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103 A simple noninvasive index to predict fibrosis in HCV-infected liver transplant recipients
Category 1: Liver Transplantation~Surgery~AcuteLiver Failure
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IMMUNOLOGICAL MONITORING IN LIVER T R A N S P L A N T PATIENTS WITH C O M B I N E D MMF AND LOW DOSE CNI THERAPY
Z. Yu 1, S. Beckebaurn 1,2, VR. Cicinnati 1,2, X. Chen 1, A. Frilling 1, G. Gerken 2, C.E. Broelsch ~. :Department of General Surgery and
Transplantation, University HospitalEssen, Essen, Germany; 2Department of Gastroenterology and Hepatology. University Hospital Essen, Essen, Germany Background and Aim: Long term stable liver transplant patients with renal dysfunction under CNI treatment were randomized to receive either combined MMF and low dose CNI therapy or to continue their current CNI dose. Immunological monitoring has been performed to assess the safety and efficacy of the immunosuppressive therapy. Methods: PBMC were isolated from patient blood at baseline and after conversion to MMF/low dose CNI regimen. The number and phenotype of distinct T cell subsets was assessed by FACS analysis. Moreover, freshly-isolated PBMC from healthy volunteers were exposed in vitro to mycophenolic acid (MPA), cyclosporine (CsA), tacrolimus (TALC), combined CSA/MPA or TAC/MPA to assess inhibition ofT-cell activation induced by T cell receptor/CD3-mediated signaling. T cell proliferation, cell cycle analysis, expression of activation markers and Thl/Th2 cytoldne profile were evaluated by FACS analysis. Furtherrnore, mRNA expression of IL-2, NFATc and TNF-o, in PBMC from patients and healthy controls was investigated by real time PCR. Results: Combined MMF/Iow dose CNI therapy leads to a reduction of circulating CD8+, CD45R©+CD4+ and CD3+CD56+ T cells as compared to controls receiving CNI monothempy. In addition, a decreased expression of early (CD69, CD71), late (CD25) and CD40 dependent (CD154) activation markers was detectable in T cells from tile study group as compared to controls. In vitro experiments indicate that as much as 1 uM MPA completely blocks T cell proliferation and stops the cell cycle o f activated T cells in G0/G1 phase at a dose-dependent manner. Low dose CNIs inhibit expression of NFATc and T cell activation markers efficiently and this effect is enhanced by combined administration of MPA and CNI. Conclusion: FACS analysis and assessment of cytokine expression o f PBMC represent important tools for monitoring and optimizing tile irnmunosuppressive regimen within tile liver transplant setting. Combined MMF and low dose CNI efficiently suppress T cells as evidenced by a) arrest of the cell cycle in G0/G1 phase, b) inhibition of NFATc-related gene expression and c) decreased activation marker expression. Our results suggest that adjustment of the MMF dosage by AUC-monitoring may be required to avoid over-immunosuppression.
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SIMPLE NONINVASIVE INDEX TO PREDICT FIBROSIS IN HCV-INFECTED LIVER T R A N S P L A N T RECIPIENTS
S. Benlloch I , M. Berenguer ~, J.M. Raydn 2, M. Prieto ~, V Agnilera ~, J. BerenguerI . I Hepatogastroenterology Department Hospital
Universitario La Fe, Valencia, Spain; 2Pathology Department Hospital Universitario La Fe, Valencia, Spain Background: Recurrent histologic hepatitis occurs in the majority of patients undergoing liver transplantation (LT) for HCV-related cirrhosis, with progression to cirrhosis in up to 30% after 5 years of follow-up. Serial liver biopsies remain the best way of monitoring disease progression, but they have risks and known limitations. Aims: To construct a non-invasive model consisting of routine laboratory data to predict fibrosis in HCV-infected liver transplant patients. Methods: 510 yearly protocol liver biopsies performed at yearly intervals in 188 LT recipients (67% male, median age 54) were divided into 2 groups: training set (n=414) and validation set (n=96). Laboratory variables obtained within 2 months of liver biopsies were recorded. Time from liver transplantation (TFLT) was also included.
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Results: By bivariate analysis, the following variables were associated with significant fibrosis: creatinine, cholesterol, AST, ALT, ALP, albumin, sodium, platelet count, prothrombin time (PT), albumin/total proteins ratio (percentage of albumin) and TFLT. Multivariate analysis identified 4 variables as independent predictors of fibrosis: prothrornbin time, albumin/total proteins ratio, aspartate aminotransferase (AST) and TFLT. The area under the receiver operating characteristic (ROC) curves were 0.80 and 0.84 for the training and the validation set, respectively. In the training set, using a cut-off of 0.2, the model had a sensitivity and NPV of 74% and 90% respectively to differentiate significant (bricl~ng fibrosis and cirrhosis) from mild fibrosis (none or portal). In the validation cohort, these values increased to 87% and 95% respectively, indicating that this model predicts absence of significant fibrosis with 95% certainty at this cutoff point and lower. 71% of biopsies without significant fibrosis could have been avoided at this cutoff value. Conclusions: In the liver transplant setting, a simple fibrosis index is useful to select HCV-infected patients with very low risk of significant fibrosis in whom protocol liver biopsies might be avoided.
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SIGNIFICANT IMPROVEMENT IN THE O U T C O M E OF HCV-INFECTED T R A N S P L A N T RECIPIENTS FOLLOWING THE IMPLEMENTATION OF SIMPLE MEASURES
M. Berenguer 1, V Aguilera 1, M. Prieto 1, F. San Juan 2, S. Benlloch I , J.M. Raydn 3, J. Berenguer I . 1Hepatogastroenterology Department
Hospital Universitario La Fe, Valencia, Spain," 2Liver Unit, Surgery Depar#nent, Hospital Universitario La Fe, Valencia, Spain," SPathology Depar#nent Hospital Universitario La Fe, Valencia, Spain Background: Recurrent HCV-cirrhosis occurs in a substantial proportion of recipients, with higher rates reported in patients transplanted recently. Both the aging of the donors and over-immunosuppression have been implicated in this worse outcome. In addition, controversial results have been reported with regards to tile role of specific calcinenrin-inhibitors. Aims: To determine (1) whether the implementation of specific measures aimed at reducing or avoiding the negative predictive variables is associated with an improvement in tile outcome of recurrent hepatitis C; (2) whether there are differences in outcome based on the induction immunosuppression (tacrolimus vs cyclosporine-based). Methods: (1) Comparative study between a cohort of patients transplanted recently (2001 2003) and a control group of HCV-infected patients transplanted before the implementation of three simple measures (1999-2000): (i) use dual immunosuppression (steroids + cyclosporine neoral or tacrolimus); (ii) Slow steroid tapering; and (iii) selection, whenever possible, of organs from younger donors for HCV-candidates. (2) Prospective randomized trial comparing fibrosis progression and rate of HCV-related severe disease (F3, F4, cholestatic hepatitis) between tacrolimus and cyclosporine-based immunosuppressed using tile most recent cohort. Yearly biopsies were performed in these recipients, and only those with at least one protocol biopsy and those with cholestatic hepatitis (regardless of follow-up) were included in the study. Results: Severe disease (defined as bridong fibrosis, cirrhosis, or fibrosing cholestatic hepatitis in the first two years) was significantly lower in this cohort compared to tile control group (13/42, 31% vs 26/47, 50%; p = 0.02). While tile age of tile donor had not changed significantly between the two cohorts, the proportion of patients on triple-quadruple regimes was lower and the duration of prednisone therapy longer in patients transplanted more recently. Cyclosporine (n=26) and tacrolimus (n= 16) patients were similar with regards to demographics, donor age and sex, duration of prednisone, rejection, methyl-prednisolone bohlses, surgicalrelated variables and follow-up. The percentage of patients developing severe disease was not statistically different between tile cyclosporine and tacrolimus groups (27% vs 37.5%). Conclusions: Improving the outcome of recurrent hepatitis C might be achieved by reducing overall immunosuppression and avoiding abrupt changes in immunosuppression.
I•
IMMUNOLOGICAL MONITORING IN LIVER T R A N S P L A N T PATIENTS WITH C O M B I N E D MMF AND LOW DOSE CNI THERAPY
Z. Yu 1, S. Beckebaurn 1,2, VR. Cicinnati 1,2, X. Chen 1, A. Frilling 1, G. Gerken 2, C.E. Broelsch ~. :Department of General Surgery and
Transplantation, University HospitalEssen, Essen, Germany; 2Department of Gastroenterology and Hepatology. University Hospital Essen, Essen, Germany Background and Aim: Long term stable liver transplant patients with renal dysfunction under CNI treatment were randomized to receive either combined MMF and low dose CNI therapy or to continue their current CNI dose. Immunological monitoring has been performed to assess the safety and efficacy of the immunosuppressive therapy. Methods: PBMC were isolated from patient blood at baseline and after conversion to MMF/low dose CNI regimen. The number and phenotype of distinct T cell subsets was assessed by FACS analysis. Moreover, freshly-isolated PBMC from healthy volunteers were exposed in vitro to mycophenolic acid (MPA), cyclosporine (CsA), tacrolimus (TALC), combined CSA/MPA or TAC/MPA to assess inhibition ofT-cell activation induced by T cell receptor/CD3-mediated signaling. T cell proliferation, cell cycle analysis, expression of activation markers and Thl/Th2 cytoldne profile were evaluated by FACS analysis. Furtherrnore, mRNA expression of IL-2, NFATc and TNF-o, in PBMC from patients and healthy controls was investigated by real time PCR. Results: Combined MMF/Iow dose CNI therapy leads to a reduction of circulating CD8+, CD45R©+CD4+ and CD3+CD56+ T cells as compared to controls receiving CNI monothempy. In addition, a decreased expression of early (CD69, CD71), late (CD25) and CD40 dependent (CD154) activation markers was detectable in T cells from tile study group as compared to controls. In vitro experiments indicate that as much as 1 uM MPA completely blocks T cell proliferation and stops the cell cycle o f activated T cells in G0/G1 phase at a dose-dependent manner. Low dose CNIs inhibit expression of NFATc and T cell activation markers efficiently and this effect is enhanced by combined administration of MPA and CNI. Conclusion: FACS analysis and assessment of cytokine expression o f PBMC represent important tools for monitoring and optimizing tile irnmunosuppressive regimen within tile liver transplant setting. Combined MMF and low dose CNI efficiently suppress T cells as evidenced by a) arrest of the cell cycle in G0/G1 phase, b) inhibition of NFATc-related gene expression and c) decreased activation marker expression. Our results suggest that adjustment of the MMF dosage by AUC-monitoring may be required to avoid over-immunosuppression.
I
•
A
SIMPLE NONINVASIVE INDEX TO PREDICT FIBROSIS IN HCV-INFECTED LIVER T R A N S P L A N T RECIPIENTS
S. Benlloch I , M. Berenguer ~, J.M. Raydn 2, M. Prieto ~, V Agnilera ~, J. BerenguerI . I Hepatogastroenterology Department Hospital
Universitario La Fe, Valencia, Spain; 2Pathology Department Hospital Universitario La Fe, Valencia, Spain Background: Recurrent histologic hepatitis occurs in the majority of patients undergoing liver transplantation (LT) for HCV-related cirrhosis, with progression to cirrhosis in up to 30% after 5 years of follow-up. Serial liver biopsies remain the best way of monitoring disease progression, but they have risks and known limitations. Aims: To construct a non-invasive model consisting of routine laboratory data to predict fibrosis in HCV-infected liver transplant patients. Methods: 510 yearly protocol liver biopsies performed at yearly intervals in 188 LT recipients (67% male, median age 54) were divided into 2 groups: training set (n=414) and validation set (n=96). Laboratory variables obtained within 2 months of liver biopsies were recorded. Time from liver transplantation (TFLT) was also included.
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Results: By bivariate analysis, the following variables were associated with significant fibrosis: creatinine, cholesterol, AST, ALT, ALP, albumin, sodium, platelet count, prothrombin time (PT), albumin/total proteins ratio (percentage of albumin) and TFLT. Multivariate analysis identified 4 variables as independent predictors of fibrosis: prothrornbin time, albumin/total proteins ratio, aspartate aminotransferase (AST) and TFLT. The area under the receiver operating characteristic (ROC) curves were 0.80 and 0.84 for the training and the validation set, respectively. In the training set, using a cut-off of 0.2, the model had a sensitivity and NPV of 74% and 90% respectively to differentiate significant (bricl~ng fibrosis and cirrhosis) from mild fibrosis (none or portal). In the validation cohort, these values increased to 87% and 95% respectively, indicating that this model predicts absence of significant fibrosis with 95% certainty at this cutoff point and lower. 71% of biopsies without significant fibrosis could have been avoided at this cutoff value. Conclusions: In the liver transplant setting, a simple fibrosis index is useful to select HCV-infected patients with very low risk of significant fibrosis in whom protocol liver biopsies might be avoided.
I•
SIGNIFICANT IMPROVEMENT IN THE O U T C O M E OF HCV-INFECTED T R A N S P L A N T RECIPIENTS FOLLOWING THE IMPLEMENTATION OF SIMPLE MEASURES
M. Berenguer 1, V Aguilera 1, M. Prieto 1, F. San Juan 2, S. Benlloch I , J.M. Raydn 3, J. Berenguer I . 1Hepatogastroenterology Department
Hospital Universitario La Fe, Valencia, Spain," 2Liver Unit, Surgery Depar#nent, Hospital Universitario La Fe, Valencia, Spain," SPathology Depar#nent Hospital Universitario La Fe, Valencia, Spain Background: Recurrent HCV-cirrhosis occurs in a substantial proportion of recipients, with higher rates reported in patients transplanted recently. Both the aging of the donors and over-immunosuppression have been implicated in this worse outcome. In addition, controversial results have been reported with regards to tile role of specific calcinenrin-inhibitors. Aims: To determine (1) whether the implementation of specific measures aimed at reducing or avoiding the negative predictive variables is associated with an improvement in tile outcome of recurrent hepatitis C; (2) whether there are differences in outcome based on the induction immunosuppression (tacrolimus vs cyclosporine-based). Methods: (1) Comparative study between a cohort of patients transplanted recently (2001 2003) and a control group of HCV-infected patients transplanted before the implementation of three simple measures (1999-2000): (i) use dual immunosuppression (steroids + cyclosporine neoral or tacrolimus); (ii) Slow steroid tapering; and (iii) selection, whenever possible, of organs from younger donors for HCV-candidates. (2) Prospective randomized trial comparing fibrosis progression and rate of HCV-related severe disease (F3, F4, cholestatic hepatitis) between tacrolimus and cyclosporine-based immunosuppressed using tile most recent cohort. Yearly biopsies were performed in these recipients, and only those with at least one protocol biopsy and those with cholestatic hepatitis (regardless of follow-up) were included in the study. Results: Severe disease (defined as bridong fibrosis, cirrhosis, or fibrosing cholestatic hepatitis in the first two years) was significantly lower in this cohort compared to tile control group (13/42, 31% vs 26/47, 50%; p = 0.02). While tile age of tile donor had not changed significantly between the two cohorts, the proportion of patients on triple-quadruple regimes was lower and the duration of prednisone therapy longer in patients transplanted more recently. Cyclosporine (n=26) and tacrolimus (n= 16) patients were similar with regards to demographics, donor age and sex, duration of prednisone, rejection, methyl-prednisolone bohlses, surgicalrelated variables and follow-up. The percentage of patients developing severe disease was not statistically different between tile cyclosporine and tacrolimus groups (27% vs 37.5%). Conclusions: Improving the outcome of recurrent hepatitis C might be achieved by reducing overall immunosuppression and avoiding abrupt changes in immunosuppression.