J.M. Sousa

Antibodies against glutathione S-transferase T1 (GSTT1) in patients with de novo immune hepatitis following liver transplantation

Four patients of 283 liver‐transplant recipients (1·4%) developed de novo immune‐mediated hepatitis approximately 2 years after transplantation. Antibodies showing an unusual liver/kidney cytoplasmic staining pattern were detected in the sera of all four patients and one of them was used to screen a human liver cDNA expression library with the aim of identifying the antigenic target of these newly developed antibodies. After cloning and sequencing the gene, it was identified as the gene encoding the glutathion‐S‐transferase T1 (GSTT1), a 29‐kD molecular weight protein, expressed abundantly in liver and kidney. Sera from the other three patients also contained anti‐GSTT1 antibodies, two of them demonstrated by immunoblot analysis against the recombinant antigen and the other, which was negative by immunoblot, gave a positive reaction when used directly to screen the same library, suggesting it to be directed to a conformational epitope. The GSTT1 enzyme is the product of a single polymorphic gene that is absent from 20% of the Caucasian population. When we analysed the GSTT1 genotype of the four patients described above, we found that this gene is absent from all of them. Three donor paraffin embedded DNA samples were available and were shown to be positive for GSSTT1 genotype. In accordance with these results, we suggest that this form of post‐transplant de novo immune hepatitis, that has been reported as autoimmune hepatitis by others, could be the result of an antigraft reaction in individuals lacking the GSTT1 phenotype, in which the immune system recognizes the GSTT1 protein as a non‐self antigen, being the graft dysfunction not the result of an autoimmune reaction, but the consequence of an alo‐reactive immune response.

Glutathione S‐transferase T1 mismatch constitutes a risk factor for de novo immune hepatitis after liver transplantation

A new form of autoimmune hepatitis referred to as de novo, has been reported after liver transplantation during the past 5 years. The features are identical to those of classical autoimmune hepatitis (AIH), but the facts involved in the onset and outcome of this type of graft dysfunction are still unclear. The identification of antibodies directed to glutathione S‐transferase T1 (GSTT1) in the sera of patients with de novo immune hepatitis led us to the description of an alloimmune reaction due to a GSTT1 genetic incompatibility between donor and recipient. We analyzed a cohort of 110 liver transplant patients treated in the liver transplant unit of our hospital during a period of 1 year, from September 2002 to October 2003. We found the following distribution of the GSTT1 genotypes (recipient/donor): +/+ = 66, +/− = 23, −/+ = 15, −/− = 6. Six of these patients were diagnosed with de novo immune hepatitis; all of them belong to the group of negative recipients with positive donors, and all produced anti‐GSTT1 antibodies. This genetic combination is associated with a statistically significant increased risk of de novo immune hepatitis (IH) in liver transplant patients (P < .0001 by the Fisher exact test). In conclusion, our results clearly establish the importance of the GSTT1 genotype from donor and recipient of a liver transplant as a predictive marker for de novo IH. At the same time, we confirmed our initial results that only this particular donor/recipient combination triggers the anti‐GSTT1 antibody production. (Liver Transpl 2004;10:1166–1172.)

Prevalence and Severity of Hepatopulmonary Syndrome and Its Influence on Survival in Cirrhotic Patients Evaluated for Liver Transplantation

The prevalence of hepatopulmonary syndrome (HPS) and its influence on survival before and after liver transplantation (LT) remain controversial. Additionally, the chronology of post‐LT reversibility is unclear. This study prospectively analyzed 316 patients with cirrhosis who were evaluated for LT in 2002–2007; 177 underwent LT at a single reference hospital. HPS was defined by a partial pressure of arterial oxygen (PaO2) <70 mmHg and/or an alveolar‐arterial oxygen gradient (A‐a PO2) ≥20 mmHg in the supine position and positive contrast echocardiography. The prevalence of HPS was 25.6% (81/316 patients), and most patients (92.6%) had mild or moderate HPS. High Child‐Pugh scores and the presence of ascites were independently associated with HPS. Patients with and without HPS did not significantly differ in LT waiting list survival (mean 34.6 months vs. 41.6 months, respectively; log‐rank, p = 0.13) or post‐LT survival (mean 45 months vs. 47.6 months, respectively; log‐rank, p = 0.62). HPS was reversed in all cases within 1 year after LT. One‐fourth of the patients with cirrhosis who were evaluated for LT had HPS (mostly mild to moderate); the presence of HPS did not affect LT waiting list survival. HPS was always reversed after LT, and patient prognosis did not worsen.

Complement component 4d immunostaining in liver allografts of patients with de novo immune hepatitis

De novo immune hepatitis (DNIH) is a form of late graft dysfunction after liver transplantation. The fine mechanisms leading to the development of DNIH are not known, and whether this hepatitis is a form of rejection or a result of an auto/alloimmune injury has not been established. In our patients, DNIH was always preceded by the production of donor‐specific antibodies against the glutathione S‐transferase T1 (GSTT1) enzyme because of a genetic mismatch in which the donors carried the wild‐type gene and the recipients displayed the null genotype. Complement component 4d (C4d) immunopositivity in 12 paraffin‐embedded liver biopsy samples from 8 patients diagnosed with DNIH associated with anti‐GSTT1 antibodies was retrospectively evaluated. Six patients with a diagnosis of chronic rejection (CR) and 7 patients with hepatitis C virus recurrence were included as control groups. Among the patients with DNIH, 7 showed C4d‐positive immunostaining localized in the portal tracts, whereas in the tested biopsy samples of the 2 control groups, this staining pattern was absent. Four biopsy samples of the CR group showed C4d‐positive sinusoidal staining. This study confirms the activation of the complement pathway in the presence of donor‐specific antibodies, which was shown by the deposition of C4d elements in liver biopsy samples of patients with DNIH. The use of C4d as a marker of antibody‐mediated rejection in liver allografts in the presence of antidonor antibodies is discussed, and it may contribute to improved differential diagnoses based on biopsy findings. Liver Transpl 17:779‐788, 2011.

Choice of calcineurin inhibitor may influence the development of de novo immune hepatitis associated with anti-GSTT1 antibodies after liver transplantation

Aguilera I, Sousa JM, Praena JM, Gómez‐Bravo MA, Núñez‐Roldan A. Choice of calcineurin inhibitor may influence the development of de novo immune hepatitis associated with anti‐GSTT1 antibodies after liver transplantation. 
Clin Transplant 2011: 25: 207–212.

Antibodies against glutathione S-transferase T1 in non-solid organ transplanted patients

BACKGROUND: This article describes the presence of antibodies against glutathione S‐transferase T1 (GSTT1) in a group of patients who never received a solid organ graft. These antibodies have been previously detected in liver and kidney transplant subjects with donor‐recipient mismatch for this enzyme at the genetic level. In liver‐grafted subjects, the appearance of these antibodies correlated with de novo immune hepatitis.

Safety and efficacy of triple therapy with peginterferon, ribavirin and boceprevir within an early access programme in Spanish patients with hepatitis C genotype 1 with severe fibrosis: SVRw12 analysis

The addition of protease inhibitors (PIs) changed the hepatitis C virus (HCV) treatment standards and improved sustained viral response (SVR) rates in patients with genotype 1 HCV infection.

Response to a Vaccination Schedule With 4 Doses of 40 μg Against Hepatitis B Virus in Cirrhotic Patients Evaluated for Liver Transplantation

We conducted a retrospective study to evaluate the response to recombinant hepatitis B vaccine after 4 intramuscular doses (40 microg) administered at 0, 1, 2, and 6 months in 157 cirrhotic patients who were liver transplant candidates. Seventeen nonresponders were revaccinated with the same schedule. We studied the association between the following variables and the vaccine response: age, gender, etiology of cirrhosis, diabetes, severity of liver disease (Child-Pugh class and Model for End-Stage Liver Disease [MELD] score), and the number of administered doses. The response rates were: 1 dose, 40% (2/5); 2 doses, 0% (0/7); 3 doses, 32.7% (16/49); and 4 doses, 31.3% (30/96) of patients. The median hepatitis B surface antibody (anti-HBs) titer was 45 mU/mL (range, 11-620 mU/mL). The response rate to revaccination was 41.2% (median anti-HBs titer, 88 mU/mL; range, 18-190 mU/mL). Diabetics showed a lower response rate than nondiabetic patients (17.2% vs 35.3%; P = .046). No association was observed between the response rate to vaccine and the other variables. In conclusion, the response rate to hepatitis B vaccine reached a little more than 30% in cirrhotic patients who received 3 or 4 doses. No higher response rate was observed among patients who received 4 doses. Diabetes was associated with a lower response rate. Anti-HBs seroconversion rates were not associated with the other variables. Revaccination may significantly increase the response rate to hepatitis B vaccine in cirrhotic patients, and may be considered in nonresponders after the third dose. Early vaccination against HBV should be considered in such patients.

Hepatic Cirrhosis With Sarcoid Granulomas. Differential Diagnosis and Liver Transplantation: A Case Report

ARCOIDOSIS is a systemic disease of unknown etiology, often affecting several organs, with hepatic involvement in 17% to 90 % of cases. A few patients develop progressive liver disease. Response to treatment is poor, resulting in the necessity of liver transplantation, with the possibility of disease recurrence. 1–3 We report an unusual case of ductopenic cirrhosis due to liver sarcoidosis, the diagnosis of which was made in the hepatectomy specimen. CASE REPORT A 33-year-old woman was admitted to our institution with cryptogenetic cirrhosis. She had increased serum levels of bilirubin, without pruritus, or elevations of AST, ALT, alkaline phosphatase or GGT. Studies were performed to assess possible etiological factors, including viral markers and ANA, AMA, SMA, LKM, SP 100, and GP 210 antibodies. Serum levels of copper, iron, and alpha-1 antitrypsin were normal. Endoscopic retrograde cholangiography (ERCP) showed no biliary tract alterations. Chest X ray was also normal. Oral endoscopy showed esophageal varices. The patient presented with a history of episodes of ascites. She underwent liver transplantation with a favorable evolution and no evidence of disease recurrence in the allograft up to 21 months. Histopathological examination of the explanted liver revealed micronodular cirrhosis with segmental loss of interlobular bile ducts but with multiple epithelioid noncaseating granulomas. These contained aggregates of several epithelioid histiocytes with multinucleated giant cells, some of which showed eosinophilic central necrosis, distinct from a caseation process. Granulomas were more frequently found in the periportal area (zone 1), although they also appeared in a centronodular location. No asteroid or Schaumann bodies were seen. No infectious agents were identified by special stains, including Ziehl–Nielssen and PAS– diastase. Occasional periductal fibrosis without inflammation was observed, similar to that seen in primary sclerosing cholangitis (PSC). No alterations were found in the extrahepatic biliary tree.

De novo autoimmune hepatitis after interferon treatment in a liver transplant recipient with common variable immunodeficiency.

A 23-year-old female underwent cadaveric liver transplant (LT) or hepatitis C virus (HCV) genotype 1b cirrhosis. The infection as acquired following infusions of contaminated intravenous ammaglobulins that she had been receiving regularly since he was diagnosed of a common variable immunodeficiency CVID) when she was 15 years of age. The native liver did not how overlapping features of autoimmune hepatitis (AIH). Initial mmunosuppression included tacrolimus, azathioprine and predisone but, due to neurotoxicity, tacrolimus was converted to yclosporine after the first month. Azathioprine and prednisone ere progressively tapered and discontinued 5 and 4 months ost-transplant, respectively. At this time the patient presented ith increased transaminase levels (Fig. 1) and the viral load was .67 × 106 UI/ml. Tests for autoantibodies, including anti-nuclear, nti-mitochondrial, anti-smooth-muscle, anti-liver-kidney micro-