the development of IPTH, appropriate adjustment of immunosuppression and close follow‐up is necessary for patients who suffer repeated episodes of rejection.

Application of complement component 4d immunohistochemistry to ABO‐compatible and ABO‐incompatible liver transplantation

Antibody‐mediated rejection (AMR) is difficult to diagnose after ABO‐compatible or ABO‐identical (ABO‐C) liver transplantation. To determine whether complement component 4d (C4d) immunostaining would be useful for diagnosing AMR, we compared the results of C4d immunohistochemistry for allograft biopsy samples with assays for anti‐donor antibodies performed at the time of biopsy. One hundred fourteen patients with ABO‐C grafts and 29 patients with ABO‐incompatible (ABO‐I) grafts were included. Linear C4d endothelial staining (identifiable with a 4× objective lens) or staining seen in 50% or more of the portal tracts was considered positive. Five of the 114 patients (4%) with ABO‐C grafts and 15 of the 29 patients (52%) with ABO‐I grafts showed C4d positivity. In the ABO‐C cases, C4d positivity in late biopsy samples (≥30 days after transplantation) was associated with stage 2 or higher fibrosis (METAVIR score; Pu2009=u20090.01) and with the presence of donor‐specific anti–human leukocyte antigen DR antibodies (HLA‐DR DSAs) with a mean fluorescence intensityu2009>u20095000 according to the Luminex single‐antigen bead assay (Pu2009=u20090.04). Conversely, the presence of HLA‐DR DSAs was associated with the presence of stage 2 or higher fibrosis, acute cellular rejection, and C4d positivity. During the 2‐year follow‐up, neither C4d positivity nor HLA‐DR DSAs were related to graft loss. Among ABO‐I patients, C4d positivity was not associated with allograft dysfunction or fibrosis. Only 3 of the 15 C4d‐positive patients (20%) showed periportal hemorrhagic edema, which could be a histological sign of AMR in ABO‐I grafts, and they were the only cases associated with elevations in anti‐donor A/B antibody titers. In conclusion, C4d endothelial positivity among ABO‐C patients is an uncommon event that could be associated with chronic graft damage with or without clinical AMR. C4d positivity is common among ABO‐I patients and may not be associated with allograft dysfunction if alloantibody titers are not elevated. Liver Transpl 20:200‐209, 2014.

Telomere shortening and karyotypic alterations in hepatocytes in long‐term transplanted human liver allografts

The long‐term fate of aged liver allografts in young recipients who received grafts from older donors is unknown. We evaluated graft aging by analyzing hepatocytic telomere length and karyotypic changes. Seventeen pediatric individuals who underwent living‐donor liver transplantation for congenital biliary diseases were selected. At a median of 10.4u2003years post‐transplant, ten had tolerated grafts with weaned off immunosuppressants, and seven had idiopathic post‐transplantation hepatitis. Fluorescence in situ hybridization was used to evaluate the telomere signal intensity (TI) and karyotypic changes. First, we measured predictive age‐dependent TI decline with regression analysis of donor livers. The mean TI at the earliest (within a year) and latest biopsies was significantly lower than the predicted TI of the studied allografts. With univariate analysis, a higher abnormal karyotype ratio in the donor liver was correlated with development of idiopathic post‐transplantation hepatitis. With multivariate analysis that included clinical parameters, a greater TI decline at the earliest biopsy was correlated with the development of idiopathic post‐transplantation hepatitis. In conclusion, graft aging as measured by TI decline and donor abnormal karyotype ratio was associated with idiopathic post‐transplantation hepatitis of long‐term transplanted liver allografts.

Significance of semiquantitative assessment of preformed donor-specific antibody using luminex single bead assay in living related liver transplantation.

Aim. To analyze the risks of preoperatively produced donor-specific antibody (DSA) in liver transplantation. Methods. DSA was assessed using direct complement-dependent cytotoxicity (CDC) and anti-human globulin- (AHG-) CDC tests, as well as the Luminex Single Antigen assay. Among 616 patients undergoing blood type identical or compatible living donor liver transplantation (LDLT), 21 patients were positive for CDC or AHG-CDC tests, and the preserved serum from 18 patients was examined to determine targeted Class I and II antigens. The relationships between the mean fluorescence intensity (MFI) of DSA and the clinical outcomes were analyzed. Results. Patients were divided into 3 groups according to the MFI of anti-Class I DSA: high (11 patients with MFI > 10,000), low (2 patients with MFI < 10,000), and negative (5 patients) MFI groups. Six of 11 patients with high Class-I DSA showed positive Class-II DSA. Hospital death occurred in 7 patients of the high MFI group. High MFI was a significant risk factor for mortality (P = 0.0155). Univariate analysis showed a significant correlation between MFI strength and C4d deposition (P = 0.0498). Conclusions. HLA Class I DSA with MFI > 10,000 had a significant negative effect on the clinical outcome of patients with preformed DSA in LDLT.

Non‐specific interstitial pneumonia as a manifestation of graft‐versus‐host disease following pediatric allogeneic hematopoietic stem cell transplantation

Bronchiolitis obliterans (BO) is generally believed to be a marker of pulmonary manifestation of graft‐versus‐host disease (GVHD) in patients who have undergone bone marrow transplantation for hematological malignancy. Pulmonary manifestations reported as GVHD (other than BO) include lymphocytic bronchiolitis with cellular interstitial pneumonia, lymphoid interstitial pneumonia, veno‐occlusive disease, and diffuse alveolar damage. Morphological reactions in the lungs of bone marrow transplant recipients associated with interstitial pneumonia have not been described systematically. Reported herein is a fibrosing non‐specific interstitial pneumonia (NSIP) pattern together with BO in both lungs in an 8‐year‐old girl following a second allogeneic hematopoietic stem cell transplantation for relapsed neuroblastoma of adrenal origin. The course was complicated by bilateral pneumothoraces, and the patient underwent lung transplantation 3u2003years after the second stem cell transplantation. Because the patient had chronic GVHD of the skin and the liver preceeded by the development of pulmonary involvement, NSIP may represent one of the facets of pulmonary GVHD.