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Hepatic B cells: a role in rejection following human orthotopic liver transplantation
646A
AASLD ABSTRACTS
HEPATOLOGY October 2001
1895
1896
EARLY REJECTION IN FULMINANT HEPATIC FAILURE. OUR EXPERIENCE W I T H NEORAL.. Pedro L Trigo, Javier C Lendoire, Gustavo A
SUCCESSFUL PROPHYLAXIS OF HEPATITIS C VIRAL (HCV) RE-INFECTION A N D RECURRENT MULTIPLE HEPATOCELLULAR CARCINOMA (HCC) AFTER LIVING DONOR LIVER TRANSPLANTATION (LDLT) W I T H INTERFERON BETA A N D D O N O R SPECIFIC TRANSFUSION.
Braslavsky, Marcelo F Amante, Maria C Romero, Oscar C Imventarza, Hospital Argerich, Buenos Aires Argentina INTRODUCTION: Fulminant hepatic failure (FHF) is the first indication for orthotopic liver transplantation (OLT) in our center since 1997. Few reports describes the incidence and characteristics of rejection in this type of patients. PURPOSE: Analyze the incidence and response of rejection episodes in patients with orthotopic liver transplantation for fulminant hepatic failure in comparison with other indications (non fulminant hepatic failure). PATIENTS AND METHODS: From June 1995 to November 2000, 140 patients were transplanted in our unit. Inclusion criteria : Induction immunosuppression with triple drugs regimen (cyclosporine Neoral, prednisone and azathioprine). Exclusion criteria: second graf, multivisceral transplantation, familial amyloid patients. Study cohorts: 19 patients (p) with fulminant hepatic failure (autoimmune 5 p, hepatitis A 3p, hepatitis B 3, drugs 3, cryptogenic 3, others 2), and 74 non fulminant hepatic failure (primary biliary cirrhosis 22 p, autoimmune 15 p, cryptogenic 10, hepatitis C 8 p, alcoholic 6 p, primary sclerosis cholangirls 4, alcohol plus hepatitis C 3, miscellaneous 6) were analyzed. Non protocol biopsies were performed. Early rejection: Based on Banff schema and considered within the first 6 weeks postransplantation. Steroid Resistant Rejection: persistence of rejection after three intravenous bolus of i gr of metilprednisolone each. The sex, age, incidence and treatment response of the first rejection episodes were analyzed. The period from transplantation to rejection was documented. RESULTS: See table I. CONCLUSION: Liver transplantation in patients with fulminant hepatic failure demonstrate a higher incidence of early rejection. The younger age and the previous healthy status could explain why in this group of patients, with a better immune relative system more potent immunosuppression could be needed. Based in these result, we started using a quadruple drug regimen with basiliximab as induction immunosuppression in patients transplanted for fulminant hepatic failure. TABLEI
_N Male Age Early Rejection Days OL¥. RX Steroid Resistant Rejection
FHF
non FHF
p
19 6 (31.5%) 27.1+_ 9.6 years 11 (57.8%) 9.5 ± 6.7 5 (45%)
74 24 (32,4%) 38 ± 14.1 years 22 (29.7%) 13.2 ± 9.2 5 (23%)
NS p 0.03 p 0.02 NS NS
Takafumi Ichida, Yoshinobn Sato, Hisami Watanabe, Satoshi Yamamoto, Satoshi Sugahara, Satoshi Yamagiwa, Koichi Tanaka, Toru Abo, Katsuyoshi Hatakeyama, Hitoshi Asakura, Niigata University School of Medicine, Niigata Japan Introduction:We conductedLDLTfor advancedrecurrent HCC related with HCV. To prevention of re-infectionof HCV,pre-administrationof interferonbeta had done two weeksbeforeprogramming LDLT.Also,we conducted transcatheterarterialembolizationand systemicinfusiontherapy before LDLT. In addition, we programmed to do donor specifictransfusionvia portal vein with chemotherapywhich obtained from donor after LDLTfor 4 weeks.Two yearsafter LRDT, there is no recurrenceof HCVand HCC with histological,serologicaland total imagingwith maintainedof only 0.Smg of FKS06 daftly. Case report (Material Method) A 62 year-old-womanhad been infected with HCV during the blood transfusion at her daughter s birth, in 1965. Single HCC located segment 2 was detected with compensatedliver cirrhosis.She receivedlateral segmentectomy in 1994. After 2 years, recurrent HCC nodule could be detected receivingalcoholinjection therapy. Then 2 years more later, 2 nodules of HCC was detected receivingalcoholinjection and microwave coagulation therapy. Finally, at 1999, multiple nodules could be observed by total imaging, but, hepatic functional reserve have been still preserved Child-Pugh classificationA). Systemic existence of cancer cells was suspected due to a positive teat for AFP mRNA in the peripheral blood. Prophylaxisbefore LRDT; The patient was given 5FU of 1000mg/dayfor 5 consecutivedayspreoperativelyfor neoadjnvantchemotherapyand receivedTAE therapy I week before operation. In addition, we treated with interferon (IFN) beta nine times of six million international units intravenously to the prophylaxis of HCV reinfection. Before LRDT, serum levelsof HCVRNAwas negativeby HCVPCRfrom 4.2Meq/mlbefore treatmentin the sera. LRDT was done on 1~tofJuly, 1999with graftusing right lobe of her daughter. ProphylaxisafterLRD liver transplantation:Adjuvantchemotherapywith systemic administration of 10rag of doxorubicine (adriamycin)once a weekand intraportal treatmentwith 250ragof 5FU for three consecutivedays, was startedas a singlecourse on day 7 afterLRDLT.In total, she had three coursesof the sandwich chemotherapy. Transfer of donor blood via the portal vein was started immediately after the reconstructionof hepatic artery.Transfusionof 50 ml or 100 ml of donor blood via the portal vein was performed almost once a week starting on day 1. Immunologicalstudies:Liverspecimenswere obtained by open biopsy during LRDLT.Two or three color-flowcytometrywith severalmonoclonalantibodieshad done. CD56+ CD3+ T of liverinfiltratinglymphocytesincreasednoticeably from 20% to 45% compared to those in the peripheral blood after LRDLT.These cells increased graduallyfollowingtransplantation.CD56-T cellsin the graftand the lymphocytesof the peripheral blood were almostrecipient type. 17.4%of CD56+ T cellswere the donor type evenon day 42 after LRDLTindication macrochymerism.Clinicalcourse:There were no eventfulside effectand episode of rejection after two years.At September2001, liver biopsy was performed. Both histologicaland serological,there were no evidenceof recurred hepatitis and recurred HCC. Resultand DiscussionLDLTis one of the representativeprogrammingoperation with well organizingpreparation for prophylaxisand post transplant treatment.We conducted preliminarywith reduction of FICVRNAfrom recipient s serum with interferonbeta, and acquired immunotorelanceby DST and pre and post adjuvant chemotherapy. Our result might be useful to promote LDLTfor HCV positiveHCC.
1897
1898
MICA ALLELES DO NOT PREDISPOSE TO CHRONIC REJECTION FOLLOWING OLT. M Clare, Guy's Hospital, London United Kingdom; S Cookson, King's College Hospital, London United Kingdom; B Collins, B Vaughan, Guy's Hospital, London United Kingdom; P Donaldson, University of Newcastle, Newcastle United Kingdom; P Muiesan, M Rela, N Heaton, J O'Grady, S Norris, King's College Hospital, London United Kingdom
HEPATIC B CELLS: A ROLE IN REJECTION FOLLOWING HUMAN ORTHOTOPIC LIVER TRANSPLANTATION?. Raghu Varadarajan, Deignan
Chronic rejection (CR) is characterised by destruction of the small bile ducts and arteriopathy, and is usually preceded by intense portal tract infitration by predominantly CD8 + T cells. While the precise immunologic mechanisms underlying this process are not clear, active duct destruction appears to result from both T cell-mediated cholangitis and ischaemia, and this is likely mediated by interactions between cytokines, T cells and biliary epithelial cells. Recent studies have reported an association between chronic inflammatory states and mICA, a protein normally expressed only by "stressed" epithelia which acts as an activation signal for cytotoxic T cells. We have previously reported a strong association between MICA*008 allele and PSC, and a protective effect with MICA*002-. The aim of the current study was to examine the relationship between MICA alleles and CR development after OLT. Methods: 25 patients who developed CR following OLT and 25 age-, sex-, and disease-matched controls who did not develop CR over the same follow-up period after OLT were identified. DNA was extracted by standard methods and tested for the 16 common alleles of the MICA locus by standard PCR protocol. For patients with CR, donor/recipient MICA aUotypes were also analyzed. Results: The MICA*008 allele was more common in patients with CR compared to non-CR controls (gene frequency 64% v 55%, p = n s ) but this did not reach statistical significance. In addition, there was no difference in the frequency of MICA*008/008 homozygosity between the two groups. The MICA*002 allele was less commonly identified in the CR group (gene frequency 6% v 18%, OR=0.3) but this trend did not reach statistical significance (p=0.08). There was no statistically significant genotype differences between the MICA allotypes of donor and recipients who developed CR. Conclusion: MICA genotypes do not appear to be associated with increased risk for developing CR following OLT. This is the first study to address the impact of MICA genes in CR. ~Norris et al, Gastro 2001;120:1475.
Tina, Crona Gallagher, Niamh Nolan, Oscar Traynor, Gerard McEntee,John E Hegarty, Justin Geoghegan, Cliona O'Farrelly, St Vincent's Univ Hosp, Dublin Ireland Normal h u m a n liver contains a unique subset of lymphocytes that may influence hepatic immune responses. These lymphocytes can be transferred from donor to recipient during orthotopic liver transplantation (OLT). The aim of this study was to investigate whether the numbers of these T and B 'passenger' lymphocytes in the donor liver are associated with the occurrence and severity of acute cellular rejection (ACR) and to study the variation of the lymphocyte repertoire in the liver during ACR following human OLT. Donor liver tissue taken from 17 adult donors prior to transplantation was stained by immunohistochemistry for CD3 (T ceils) and CD20 (B cells). Positively stained cells in the portal tract and parenchyma were identified by light microscopy. Clinically diagnosed episodes of rejection were confirmed by histological examination of post transplantation biopsies. Eighteen biopsies from 12 patients who had ACR post OLT were also stained by immunohistochemistry for T and B cells. Five patients had no evidence of ACR, 6 had one rejection episode, 4 had two episodes and the other two patients had three and four episodes respectively. There was a significant correlation between the number of B lymphocytes in the parenchyma of the donor livers and the number of episodes of rejection (P=0.02) and the severity of rejection (P=0.04). The results of B and T cell counts in the donor biopsies and post OLT rejection biopsies are shown in the table below. Conclusions: At the time of OLT higher numbers of B lymphocytes are present in the donor liver destined to subsequently develop ACR. However B lymphocyte numbers are reduced in the presence of ACR. Further studies are needed to explain the relationship between B lymphocytes and ACR. Mean Cell Counts(range)
CD3+ T cell in portal tract CD3+ T cells in parenchyma CD20+ B cells in the portal tract CD20+ cells in the parenchyma
Donor
ACR
p value
351(64-1219)
940(184-2912)
0,00080
56(34-117)
105(9-229)
0.0002
98(6-276)
126(11-618)
0,5
26(5-57)
8(1-24)
0.0003
AASLD ABSTRACTS
HEPATOLOGY October 2001
1895
1896
EARLY REJECTION IN FULMINANT HEPATIC FAILURE. OUR EXPERIENCE W I T H NEORAL.. Pedro L Trigo, Javier C Lendoire, Gustavo A
SUCCESSFUL PROPHYLAXIS OF HEPATITIS C VIRAL (HCV) RE-INFECTION A N D RECURRENT MULTIPLE HEPATOCELLULAR CARCINOMA (HCC) AFTER LIVING DONOR LIVER TRANSPLANTATION (LDLT) W I T H INTERFERON BETA A N D D O N O R SPECIFIC TRANSFUSION.
Braslavsky, Marcelo F Amante, Maria C Romero, Oscar C Imventarza, Hospital Argerich, Buenos Aires Argentina INTRODUCTION: Fulminant hepatic failure (FHF) is the first indication for orthotopic liver transplantation (OLT) in our center since 1997. Few reports describes the incidence and characteristics of rejection in this type of patients. PURPOSE: Analyze the incidence and response of rejection episodes in patients with orthotopic liver transplantation for fulminant hepatic failure in comparison with other indications (non fulminant hepatic failure). PATIENTS AND METHODS: From June 1995 to November 2000, 140 patients were transplanted in our unit. Inclusion criteria : Induction immunosuppression with triple drugs regimen (cyclosporine Neoral, prednisone and azathioprine). Exclusion criteria: second graf, multivisceral transplantation, familial amyloid patients. Study cohorts: 19 patients (p) with fulminant hepatic failure (autoimmune 5 p, hepatitis A 3p, hepatitis B 3, drugs 3, cryptogenic 3, others 2), and 74 non fulminant hepatic failure (primary biliary cirrhosis 22 p, autoimmune 15 p, cryptogenic 10, hepatitis C 8 p, alcoholic 6 p, primary sclerosis cholangirls 4, alcohol plus hepatitis C 3, miscellaneous 6) were analyzed. Non protocol biopsies were performed. Early rejection: Based on Banff schema and considered within the first 6 weeks postransplantation. Steroid Resistant Rejection: persistence of rejection after three intravenous bolus of i gr of metilprednisolone each. The sex, age, incidence and treatment response of the first rejection episodes were analyzed. The period from transplantation to rejection was documented. RESULTS: See table I. CONCLUSION: Liver transplantation in patients with fulminant hepatic failure demonstrate a higher incidence of early rejection. The younger age and the previous healthy status could explain why in this group of patients, with a better immune relative system more potent immunosuppression could be needed. Based in these result, we started using a quadruple drug regimen with basiliximab as induction immunosuppression in patients transplanted for fulminant hepatic failure. TABLEI
_N Male Age Early Rejection Days OL¥. RX Steroid Resistant Rejection
FHF
non FHF
p
19 6 (31.5%) 27.1+_ 9.6 years 11 (57.8%) 9.5 ± 6.7 5 (45%)
74 24 (32,4%) 38 ± 14.1 years 22 (29.7%) 13.2 ± 9.2 5 (23%)
NS p 0.03 p 0.02 NS NS
Takafumi Ichida, Yoshinobn Sato, Hisami Watanabe, Satoshi Yamamoto, Satoshi Sugahara, Satoshi Yamagiwa, Koichi Tanaka, Toru Abo, Katsuyoshi Hatakeyama, Hitoshi Asakura, Niigata University School of Medicine, Niigata Japan Introduction:We conductedLDLTfor advancedrecurrent HCC related with HCV. To prevention of re-infectionof HCV,pre-administrationof interferonbeta had done two weeksbeforeprogramming LDLT.Also,we conducted transcatheterarterialembolizationand systemicinfusiontherapy before LDLT. In addition, we programmed to do donor specifictransfusionvia portal vein with chemotherapywhich obtained from donor after LDLTfor 4 weeks.Two yearsafter LRDT, there is no recurrenceof HCVand HCC with histological,serologicaland total imagingwith maintainedof only 0.Smg of FKS06 daftly. Case report (Material Method) A 62 year-old-womanhad been infected with HCV during the blood transfusion at her daughter s birth, in 1965. Single HCC located segment 2 was detected with compensatedliver cirrhosis.She receivedlateral segmentectomy in 1994. After 2 years, recurrent HCC nodule could be detected receivingalcoholinjection therapy. Then 2 years more later, 2 nodules of HCC was detected receivingalcoholinjection and microwave coagulation therapy. Finally, at 1999, multiple nodules could be observed by total imaging, but, hepatic functional reserve have been still preserved Child-Pugh classificationA). Systemic existence of cancer cells was suspected due to a positive teat for AFP mRNA in the peripheral blood. Prophylaxisbefore LRDT; The patient was given 5FU of 1000mg/dayfor 5 consecutivedayspreoperativelyfor neoadjnvantchemotherapyand receivedTAE therapy I week before operation. In addition, we treated with interferon (IFN) beta nine times of six million international units intravenously to the prophylaxis of HCV reinfection. Before LRDT, serum levelsof HCVRNAwas negativeby HCVPCRfrom 4.2Meq/mlbefore treatmentin the sera. LRDT was done on 1~tofJuly, 1999with graftusing right lobe of her daughter. ProphylaxisafterLRD liver transplantation:Adjuvantchemotherapywith systemic administration of 10rag of doxorubicine (adriamycin)once a weekand intraportal treatmentwith 250ragof 5FU for three consecutivedays, was startedas a singlecourse on day 7 afterLRDLT.In total, she had three coursesof the sandwich chemotherapy. Transfer of donor blood via the portal vein was started immediately after the reconstructionof hepatic artery.Transfusionof 50 ml or 100 ml of donor blood via the portal vein was performed almost once a week starting on day 1. Immunologicalstudies:Liverspecimenswere obtained by open biopsy during LRDLT.Two or three color-flowcytometrywith severalmonoclonalantibodieshad done. CD56+ CD3+ T of liverinfiltratinglymphocytesincreasednoticeably from 20% to 45% compared to those in the peripheral blood after LRDLT.These cells increased graduallyfollowingtransplantation.CD56-T cellsin the graftand the lymphocytesof the peripheral blood were almostrecipient type. 17.4%of CD56+ T cellswere the donor type evenon day 42 after LRDLTindication macrochymerism.Clinicalcourse:There were no eventfulside effectand episode of rejection after two years.At September2001, liver biopsy was performed. Both histologicaland serological,there were no evidenceof recurred hepatitis and recurred HCC. Resultand DiscussionLDLTis one of the representativeprogrammingoperation with well organizingpreparation for prophylaxisand post transplant treatment.We conducted preliminarywith reduction of FICVRNAfrom recipient s serum with interferonbeta, and acquired immunotorelanceby DST and pre and post adjuvant chemotherapy. Our result might be useful to promote LDLTfor HCV positiveHCC.
1897
1898
MICA ALLELES DO NOT PREDISPOSE TO CHRONIC REJECTION FOLLOWING OLT. M Clare, Guy's Hospital, London United Kingdom; S Cookson, King's College Hospital, London United Kingdom; B Collins, B Vaughan, Guy's Hospital, London United Kingdom; P Donaldson, University of Newcastle, Newcastle United Kingdom; P Muiesan, M Rela, N Heaton, J O'Grady, S Norris, King's College Hospital, London United Kingdom
HEPATIC B CELLS: A ROLE IN REJECTION FOLLOWING HUMAN ORTHOTOPIC LIVER TRANSPLANTATION?. Raghu Varadarajan, Deignan
Chronic rejection (CR) is characterised by destruction of the small bile ducts and arteriopathy, and is usually preceded by intense portal tract infitration by predominantly CD8 + T cells. While the precise immunologic mechanisms underlying this process are not clear, active duct destruction appears to result from both T cell-mediated cholangitis and ischaemia, and this is likely mediated by interactions between cytokines, T cells and biliary epithelial cells. Recent studies have reported an association between chronic inflammatory states and mICA, a protein normally expressed only by "stressed" epithelia which acts as an activation signal for cytotoxic T cells. We have previously reported a strong association between MICA*008 allele and PSC, and a protective effect with MICA*002-. The aim of the current study was to examine the relationship between MICA alleles and CR development after OLT. Methods: 25 patients who developed CR following OLT and 25 age-, sex-, and disease-matched controls who did not develop CR over the same follow-up period after OLT were identified. DNA was extracted by standard methods and tested for the 16 common alleles of the MICA locus by standard PCR protocol. For patients with CR, donor/recipient MICA aUotypes were also analyzed. Results: The MICA*008 allele was more common in patients with CR compared to non-CR controls (gene frequency 64% v 55%, p = n s ) but this did not reach statistical significance. In addition, there was no difference in the frequency of MICA*008/008 homozygosity between the two groups. The MICA*002 allele was less commonly identified in the CR group (gene frequency 6% v 18%, OR=0.3) but this trend did not reach statistical significance (p=0.08). There was no statistically significant genotype differences between the MICA allotypes of donor and recipients who developed CR. Conclusion: MICA genotypes do not appear to be associated with increased risk for developing CR following OLT. This is the first study to address the impact of MICA genes in CR. ~Norris et al, Gastro 2001;120:1475.
Tina, Crona Gallagher, Niamh Nolan, Oscar Traynor, Gerard McEntee,John E Hegarty, Justin Geoghegan, Cliona O'Farrelly, St Vincent's Univ Hosp, Dublin Ireland Normal h u m a n liver contains a unique subset of lymphocytes that may influence hepatic immune responses. These lymphocytes can be transferred from donor to recipient during orthotopic liver transplantation (OLT). The aim of this study was to investigate whether the numbers of these T and B 'passenger' lymphocytes in the donor liver are associated with the occurrence and severity of acute cellular rejection (ACR) and to study the variation of the lymphocyte repertoire in the liver during ACR following human OLT. Donor liver tissue taken from 17 adult donors prior to transplantation was stained by immunohistochemistry for CD3 (T ceils) and CD20 (B cells). Positively stained cells in the portal tract and parenchyma were identified by light microscopy. Clinically diagnosed episodes of rejection were confirmed by histological examination of post transplantation biopsies. Eighteen biopsies from 12 patients who had ACR post OLT were also stained by immunohistochemistry for T and B cells. Five patients had no evidence of ACR, 6 had one rejection episode, 4 had two episodes and the other two patients had three and four episodes respectively. There was a significant correlation between the number of B lymphocytes in the parenchyma of the donor livers and the number of episodes of rejection (P=0.02) and the severity of rejection (P=0.04). The results of B and T cell counts in the donor biopsies and post OLT rejection biopsies are shown in the table below. Conclusions: At the time of OLT higher numbers of B lymphocytes are present in the donor liver destined to subsequently develop ACR. However B lymphocyte numbers are reduced in the presence of ACR. Further studies are needed to explain the relationship between B lymphocytes and ACR. Mean Cell Counts(range)
CD3+ T cell in portal tract CD3+ T cells in parenchyma CD20+ B cells in the portal tract CD20+ cells in the parenchyma
Donor
ACR
p value
351(64-1219)
940(184-2912)
0,00080
56(34-117)
105(9-229)
0.0002
98(6-276)
126(11-618)
0,5
26(5-57)
8(1-24)
0.0003