Dennis Eurich

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.

Successful prevention of hepatitis C virus (HCV) liver graft reinfection by silibinin mono-therapy

To the Editor:Therapeutic measurements to control hepatitis C reinfection afterorthotopic liver transplantation (OLT) still pose many problemsand remain unsatisfactory [1]. While hepatitis C viremiadecreases strongly during the anhepatic phase of OLT, initiationof viral replication does occur within hours or days [2,3]. At thisearly stage after OLT, i.e. once chronic HCV reinfection is estab-lished, the virologic response is often markedly reduced.Although specifically targeted antiviral therapeutic regimes forhepatitis C (STAT-C) are currently extensively studied, none ofthem have been tried in the post-OLT period treatment.However, as recently described by Ferenci et al. [4], high doseintravenous silibinin (Legalon SIL ) can express potent antiviralactivity. This effect was shown to be driven by direct inhibitionof the viral RNA polymerase NS5B [5,6].In this letter, we can report the first successful prevention ofHCV reinfection after OLT by the administration of silibinin(1400 mg/d). This drug was applied immediately after OLT bydaily infusions for 14 days.At the time of OLT, the 57-year-old male patient exhibited aMELD Score of 23, Child-Pugh stage C liver cirrhosis, and a25 mm hepatocellular carcinoma in the left lobe. HCV infection(genotype 3a) was first diagnosed in 1997 and three interferon-based treatment regimens – at last PegInterferon alpha and Riba-virin were given for 48 weeks 6 years before OLT – failed toinduce a sustained virologic response (SVR). The anhepatic phaseduring OLT surgical procedures lasted 61 min and postoperativecare transpired without complication after a short phase of renalinsufficiency and haemodialysis treatment on day 1 and 2.Immunosuppressive therapy included methyl-prednisolone,mycophenolatmofetil, and belatacept. Aminotransferase levelsreached normal values within 12 postoperative days. Bilirubinlevels rose to a maximum of 9.5 mg/dl 7 days after OLT andshowed a protracted mild elevation until 4 weeks later. Thepatient was discharged from the hospital 21 days after OLT.The levels of HCV RNA 3 months prior to OLT were rather low(17.800 IU/ml), and further declined significantly during theanhepatic phase. Silibinin infusions were started 8 h after OLT.At this time HCV RNA levels measured 182 IU/ml, and droppedagain to 127 IU/ml after 48 h (RNA levels measured directly afterhaemodialysis are not available). Already from day 3 onwards,HCV RNA levels were below <15 IU/ml and became undetectableat day 9. During follow-up HCV RNA remained negative whenexamined at day 14, 21, 66, 84, and 168 (Fig. 1).This is the first report of the successful suppression of earlyHCV reinfection after OLT with a 14 day course of silibininmono-therapy. This new treatment regimen thus induced anSVR, as after 6 months of follow-up, RNA for HCV was undetect-able. Accordingly, liver histology 6 months after OLT did notshow any cellular inflammation. Low pre-transplant HCV RNAlevels may be taken as a favourable prognostic factor for theunexpected therapeutic efficiency of silibinin. Applying silibininduring the anhepatic phase or even in the days before transplantmay expand the number of patients benefiting from thisapproach. This report may stimulate further trials and the con-cept of interferon-free HCV clearance induced by directantivirals.Conflicts of interestThe Authors have declared that they received funding from thedrug companies involved in order to carry out their research inthis manuscript.References

Relationship between the interleukin‐28b gene polymorphism and the histological severity of hepatitis C virus–induced graft inflammation and the response to antiviral therapy after liver transplantation

Up to 30% of liver transplants will develop graft cirrhosis within 5 years after liver transplantation (LT) due to recurrent HCV‐infection forwarding accelerated graft damage. Genetic variants of cytokines involved in the immune response may contribute to the degree of graft inflammation, fibrosis progression, and antiviral therapy outcome. The aim of our study was to analyze biochemical and histological inflammation extent based on protocol liver biopsies and to evaluate the role of genetic variants of IL‐28b in HCV‐related graft disease and antiviral treatment response. 183 patients, who underwent liver transplantation for HCV‐induced liver disease, were genotyped for IL‐28b (rs8099917, G ≥ T) by TaqMan Genotyping Assay. 56 of 159 patients have been successfully treated with interferon‐based antiviral therapy. 605 protocol liver biopsies performed 0.5 to 10 and more than 10 years after transplantation were evaluated according to Desmet and Scheuer classification of inflammation and fibrosis. Prevalence of IL‐28b‐genotypes was correlated with histological severity of graft damage, levels of aminotransferases, occurrence of acute cellular rejection, pre‐treatment viremia, and antiviral therapy outcome. Significant association of IL‐28b‐genotype distribution was observed to the median grade of inflammation (p < 0.001), mean levels of aminotransferases (ALT: p = 0.001, AST: p = 0.003), median pre‐treatment viremia level within 1 year after LT (p = 0.046) and interferon‐based antiviral therapy failure (p < 0.001). Among successfully treated patients, G‐allele was significantly less frequent, and the genotype GG was not present at all. No differences were observed regarding acute cellular rejection (p = 0.798) and fibrosis stages (p = 0.586). IL‐28b polymorphism seems to influence the degree of graft inflammation at biochemical and histological levels. G‐allele might serve as a marker for graft inflammation and as a predictor for unfavorable antiviral therapy outcome in HCV‐re‐infected LT‐population. Liver Transpl, 2011.

Role of IL28B polymorphism in the development of hepatitis C virus-induced hepatocellular carcinoma, graft fibrosis, and posttransplant antiviral therapy.

Background. The development of liver graft disease is partially determined by individual genetic background. Interleukin 28B (IL28B) is strongly suspected to be involved in susceptibility for hepatitis C virus (HCV) infection, inflammation, and antiviral treatment response before and after liver transplantation (LT). Currently, the role of IL28B polymorphism (rs12979860) in the development of hepatocellular carcinoma (HCC) is unclear, and only limited data are available on the course of HCV recurrence. Methods. One hundred sixty-seven HCV-positive patients after LT were genotyped for IL28B (C→T; rs12979860). Sixty-one patients with histologically confirmed HCC in the explanted liver were compared with 106 patients without HCC regarding IL28B genotypes. Among patients with HCC, IL28B genotypes were correlated with tumor histology and pretransplant &agr;-fetoprotein (AFP) levels. Furthermore, the role of IL28B polymorphism was evaluated regarding interferon-based treatment success and fibrosis progression after LT. Results. The prevalence of HCC in explanted livers was significantly higher among patients with TT genotype, suggesting a protective role of the C allele in HCC development (P=0.041). Median AFP level was closely to significance higher in the presence of T allele (P=0.052). Significant differences in IL28B genotype distribution were detected between AFP-negative and AFP-positive HCCs (<15 &mgr;g/L vs. >15 &mgr;g/L; P=0.008). Although no impact could be observed regarding acute cellular rejection (P=0.940), T allele was significantly associated with antiviral therapy failure (P=0.028) and faster development of advanced fibrosis (P=0.017) after LT. Conclusion. IL28B polymorphism seems to be involved in the development of HCV-induced HCC and in the course of HCV recurrence after LT. T allele may be regarded as a genetic risk factor for HCV-related carcinogenesis, posttransplant fibrosis progression, and antiviral therapy failure.

Chances and limitations of non-invasive tests in the assessment of liver fibrosis in liver transplant patients

Kamphues C, Lotz K, Röcken C, Berg T, Eurich D, Pratschke J, Neuhaus P, Neumann UP. Chances and limitations of non‐invasive tests in the assessment of liver fibrosis in liver transplant patients.
Clin Transplant 2009 DOI:10.1111/j.1399‐0012.2009.01152.x
© 2009 John Wiley & Sons A/S.

Transforming Growth Factor β1 Polymorphisms and Progression of Graft Fibrosis After Liver Transplantation for Hepatitis C Virus-Induced Liver Disease

Re‐infection with the hepatitis C virus (HCV) is an important development after liver transplantation (LT); it can lead to graft fibrosis. The aim of this study was to assess the role of transforming growth factor β1 (TGF‐β1) polymorphisms in the development of HCV‐related graft disease by evaluating protocol liver biopsies. A total of 192 patients with a recurrence of HCV infection after LT were genotyped for TGF‐β1 codon 10 (C→T) and codon 25 (G→C) using the polymerase chain reaction. Histological evaluation of 614 protocol liver biopsies obtained from these patients was undertaken using the classification of Desmet and Scheuer to stage the degree of fibrosis. Mild stages of fibrosis (0‐2) were compared to advanced stages of fibrosis (3‐4) that developed during the period of infection with the virus. Correlations between the prevalence of TGF‐β1 genotypes and the different degrees of fibrosis that developed were determined. No statistically significant differences were found for genotype distributions (codons 10 and 25) with respect to recipient age, donor sex, occurrence of acute cellular rejection, and response to antiviral therapy. However, the C allele at codon 25 was significantly less frequent in the group with advanced fibrosis (P = 0.001). Furthermore, a positive association was found between progression of fibrosis and male recipient sex (P = 0.024), donor age (P = 0.041), and viral genotype 1b (P = 0.002). In conclusion, this study, in which the evolution of hepatic fibrosis was assessed histologically in a large cohort of patients with HCV re‐infection after LT, has demonstrated that the C allele at codon 25 of the TGF‐β1 gene is a marker for the development of graft fibrosis. Liver Transpl, 2011.

A 7‐gene signature of the recipient predicts the progression of fibrosis after liver transplantation for hepatitis C virus infection

Fibrosis recurrence after liver transplantation (LT) for hepatitis C virus (HCV) is a universal event and strongly determines a patients prognosis. The recipient risk factors for fibrosis recurrence are still poorly defined. Here we assess a genetic risk score as a predictor of fibrosis after LT. The cirrhosis risk score (CRS), which comprises allele variants in 7 genes (adaptor‐related protein complex 3 S2, aquaporin 2, antizyme inhibitor 1, degenerative spermatocyte homolog 1 lipid desaturase, syntaxin binding protein 5‐like, toll‐like receptor 4, and transient receptor potential cation channel M5), was calculated for 137 patients who underwent LT for HCV infection and experienced HCV reinfection of the graft. The patients were stratified into 3 CRS categories: <0.5, 0.5 to 0.7, and >0.7. All patients underwent protocol biopsy after LT (median follow‐up = 5 years), and liver fibrosis was assessed according to the Desmet and Scheuer score. The data were analyzed with univariate and multivariate analyses. The results showed that the highest CRS category was strongly associated with the presence of F2 or F3 fibrosis in protocol biopsy samples 1, 3, and 5 years after LT (P = 0.006, P = 0.001, and P = 0.02, respectively). Overall, 75.0% of the patients with a CRS > 0.7 developed at least F2 fibrosis, whereas 51.5% developed F3 fibrosis during follow‐up. The predictive value of the CRS for fibrosis progression was independent of known clinical risk factors, including the age of the donor, the sex of the recipient, and the occurrence of acute rejection. A Kaplan‐Meier analysis confirmed the prognostic value of the CRS with respect to the recurrence of severe liver fibrosis in HCV‐infected patients after LT (log rank = 6.23, P = 0.03). In conclusion, the genetic signature of the recipient predicts the likelihood of severe liver fibrosis in the graft after HCV recurrence. The CRS might help with early clinical decision making (eg, the selection of patients for antiviral therapy after LT). Liver Transpl 18:298–304, 2012.

IL-6 and IL-10 in post-transplant lymphoproliferative disorders development and maintenance: a longitudinal study of cytokine plasma levels and T-cell subsets in 38 patients undergoing treatment

IL‐6 and IL‐10 have previously been implicated in the pathogenesis of post‐transplant lymphoproliferative disorders (PTLD) and, like peripheral lymphocyte populations, are markers of immune status that are amenable to study in vivo. Thus, we analyzed cytokine plasma levels as well as lymphocyte subsets in a longitudinal analysis of 38 adult transplant recipients undergoing treatment for PTLD. Pretherapeutically, we found significantly elevated IL‐6 (13.8 pg/ml) and IL‐10 plasma levels (54.7 pg/ml) – in the case of IL‐10, even higher in treatment nonresponders than in responders (116 vs. 14 pg/ml). Over time, however, IL‐10 levels did not correlate with the course of disease, whereas those of IL‐6 did, falling in responders and rising in nonresponders. These findings were independent of histological EBV‐status, treatment type, and total peripheral T‐cell counts, which were significantly reduced in patients with PTLD. Our observations support the idea that although IL‐10 is important for creating a permissive environment for post‐transplant lymphoma development, IL‐6 is associated with PTLD proliferation. The analysis of lymphocyte subsets further identified HLA‐DR+ CD8+ lymphocyte numbers as significantly different in non‐PTLD controls (33%), treatment responders (44%) and nonresponders (70%). Although the specificity of these cells is unclear, their increase might correlate with the impaired tumor‐specific cytotoxic‐T‐lymphocyte (CTL)‐response in PTLD.

Transforming growth factor-β1-gene polymorphism in the development of kidney disease after liver transplantation.

Background. The development of kidney dysfunction is one of the most important after liver transplantation (LT). Genetic variants of pathogenetically relevant cytokines may influence the development and course of the disease. The aim of our study was to evaluate the role of transforming growth factor-&bgr;1 (TGF-&bgr;1) polymorphism in this context. Methods. Four hundred eighty-six liver graft recipients were genotyped for TGF-&bgr;1 codon 25 (guanine→cytosine, G→C) by polymerase chain reaction. Renal function before and after LT was characterized by estimation of glomerular filtration rate (GFR) using four-parameter-modification of diet in renal disease formula on defined dates. GFR was compared among TGF-&bgr;1-genotype groups of the entire cohort within the median observation period of 7 years. For the assessment of renal function recovery after LT, patients were divided into three groups by GFR difference (&Dgr;GFR=±10 mL/min). Results. Mean pretransplant GFR differed significantly among TGF-&bgr;1-genotype groups (GG: 85.0 mL/min vs. GC/CC: 75.3 mL/min; P=0.016). The significance disappeared in the follow-up period. Although GG genotype demonstrated higher mean GFR levels, patients with GC/CC genotype tended to improve kidney function compared with GG genotype (P=0.013). Interestingly, lower mean GFR rates were observed among female compared with male recipients before (P=0.002), separately at all dates and cumulatively after LT (P<0.001). Conclusions. Genetic variants of one of the most important cytokine TGF-&bgr;1 at codon 25 may have an impact on kidney function, suggesting an unfavorable effect of C allele in pretransplant setting and serve as marker for the recovery of renal function after LT. The identification of further confounders seems to be promising.

Association of mannose-binding lectin-2 gene polymorphism with the development of hepatitis C-induced hepatocellular carcinoma.

Background: Development of end‐stage liver and graft disease is suspected to be partially determined by the individual genetic background. Mannose‐binding lectin (MBL) is an important immunomodulatory factor, which is supposed to be involved in complement activation and oncogenesis. Genetic polymorphisms of MBL‐2 alter MBL functionality. The aim of our study was to determine the prevalence of MBL‐2 polymorphism (rs7096206) in hepatitis C virus (HCV)‐induced hepatocellular carcinoma (HCC) based on histological analysis of explanted livers in patients undergoing liver transplantation (LT).