Acute Cellular Rejection Occurring in Allograft Livers after Combined Small Bowel/Liver Transplantion and Multivisceral Transplantation
S Kerkoutian, SH Ra, GR Cortina, D Farmer, CR Lassman. University of California Los Angeles, Los Angeles, CA
Background: Patients undergoing combined small bowel/liver transplantation (SBLTx) or multivisceral transplantation (MVTx) typically undergo a more aggressive immunosuppression (IS) regimen than patients with orthotopic liver transplantation alone. Due to the IS regimen, acute cellular rejection (ACR) in allograft liver biopsies after SBLTx or MVTx is an uncommon occurrence, especially with small bowel biopsies that are negative for ACR.
Design: We reviewed 58 allograft liver biopsies and their concurrent small bowel biopsies from 33 SBLTx and MVTx patients performed between the years 1995 to 2009.
Results: The 58 liver biopsies with concurrent small biopsies revealed: no ACR in 36 cases (62%), ACR of the small bowel alone in 13 cases (22%), ACR of the liver alone in 8 cases (14%), and ACR of both the liver and small bowel in 1 case (2%). The nine allograft liver biopsies with ACR were from five patients, four female and one male, ranging in age from 2 to 29 yrs. (median: 4 yrs.). Four of the allograft liver ACRs were from one case and two ACRs from another. SBLTxs and MVTxs were initially performed for gastroschisis in four patients and abdominal trauma in one patient. All five patients were cirrhotic from TPN toxicity. One patient underwent a redo SBLTx due to severe exfoliative small bowel rejection. All five patients had elevated liver function tests at the time of biopsy. The biopsies were performed 22 to 3192 days from SBLTx or MVTx (median: 207 days). The allograft liver biopsies revealed mild ACR in seven cases and moderate ACR in two cases. Classic features of ACR including mixed portal inflammatory infiltrates, bile duct infiltration, and portal and central vein endothelitis were seen in 7 cases. Two of the biopsies demonstrated perivenular inflammation with hepatocyte dropout and a mild hepatitis consistent with late acute rejection. Four patients were successfully treated with intravenous steroids and one patient was treated with an increase in immunosuppression.
Conclusions: The diagnosis of ACR in allograft liver biopsies after SBLTx and MVTx is not an uncommon occurrence and can occur in the presence of a normal small bowel biopsy. Although the majority of cases show classical mild acute ACR, moderate ACR and late ACR can be seen in this setting. Also, multiple episodes of allograft liver ACR can be seen despite heavy IS.
Category: Liver & Pancreas
Tuesday, March 23, 2010 9:30 AM
Poster Session III # 242, Tuesday Morning