Liver transplantation acute rejection: Difference between revisions
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==Overview== | ==Overview== | ||
==Liver transplantation acute rejection== | ==Liver transplantation acute rejection== | ||
Early acute cellular rejection mostly occurs within 90 days. | Early acute cellular rejection mostly occurs within 90 days.<ref name="pmid27567694">{{cite journal| author=Levitsky J, Goldberg D, Smith AR, Mansfield SA, Gillespie BW, Merion RM et al.| title=Acute Rejection Increases Risk of Graft Failure and Death in Recent Liver Transplant Recipients. | journal=Clin Gastroenterol Hepatol | year= 2017 | volume= 15 | issue= 4 | pages= 584-593.e2 | pmid=27567694 | doi=10.1016/j.cgh.2016.07.035 | pmc=5326609 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27567694 }}</ref> | ||
'''Risk factors for acute rejection''' | '''Risk factors for acute rejection''':<ref name="pmid9731552">{{cite journal| author=Wiesner RH, Demetris AJ, Belle SH, Seaberg EC, Lake JR, Zetterman RK et al.| title=Acute hepatic allograft rejection: incidence, risk factors, and impact on outcome. | journal=Hepatology | year= 1998 | volume= 28 | issue= 3 | pages= 638-45 | pmid=9731552 | doi=10.1002/hep.510280306 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9731552 }}</ref><ref name="pmid12360439">{{cite journal| author=Ramji A, Yoshida EM, Bain VG, Kneteman NM, Scudamore CH, Ma MM et al.| title=Late acute rejection after liver transplantation: the Western Canada experience. | journal=Liver Transpl | year= 2002 | volume= 8 | issue= 10 | pages= 945-51 | pmid=12360439 | doi=10.1053/jlts.2002.34969 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12360439 }}</ref> | ||
Recipient prothrombin time or bilirubin that remains steadily elevated | Recipient prothrombin time or bilirubin that remains steadily elevated | ||
| Line 21: | Line 21: | ||
Cold ischemia time greater than 15 hours | Cold ischemia time greater than 15 hours | ||
For risk of late rejection, low blood concentration of cyclosporine or tacrolimus | For risk of late rejection, low blood concentration of cyclosporine or tacrolimus. | ||
'''Clinical presentation''' | '''Clinical presentation''' | ||
* Fever, malaise, abdominal pain, and hepatosplenomegaly. | * Fever, malaise, abdominal pain, and hepatosplenomegaly. | ||
* None of these is specific for rejection. | * None of these is specific for rejection. | ||
* Acute cellular rejection is generally suspected based upon the development of hepatic biochemical test abnormalities: | * Acute cellular rejection is generally suspected based upon the development of hepatic biochemical test abnormalities:<ref name="pmid1505912">{{cite journal| author=Henley KS, Lucey MR, Appelman HD, Baliga P, Brown KA, Burtch GD et al.| title=Biochemical and histopathological correlation in liver transplant: the first 180 days. | journal=Hepatology | year= 1992 | volume= 16 | issue= 3 | pages= 688-93 | pmid=1505912 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1505912 }}</ref> | ||
Serum aminotransferases | Serum aminotransferases | ||
| Line 35: | Line 35: | ||
Bilirubin level | Bilirubin level | ||
Hepatocyte derived microRNAs (HDmiRs, mir-122, miR-148a) have been evaluated as markers of acute cellular rejection. | Hepatocyte derived microRNAs (HDmiRs, mir-122, miR-148a) have been evaluated as markers of acute cellular rejection.<ref name="pmid27533743">{{cite journal| author=Shaked A, Chang BL, Barnes MR, Sayre P, Li YR, Asare S et al.| title=An ectopically expressed serum miRNA signature is prognostic, diagnostic, and biologically related to liver allograft rejection. | journal=Hepatology | year= 2017 | volume= 65 | issue= 1 | pages= 269-280 | pmid=27533743 | doi=10.1002/hep.28786 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27533743 }}</ref> | ||
'''Liver biopsy''' | '''Liver biopsy''' | ||
* Liver histology is the gold standard for the diagnosis of acute cellular rejection. | * Liver histology is the gold standard for the diagnosis of acute cellular rejection.<ref name="pmid1959854">{{cite journal| author=Bubak ME, Porayko MK, Krom RA, Wiesner RH| title=Complications of liver biopsy in liver transplant patients: increased sepsis associated with choledochojejunostomy. | journal=Hepatology | year= 1991 | volume= 14 | issue= 6 | pages= 1063-5 | pmid=1959854 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1959854 }}</ref> | ||
* Presence of biliary strictures and biliary anastomosis with mixed inflammatory infiltrate in the portal triad is sign of rejection. | * Presence of biliary strictures and biliary anastomosis with mixed inflammatory infiltrate in the portal triad is sign of rejection.<ref name="pmid9397978">{{cite journal| author=Larson AM, Chan GC, Wartelle CF, McVicar JP, Carithers RL, Hamill GM et al.| title=Infection complicating percutaneous liver biopsy in liver transplant recipients. | journal=Hepatology | year= 1997 | volume= 26 | issue= 6 | pages= 1406-9 | pmid=9397978 | doi=10.1002/hep.510260605 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9397978 }}</ref> | ||
* Nonsuppurative cholangitis is important for the prognosis of rejection. The affected ducts are surrounded by immunocytes, which may also be found between epithelial cells, inside the basement membrane, or even in the lumen. | * Nonsuppurative cholangitis is important for the prognosis of rejection. The affected ducts are surrounded by immunocytes, which may also be found between epithelial cells, inside the basement membrane, or even in the lumen. | ||
'''Histologic rejection activity index for liver transplants''' | '''Histologic rejection activity index for liver transplants''' | ||
Revision as of 01:06, 18 December 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Liver trasnsplantation Microchapters |
Overview
Liver transplantation acute rejection
Early acute cellular rejection mostly occurs within 90 days.[1]
Risk factors for acute rejection:[2][3]
Recipient prothrombin time or bilirubin that remains steadily elevated
Donors older than 50 years
Donor pre-procurement acidosis
Cytomegalovirus genotype gB1 infection
Fewer human leukocyte antigen (HLA)-DR matches
Cold ischemia time greater than 15 hours
For risk of late rejection, low blood concentration of cyclosporine or tacrolimus.
Clinical presentation
- Fever, malaise, abdominal pain, and hepatosplenomegaly.
- None of these is specific for rejection.
- Acute cellular rejection is generally suspected based upon the development of hepatic biochemical test abnormalities:[4]
Serum aminotransferases
Alkaline phosphatase
Gamma-glutamyl transpeptidase
Bilirubin level
Hepatocyte derived microRNAs (HDmiRs, mir-122, miR-148a) have been evaluated as markers of acute cellular rejection.[5]
Liver biopsy
- Liver histology is the gold standard for the diagnosis of acute cellular rejection.[6]
- Presence of biliary strictures and biliary anastomosis with mixed inflammatory infiltrate in the portal triad is sign of rejection.[7]
- Nonsuppurative cholangitis is important for the prognosis of rejection. The affected ducts are surrounded by immunocytes, which may also be found between epithelial cells, inside the basement membrane, or even in the lumen.
Histologic rejection activity index for liver transplants
| Category | Criteria | Score |
| Portal inflammation | –– | 1 |
| Expansion of most of all of the triads, by a mixed infiltrate containing lymphocytes with occasional blasts, neutrophils and eosinophils | 2 | |
| Marked expansion of most or all of the triads by a mixed infiltrate containing numerous blasts and eosinophils with inflammatory spillover into the periportal parenchyma | 3 | |
| Bile duct inflammation damage | A minority of the ducts are cuffed and infiltrated by inflammatory cells and show only mild reactive changes such as increased nuclear:cytoplasmic ratio of the epithelial cells | 1 |
| Most or all of the ducts infiltrated by inflammatory cells. More than an occasional duct shows degenerative changes such as nuclear pleomorphism, disordered polarity and cytoplasmic vacuolization of the epithelium | 2 | |
| As above for 2, with most or all of the ducts showing degenerative changes or focal lumenal disruption | 3 | |
| Venous endothelial inflammation | Subendothelial lymphocytic infiltration involving some, but not a majority of the portal and/or hepatic venules | 1 |
| Subendothelial lymphocytic infiltration involving some, but not a majority of the portal and/or hepatic venules | 2 | |
| As above for 2, with moderate or severe perivenular inflammation that extends into the perivenular parenchyma and is associated with perivenular hepatocyte necrosis | 3 |
- ↑ Levitsky J, Goldberg D, Smith AR, Mansfield SA, Gillespie BW, Merion RM; et al. (2017). "Acute Rejection Increases Risk of Graft Failure and Death in Recent Liver Transplant Recipients". Clin Gastroenterol Hepatol. 15 (4): 584–593.e2. doi:10.1016/j.cgh.2016.07.035. PMC 5326609. PMID 27567694.
- ↑ Wiesner RH, Demetris AJ, Belle SH, Seaberg EC, Lake JR, Zetterman RK; et al. (1998). "Acute hepatic allograft rejection: incidence, risk factors, and impact on outcome". Hepatology. 28 (3): 638–45. doi:10.1002/hep.510280306. PMID 9731552.
- ↑ Ramji A, Yoshida EM, Bain VG, Kneteman NM, Scudamore CH, Ma MM; et al. (2002). "Late acute rejection after liver transplantation: the Western Canada experience". Liver Transpl. 8 (10): 945–51. doi:10.1053/jlts.2002.34969. PMID 12360439.
- ↑ Henley KS, Lucey MR, Appelman HD, Baliga P, Brown KA, Burtch GD; et al. (1992). "Biochemical and histopathological correlation in liver transplant: the first 180 days". Hepatology. 16 (3): 688–93. PMID 1505912.
- ↑ Shaked A, Chang BL, Barnes MR, Sayre P, Li YR, Asare S; et al. (2017). "An ectopically expressed serum miRNA signature is prognostic, diagnostic, and biologically related to liver allograft rejection". Hepatology. 65 (1): 269–280. doi:10.1002/hep.28786. PMID 27533743.
- ↑ Bubak ME, Porayko MK, Krom RA, Wiesner RH (1991). "Complications of liver biopsy in liver transplant patients: increased sepsis associated with choledochojejunostomy". Hepatology. 14 (6): 1063–5. PMID 1959854.
- ↑ Larson AM, Chan GC, Wartelle CF, McVicar JP, Carithers RL, Hamill GM; et al. (1997). "Infection complicating percutaneous liver biopsy in liver transplant recipients". Hepatology. 26 (6): 1406–9. doi:10.1002/hep.510260605. PMID 9397978.