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Immune-mediated liver dysfunction after antiviral treatment in liver transplanted patients with hepatitis c: Allo or autoimmune de novo hepatitis?
Available online at www.sciencedirect.com
Digestive and Liver Disease 41 (2009) 345–349
Liver, Pancreas and Biliary Tract
Immune-mediated liver dysfunction after antiviral treatment in liver transplanted patients with hepatitis c: Allo or autoimmune de novo hepatitis? M. Merli a,∗ , F. Gentili a , M. Giusto a , A.F. Attili a , S.G. Corradini a , G. Mennini b , M. Rossi b , A. Corsi c , P. Bianco c a
II Gastroenterologia, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy Clinica Chirurgica, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy Istituto di Anatomia Patologica, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy b
c
Received 5 June 2008; accepted 9 September 2008 Available online 21 January 2009
Abstract Background. The recurrence of hepatitis C after liver transplantation is extremely frequent. Antiviral therapy combining pegylatedinterferon with ribavirin is therefore increasingly used in these patients. It has been recently reported, however, that during antiviral treatment a hepatic immune-mediated liver dysfunction, similar to “de novo” autoimmune hepatitis, may develop in a few transplanted patients. Patients and methods. Three patients, treated with pegylated-interferon ␣-2a and ribavirin for recurrent hepatitis C after liver transplantation, developed an aggressive hepatitis with clinical, biochemical, and histological features similar to those of autoimmune hepatitis. Results. In all three patients, a liver enzymes increase was evident after hepatitis C virus-RNA had become undetectable. Diagnosis of “de novo” autoimmune hepatitis was proposed, based on the presence of high-titre circulating autoantibodies and liver histology features. Following the introduction of a steroid therapy, clinical and biochemical parameters progressively improved. Hepatitis C virus infection, however, relapsed after a few months in all the patients. Conclusions. Following liver transplantation, antiviral therapy with pegylated-interferon ␣-2a and ribavirin for recurrent hepatitis C may be associated, in a few patients, with severe immune-mediated graft dysfunction similar to autoimmune hepatitis. © 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Autoimmune hepatitis; Hepatitis HCV; Liver transplantation
1. Introduction The development of “de novo” autoimmune hepatitis (AIH) after liver transplantation (LT) has been described in both children [1,2] and adults [3]. The term “de novo” derives from the observation that the cause of end-stage liver disease leading to LT in these patients was not AIH, and that this condition occurs in the absence of any previous history of autoimmune disease. The presence of serum autoantibodies ∗ Corresponding author at: II Gastroenterologia, Dipartimento di Medicina Clinica, Viale dell’ Universita 37, 00185 Rome, Italy. Tel.: +39 06 49972001; fax: +39 06 49972001. E-mail address: [email protected] (M. Merli).
is an essential criterion for the diagnosis of AIH; an isolated elevation of autoantibodies, without additional clinical and histological markers, is however considered insufficient to confirm this diagnosis [4]. Specific diagnostic criteria for defining “de novo” AIH after LT are presently not available; its diagnosis is therefore based on AIH scores, but requires also the careful exclusion of other conditions [5,6]. In nine patients transplanted for hepatitis C virus (HCV)related cirrhosis undergoing antiviral treatment for viral recurrence, a liver dysfunction, due to hepatic immunemediated disorders, was recently reported [7]. On liver biopsy, these patients showed histological features similar to those present in AIH and were positive for different autoan-
1590-8658/$30 © 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2008.09.015
346
M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
Table 1 Patients’ clinical and laboratory features before antiviral therapy.
Case 1 Case 2 Case 3 a
Sex
Age (years)
Months after LT
HCV geno-type
HCV-RNA copies/ml
AST/ALT (IU/ml)a
Ishak score (grading/staging)
Autoantibodies (ANA–SMA)
M M F
63 59 56
37 58 9
1b 1b 1b
1900 × 106 2250 × 106 1360 × 106
61/106 340/592 89/87
9/2 13/2 9/2
Negative Negative Negative
Normal values:<40 IU/ml (AST), and <40 IU/ml (ALT).
3. Results
revealed a moderate, recurrent, chronic HCV infection. Genotype was 1b, and quantitative HCV-RNA viral load was 1,110,095 copies/ml. An antiviral therapy with pegIFN ␣-2a (Pegasys, Roche) (180 g/ml/week) and RBV (600 mg/die) was therefore started. RBV dosage could not be increased due to diarrhoea and high ferritin plasma levels. After the first month, HCV-RNA became undetectable and AST/ALT levels were only slightly elevated. After 5 months, the patient developed persistent hyperaemia at the site of interferon administration. Due to the progressive extension of his cutaneous reaction (hyperaemia, mild desquamation and pruritus all over the body), the antiviral therapy was stopped after 6 months. One month later, the liver enzymes had increased: ALT = 179 IU/ml, AST = 167 IU/ml, AP = 259 IU/ml, ␥GT = 153 UI/ml, and bilirubin = 1.7 mg/dl. Serology tests for hepatitis A (HAV), hepatitis B (HBV), and HCV-RNA were persistently negative. Tests for autoantibodies, including antinuclear antibodies (ANA) and smooth muscle cell antibodies (SMA), were positive while antimitochondrial antibodies (AMA) were negative. Erythrosedimentation rate (ESR) was elevated (100 mm) and gamma globulins had markedly increased (6 g/l). A liver biopsy was performed and the histology revealed portal and periportal chronic inflammatory infiltrates, including plasma cells (Fig. 1). Azathioprine (1 mg/kg/day) and prednisone (1 mg/kg/day) were added to the immunosuppressive therapy [based on cyclosporine (175 mg/daily)]. After 4 weeks, the transaminases had progressively decreased (AST: 26 IU/ml; ALT: 50 IU/ml), and the prednisone dosage was gradually tapered. One month later, the transaminases levels had raised again and HCVRNA was found to be positive.
3.1. Case 1
3.2. Case 2
A 63-year-old man underwent living-related donor LT for HCV-related cirrhosis and hepatocellular carcinoma in May 2003. The postoperative immunosuppression regimen consisted of cyclosporine, mycophenolate mofetil, and steroids. Three years after LT, due to an increase in the levels of: aspartate aminotransferase (AST) (132 IU/ml, normal values <40 IU/ml), alanine aminotransferase (ALT) (242 IU/ml, normal values < 40 IU/ml), alkaline phosphatase (AP) (239 IU/ml, normal values <120 IU/ml), and gamma-glutamyl transpeptidase (␥GT) (135 IU/ml, normal values <40 IU/ml), a liver biopsy was performed which
A 59-year-old man underwent orthotopic LT for HCVrelated cirrhosis in March 2001. Immunosuppressive medication included cyclosporine, mycophenolate mofetil, and steroids. Six months after LT, a flare of liver enzymes was seen: ALT = 150 IU/ml (normal values <40 IU/ml), AST = 286 IU/ml (normal values <40 IU/ml), and bilirubin = 2.1 mg/ml. A liver biopsy revealed expansion of the portal triads with moderate to severe portal, periportal, and intralobular chronic inflammatory infiltrates consistent with recurrent HCV infection. HCV-RNA was positive, but due to a severe
tibodies in the serum. The authors proposed to identify this condition as “de novo” AIH, based also on the good therapeutic response to the steroid therapy [7]. In our report, we describe three cases of graft dysfunction occurring during antiviral treatment in LT patients with similar features and the possible diagnosis of “de novo” AIH is discussed.
2. Patients and methods Three patients who were treated with pegylated-interferon (peg-IFN) ␣-2a and ribavirin (RBV) for HCV recurrence after LT developed graft dysfunction. One patient (case 1) had previously received interferon antiviral monotherapy for HCV 5 years before LT, without experiencing any sign of autoimmunity at that time. HCV-RNA was analysed using reverse-transcriptase polymerase chain reaction (RT-PCR) (COBAS Amplicor, Roche Diagnostics); the Banff rejection activity index (RAI) was used to grade and stage the histological features of cellular rejection [8]. Chronic HCV hepatitis was diagnosed on liver biopsies according to the criteria of the Banff Working Group [9], and the histological activity index was assessed following the Ishak scoring system [10]. The AIH score was calculated in each patient by the International Autoimmune Hepatitis Group Report [5] and, also, according to the new simplified criteria proposed in a recent paper on AIH [6]. The patients’ characteristics before the antiviral therapy are summarized in Table 1.
M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
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Fig. 1. Patient 1. Liver biopsy performed 1 month after the end of antiviral therapy. Low power magnification view in (A). Details showing portal and interface chronic inflammatory infiltrate are shown in (B) and (C), respectively. In the inflammatory infiltrate, plasma cells are numerous as shown in D. (A–D: haematoxylin–eosin).
thrombocytopaenia, antiviral treatment could not be started. Four years later, a further severe flare of liver enzymes occurred. Liver histology was consistent with a severe reinfection and a moderate fibrosis. Since the haematological values had improved, antiviral therapy with peg-IFN ␣2a (180 g/week; Pegasys, Roche) and RBV (600 mg/die) was started. After 3 months, HCV-RNA was negative and transaminases had normalized. He completed 48 weeks of therapy with normal liver enzymes and a negative HCVRNA. One month after the end of the antiviral therapy, the patient developed a severe polyarthritis. ANA and SMA were both positive. Serum bilirubin and transaminases showed a sudden moderate increase (bilirubin = 1.5 mg/dl, AST = 155 IU/ml, and ALT = 184 IU/ml) and a liver biopsy revealed an expansion of the portal triads with portal and periportal chronic inflammatory infiltrates with numerous plasma cells. The patient was treated with steroids (prednisone, 1 mg/kg/day) in addition to immunosuppressive therapy (cyclosporine, 175 mg/daily). The clinical symptoms and the liver enzymes slowly improved but did not normalize completely (ALT = 32 IU/ml, AST = 58 IU/ml). Three months later, HCV-RNA was positive again. 3.2.1. Case 3 A 56-year-old woman was transplanted for HCV-related cirrhosis in September 2005. The postoperative immunosuppressive regimen consisted of cyclosporine, mycophenolate
mofetil, and steroids. Routine serology tests carried out 2 months after LT revealed increased levels of liver enzymes. Liver biopsy histology was consistent with moderate/severe acute rejection (RAI score: 7/9). She was treated with methyl prednisone bolus and cyclosporine was switched to tacrolimus. Her liver enzymes improved. Six months after transplantation she presented a further flare of liver enzymes with ALT = 150 IU/ml (normal values <40 UI/ml), AST = 286 IU/ml (normal values <40 UI/ml), and bilirubin = 2.1 mg/ml. A liver biopsy was performed and the histology showed an extensive hepatocyte steatosis, a bridging necrosis, and a portal and periportal chronic inflammation. HCV genotype was 1b and quantitative HCVRNA viral load was 1,360,000 copies/mL. Antiviral therapy was started with peg-IFN ␣-2a (180 g/week, Pegasys, Roche) and RBV (400 mg/day). RBV dosage could not be increased due to side effects (anaemia and abdominal pain). After 6 months of treatment, HCV-RNA was negative by RT-PCR; AST and ALT, however, had not normalized (AST = 92 IU/ml, ALT = 72 IU/ml). After 9 months, the patient complained of diffuse myalgias and a further elevation in liver enzymes (AST = 123 UI/ml, ALT = 99 UI/ml) was noted. At that time, tests for autoantibodies were positive for ANA and SMA. Total IgG immunoglobulins were 1.6 g/dl. The antiviral therapy was stopped. A liver biopsy was carried out and the histology was consistent with cirrhosis (Fig. 2). She could not be treated with azathioprine due
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M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
Fig. 2. Patient 3. Liver biopsy performed 1 month after the interruption of the antiviral therapy. The low power magnification reveals features consistent with cirrhosis. (A: haematoxylin-eosin, B: Sirius Red). Table 2 Patients’ clinical and laboratory features at diagnosis of “de novo” AIH. HCV-RNA (copies/ml)
Ishak score (grading/staging)
Autoantibodies
IgG (g/dl)
AIH score (5)
AIH Simplified score (6)
Case 1
Undetectable
9/3
ANA 1/160 SMA 1/160
2.0
10
7
Case 2
Undetectable
13/2
ANA 1/80 SMA 1/40
5.3
11
7
Case 3
Undetectable
11/6
ANA 1/320 SMA 1/160
1.6
13
6
to leucopaenia and prednisone (1 mg/kg/day) was therefore started; cyclosporine was continued with the same dosage (125 mg/daily). After a few weeks, due to weight gain and a severe hyperglycaemia despite the insulin therapy, prednisone was gradually tapered and replaced by budesonide (9 mg/daily). During the next 3 months, serum transaminases levels slowly improved but HCV-RNA became positive once again. Budesonide was reduced to a maintenance dose of 3 mg/day and suspended after 6 months. The clinical and laboratory features of the three patients at the time of diagnosis of “de novo” AIH are shown in Table 2.
4. Discussion Standard guidelines for the diagnosis of “de novo” AIH after LT have not been defined as yet; the criteria of AIH have therefore been tentatively applied to this condition [3]. The diagnosis of AIH requires the fulfilment of strict biochemical and histopathological criteria which have been proposed by an international consensus [5]. These criteria include the presence of positive autoantibodies (ANA, SMA, or anti-liver-kidney-microsomal antibody) and the presence of typical laboratory and histological abnormalities. We reported three cases who developed clinical, serological, and histological features similar to “de novo” AIH during or immediately after the antiviral treatment with peg-IFN and RBV. HCV (genotype 1b) was previously diagnosed in all of them, and all showed a negative viraemia at the time of diagnosis. Primary immunosuppressive agents
were cyclosporine (two cases) and tacrolimus (one case). The beginning of the immune-mediated disorder was always acute. One patient presented with severe polyarthritis while diffuse myalgias were present in another case; the most characteristic laboratory hallmarks were an elevated ESR, a hypergammaglobulinaemia (ranging from 1.6 to 5.3 g/dl), elevated transaminases, and positive autoantibodies (mostly ANA). None of the three patients had previously suffered of any immunological disorder. In all the cases, the introduction of a steroid therapy induced a slow remission of the clinical symptoms and the lowering of transaminases levels. In all the patients, HCV relapsed after the steroid therapy. Recurrent HCV infection is very frequent post-LT and may influence graft dysfunction and mortality. The most effective therapy for recurrent post-LT HCV infection is peg-IFN in combination with RBV [11,12]. The use of interferon in transplanted patients, however, involves the possibility that immunostimulation may induce organ rejection [13]. Acute liver rejection was actually reported in a few cases treated with interferon alpha [13]. Moreover, interferon treatment was also implicated in the induction of organ-specific autoimmune diseases, such as polymyositis, autoimmune thyroiditis, rheumatoid arthritis, and AIH in non-transplanted individuals [14,15]. All the three patients reported in this study became HCV negative before the development of autoimmune stigmata. It could be hypothesized that concomitant to the loss of the viral target for the immune system some mechanisms may lead to aberrant antigen presentation, or provide costimulatory signals leading to the breaking of tolerance versus
M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
the transplanted graft. This phenomenon does not seem to be influenced by the time interval from transplantation, since it occurred in two patients (cases 1 and 2) who had been transplanted more than 3 years earlier. The development of this disease during the treatment with calcineurin inhibitors supports the opinion held by most AIH specialists that these drugs, although effective in the acute phase, are not of help in the management of autoimmune liver diseases [16]. It may also be questioned if the reported immune-mediated liver dysfunction should be considered different from a typical acute rejection. Actually, the presence of plasma cell infiltrates seems peculiar to this condition but not of acute rejection; moreover, the typical endothelialitis/venulitis and the signs of biliary damage were lacking [8]. A further characteristic in these patients was the presence of circulating autoantibodies, not present during acute rejection. Finally, similarly to AIH, it has been reported that these patients respond to a combined immunosuppressive therapy with prednisolone and azathioprine [3]. In our cases, azathioprine could not be always introduced due to leucopaenia; the steroid treatment at lower doses than those used in acute rejection was however helpful, although it probably contributed to the HCV viraemia relapse. Finally, unlike AIH in non-transplanted patients, it may be argued if the immune reaction versus a non-self organ can be defined as an autoimmune process. However, we do not know if the immune response, in this case, is directed against alloantigens, neoantigens in the liver, or self-antigens, possibly shared by donor and host cells. It is very likely that the inflammatory milieu due to alloreactive cells in the transplanted organ contributes to the disease process.
[2]
[3] [4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
Conflict of interest statement None declared.
References
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[1] Avitzur Y, Ngan BY, Lao M, Fecteau A, Ng VL. Prospective evaluation of the prevalence and clinical significance of positive autoantibod-
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ies after pediatric liver transplantation. J Pediatr Gastroenterol Nutr 2007;45:222–7. Hernandez HM, Kovarik P, Whitington PF, Alonso EM. Autoimmune hepatitis as a late complication of liver transplantation. J Pediatr Gastroenterol Nutr 2001;32:131–6. Mieli-Vergani G, Vergani D. De novo autoimmune hepatitis after liver transplantation. J Hepatol 2004;40:3–7. Czaja AJ, Freese DK. American Association for the Study of Liver Disease. Diagnosis and treatment of autoimmune hepatitis. Hepatology 2002;36:479–97. Alvarez F, Berg PA, Bianchi FB, Bianchi L, Burroughs AK, Cancado EL, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol 1999;31:929–38. Hennes EM, Zeniya M, Czaja AJ, Parés A, Dalekos GN, Krawitt EL, et al. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology 2008;48:169–76. Berardi S, Lodato F, Gramenzi A, D’Errico A, Lenzi M, Bontadini A, et al. High incidence of allograft dysfunction in liver transplanted patients treated with pegylated-interferon alpha-2b and ribavirin for hepatitis C recurrence: possible de novo autoimmune hepatitis? Gut 2007;56:237–42. Banff Working Group. Banff schema for grading liver allograft rejection: an international consensus document. Hepatology 1997;25:658–63. Banff Working GroupDemetris AJ, Adeyi O, Bellamy CO, Clouston A, Charlotte F. Liver biopsy interpretation for causes of late liver allograft dysfunction. Hepatology 2006;44:489–501. Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995;22:696–9. Bizollon T, Ahmed SN, Radenne S, Chevallier M, Chevallier P, Parvaz P, et al. Long term histological improvement and clearance of intrahepatic hepatitis C virus RNA following sustained response to interferon-ribavirin combination therapy in liver transplanted patients with hepatitis C virus recurrence. Gut 2003;52:283–7. Berenguer M, Palau A, Fernandez A, Benlloch S, Aguilera V, Prieto M, et al. Efficacy, predictors of response, and potential risks associated with antiviral therapy in liver transplant recipients with recurrent hepatitis C. Liver Transpl 2006;12:1067–76. Walter T, Dumortier J, Guillaud O, Hervieu V, Paliard P, Scoazec JY, et al. Rejection under alpha interferon therapy in liver transplant recipients. Am J Transplant 2007;7:177–84. Venezia G, Licata A, Di Marco V, Craxì A, Almasio PL. Acute polymyositis during treatment of acute hepatitis C with pegylated interferon alpha-2b. Dig Liver Dis 2005;37:882–5. Conrad B. Potential mechanisms of interferon-alpha induced autoimmunity. Autoimmunity 2003;36:519–23. Lohse AW, Weiler-Norman C, Burdelski M. De novo autoimmune hepatitis after liver transplantation. Hepatol Res 2007;37:S462.
Digestive and Liver Disease 41 (2009) 345–349
Liver, Pancreas and Biliary Tract
Immune-mediated liver dysfunction after antiviral treatment in liver transplanted patients with hepatitis c: Allo or autoimmune de novo hepatitis? M. Merli a,∗ , F. Gentili a , M. Giusto a , A.F. Attili a , S.G. Corradini a , G. Mennini b , M. Rossi b , A. Corsi c , P. Bianco c a
II Gastroenterologia, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy Clinica Chirurgica, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy Istituto di Anatomia Patologica, Policlinico “Umberto I”, Università di Roma “La Sapienza”, Italy b
c
Received 5 June 2008; accepted 9 September 2008 Available online 21 January 2009
Abstract Background. The recurrence of hepatitis C after liver transplantation is extremely frequent. Antiviral therapy combining pegylatedinterferon with ribavirin is therefore increasingly used in these patients. It has been recently reported, however, that during antiviral treatment a hepatic immune-mediated liver dysfunction, similar to “de novo” autoimmune hepatitis, may develop in a few transplanted patients. Patients and methods. Three patients, treated with pegylated-interferon ␣-2a and ribavirin for recurrent hepatitis C after liver transplantation, developed an aggressive hepatitis with clinical, biochemical, and histological features similar to those of autoimmune hepatitis. Results. In all three patients, a liver enzymes increase was evident after hepatitis C virus-RNA had become undetectable. Diagnosis of “de novo” autoimmune hepatitis was proposed, based on the presence of high-titre circulating autoantibodies and liver histology features. Following the introduction of a steroid therapy, clinical and biochemical parameters progressively improved. Hepatitis C virus infection, however, relapsed after a few months in all the patients. Conclusions. Following liver transplantation, antiviral therapy with pegylated-interferon ␣-2a and ribavirin for recurrent hepatitis C may be associated, in a few patients, with severe immune-mediated graft dysfunction similar to autoimmune hepatitis. © 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Autoimmune hepatitis; Hepatitis HCV; Liver transplantation
1. Introduction The development of “de novo” autoimmune hepatitis (AIH) after liver transplantation (LT) has been described in both children [1,2] and adults [3]. The term “de novo” derives from the observation that the cause of end-stage liver disease leading to LT in these patients was not AIH, and that this condition occurs in the absence of any previous history of autoimmune disease. The presence of serum autoantibodies ∗ Corresponding author at: II Gastroenterologia, Dipartimento di Medicina Clinica, Viale dell’ Universita 37, 00185 Rome, Italy. Tel.: +39 06 49972001; fax: +39 06 49972001. E-mail address: [email protected] (M. Merli).
is an essential criterion for the diagnosis of AIH; an isolated elevation of autoantibodies, without additional clinical and histological markers, is however considered insufficient to confirm this diagnosis [4]. Specific diagnostic criteria for defining “de novo” AIH after LT are presently not available; its diagnosis is therefore based on AIH scores, but requires also the careful exclusion of other conditions [5,6]. In nine patients transplanted for hepatitis C virus (HCV)related cirrhosis undergoing antiviral treatment for viral recurrence, a liver dysfunction, due to hepatic immunemediated disorders, was recently reported [7]. On liver biopsy, these patients showed histological features similar to those present in AIH and were positive for different autoan-
1590-8658/$30 © 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2008.09.015
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Table 1 Patients’ clinical and laboratory features before antiviral therapy.
Case 1 Case 2 Case 3 a
Sex
Age (years)
Months after LT
HCV geno-type
HCV-RNA copies/ml
AST/ALT (IU/ml)a
Ishak score (grading/staging)
Autoantibodies (ANA–SMA)
M M F
63 59 56
37 58 9
1b 1b 1b
1900 × 106 2250 × 106 1360 × 106
61/106 340/592 89/87
9/2 13/2 9/2
Negative Negative Negative
Normal values:<40 IU/ml (AST), and <40 IU/ml (ALT).
3. Results
revealed a moderate, recurrent, chronic HCV infection. Genotype was 1b, and quantitative HCV-RNA viral load was 1,110,095 copies/ml. An antiviral therapy with pegIFN ␣-2a (Pegasys, Roche) (180 g/ml/week) and RBV (600 mg/die) was therefore started. RBV dosage could not be increased due to diarrhoea and high ferritin plasma levels. After the first month, HCV-RNA became undetectable and AST/ALT levels were only slightly elevated. After 5 months, the patient developed persistent hyperaemia at the site of interferon administration. Due to the progressive extension of his cutaneous reaction (hyperaemia, mild desquamation and pruritus all over the body), the antiviral therapy was stopped after 6 months. One month later, the liver enzymes had increased: ALT = 179 IU/ml, AST = 167 IU/ml, AP = 259 IU/ml, ␥GT = 153 UI/ml, and bilirubin = 1.7 mg/dl. Serology tests for hepatitis A (HAV), hepatitis B (HBV), and HCV-RNA were persistently negative. Tests for autoantibodies, including antinuclear antibodies (ANA) and smooth muscle cell antibodies (SMA), were positive while antimitochondrial antibodies (AMA) were negative. Erythrosedimentation rate (ESR) was elevated (100 mm) and gamma globulins had markedly increased (6 g/l). A liver biopsy was performed and the histology revealed portal and periportal chronic inflammatory infiltrates, including plasma cells (Fig. 1). Azathioprine (1 mg/kg/day) and prednisone (1 mg/kg/day) were added to the immunosuppressive therapy [based on cyclosporine (175 mg/daily)]. After 4 weeks, the transaminases had progressively decreased (AST: 26 IU/ml; ALT: 50 IU/ml), and the prednisone dosage was gradually tapered. One month later, the transaminases levels had raised again and HCVRNA was found to be positive.
3.1. Case 1
3.2. Case 2
A 63-year-old man underwent living-related donor LT for HCV-related cirrhosis and hepatocellular carcinoma in May 2003. The postoperative immunosuppression regimen consisted of cyclosporine, mycophenolate mofetil, and steroids. Three years after LT, due to an increase in the levels of: aspartate aminotransferase (AST) (132 IU/ml, normal values <40 IU/ml), alanine aminotransferase (ALT) (242 IU/ml, normal values < 40 IU/ml), alkaline phosphatase (AP) (239 IU/ml, normal values <120 IU/ml), and gamma-glutamyl transpeptidase (␥GT) (135 IU/ml, normal values <40 IU/ml), a liver biopsy was performed which
A 59-year-old man underwent orthotopic LT for HCVrelated cirrhosis in March 2001. Immunosuppressive medication included cyclosporine, mycophenolate mofetil, and steroids. Six months after LT, a flare of liver enzymes was seen: ALT = 150 IU/ml (normal values <40 IU/ml), AST = 286 IU/ml (normal values <40 IU/ml), and bilirubin = 2.1 mg/ml. A liver biopsy revealed expansion of the portal triads with moderate to severe portal, periportal, and intralobular chronic inflammatory infiltrates consistent with recurrent HCV infection. HCV-RNA was positive, but due to a severe
tibodies in the serum. The authors proposed to identify this condition as “de novo” AIH, based also on the good therapeutic response to the steroid therapy [7]. In our report, we describe three cases of graft dysfunction occurring during antiviral treatment in LT patients with similar features and the possible diagnosis of “de novo” AIH is discussed.
2. Patients and methods Three patients who were treated with pegylated-interferon (peg-IFN) ␣-2a and ribavirin (RBV) for HCV recurrence after LT developed graft dysfunction. One patient (case 1) had previously received interferon antiviral monotherapy for HCV 5 years before LT, without experiencing any sign of autoimmunity at that time. HCV-RNA was analysed using reverse-transcriptase polymerase chain reaction (RT-PCR) (COBAS Amplicor, Roche Diagnostics); the Banff rejection activity index (RAI) was used to grade and stage the histological features of cellular rejection [8]. Chronic HCV hepatitis was diagnosed on liver biopsies according to the criteria of the Banff Working Group [9], and the histological activity index was assessed following the Ishak scoring system [10]. The AIH score was calculated in each patient by the International Autoimmune Hepatitis Group Report [5] and, also, according to the new simplified criteria proposed in a recent paper on AIH [6]. The patients’ characteristics before the antiviral therapy are summarized in Table 1.
M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
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Fig. 1. Patient 1. Liver biopsy performed 1 month after the end of antiviral therapy. Low power magnification view in (A). Details showing portal and interface chronic inflammatory infiltrate are shown in (B) and (C), respectively. In the inflammatory infiltrate, plasma cells are numerous as shown in D. (A–D: haematoxylin–eosin).
thrombocytopaenia, antiviral treatment could not be started. Four years later, a further severe flare of liver enzymes occurred. Liver histology was consistent with a severe reinfection and a moderate fibrosis. Since the haematological values had improved, antiviral therapy with peg-IFN ␣2a (180 g/week; Pegasys, Roche) and RBV (600 mg/die) was started. After 3 months, HCV-RNA was negative and transaminases had normalized. He completed 48 weeks of therapy with normal liver enzymes and a negative HCVRNA. One month after the end of the antiviral therapy, the patient developed a severe polyarthritis. ANA and SMA were both positive. Serum bilirubin and transaminases showed a sudden moderate increase (bilirubin = 1.5 mg/dl, AST = 155 IU/ml, and ALT = 184 IU/ml) and a liver biopsy revealed an expansion of the portal triads with portal and periportal chronic inflammatory infiltrates with numerous plasma cells. The patient was treated with steroids (prednisone, 1 mg/kg/day) in addition to immunosuppressive therapy (cyclosporine, 175 mg/daily). The clinical symptoms and the liver enzymes slowly improved but did not normalize completely (ALT = 32 IU/ml, AST = 58 IU/ml). Three months later, HCV-RNA was positive again. 3.2.1. Case 3 A 56-year-old woman was transplanted for HCV-related cirrhosis in September 2005. The postoperative immunosuppressive regimen consisted of cyclosporine, mycophenolate
mofetil, and steroids. Routine serology tests carried out 2 months after LT revealed increased levels of liver enzymes. Liver biopsy histology was consistent with moderate/severe acute rejection (RAI score: 7/9). She was treated with methyl prednisone bolus and cyclosporine was switched to tacrolimus. Her liver enzymes improved. Six months after transplantation she presented a further flare of liver enzymes with ALT = 150 IU/ml (normal values <40 UI/ml), AST = 286 IU/ml (normal values <40 UI/ml), and bilirubin = 2.1 mg/ml. A liver biopsy was performed and the histology showed an extensive hepatocyte steatosis, a bridging necrosis, and a portal and periportal chronic inflammation. HCV genotype was 1b and quantitative HCVRNA viral load was 1,360,000 copies/mL. Antiviral therapy was started with peg-IFN ␣-2a (180 g/week, Pegasys, Roche) and RBV (400 mg/day). RBV dosage could not be increased due to side effects (anaemia and abdominal pain). After 6 months of treatment, HCV-RNA was negative by RT-PCR; AST and ALT, however, had not normalized (AST = 92 IU/ml, ALT = 72 IU/ml). After 9 months, the patient complained of diffuse myalgias and a further elevation in liver enzymes (AST = 123 UI/ml, ALT = 99 UI/ml) was noted. At that time, tests for autoantibodies were positive for ANA and SMA. Total IgG immunoglobulins were 1.6 g/dl. The antiviral therapy was stopped. A liver biopsy was carried out and the histology was consistent with cirrhosis (Fig. 2). She could not be treated with azathioprine due
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M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
Fig. 2. Patient 3. Liver biopsy performed 1 month after the interruption of the antiviral therapy. The low power magnification reveals features consistent with cirrhosis. (A: haematoxylin-eosin, B: Sirius Red). Table 2 Patients’ clinical and laboratory features at diagnosis of “de novo” AIH. HCV-RNA (copies/ml)
Ishak score (grading/staging)
Autoantibodies
IgG (g/dl)
AIH score (5)
AIH Simplified score (6)
Case 1
Undetectable
9/3
ANA 1/160 SMA 1/160
2.0
10
7
Case 2
Undetectable
13/2
ANA 1/80 SMA 1/40
5.3
11
7
Case 3
Undetectable
11/6
ANA 1/320 SMA 1/160
1.6
13
6
to leucopaenia and prednisone (1 mg/kg/day) was therefore started; cyclosporine was continued with the same dosage (125 mg/daily). After a few weeks, due to weight gain and a severe hyperglycaemia despite the insulin therapy, prednisone was gradually tapered and replaced by budesonide (9 mg/daily). During the next 3 months, serum transaminases levels slowly improved but HCV-RNA became positive once again. Budesonide was reduced to a maintenance dose of 3 mg/day and suspended after 6 months. The clinical and laboratory features of the three patients at the time of diagnosis of “de novo” AIH are shown in Table 2.
4. Discussion Standard guidelines for the diagnosis of “de novo” AIH after LT have not been defined as yet; the criteria of AIH have therefore been tentatively applied to this condition [3]. The diagnosis of AIH requires the fulfilment of strict biochemical and histopathological criteria which have been proposed by an international consensus [5]. These criteria include the presence of positive autoantibodies (ANA, SMA, or anti-liver-kidney-microsomal antibody) and the presence of typical laboratory and histological abnormalities. We reported three cases who developed clinical, serological, and histological features similar to “de novo” AIH during or immediately after the antiviral treatment with peg-IFN and RBV. HCV (genotype 1b) was previously diagnosed in all of them, and all showed a negative viraemia at the time of diagnosis. Primary immunosuppressive agents
were cyclosporine (two cases) and tacrolimus (one case). The beginning of the immune-mediated disorder was always acute. One patient presented with severe polyarthritis while diffuse myalgias were present in another case; the most characteristic laboratory hallmarks were an elevated ESR, a hypergammaglobulinaemia (ranging from 1.6 to 5.3 g/dl), elevated transaminases, and positive autoantibodies (mostly ANA). None of the three patients had previously suffered of any immunological disorder. In all the cases, the introduction of a steroid therapy induced a slow remission of the clinical symptoms and the lowering of transaminases levels. In all the patients, HCV relapsed after the steroid therapy. Recurrent HCV infection is very frequent post-LT and may influence graft dysfunction and mortality. The most effective therapy for recurrent post-LT HCV infection is peg-IFN in combination with RBV [11,12]. The use of interferon in transplanted patients, however, involves the possibility that immunostimulation may induce organ rejection [13]. Acute liver rejection was actually reported in a few cases treated with interferon alpha [13]. Moreover, interferon treatment was also implicated in the induction of organ-specific autoimmune diseases, such as polymyositis, autoimmune thyroiditis, rheumatoid arthritis, and AIH in non-transplanted individuals [14,15]. All the three patients reported in this study became HCV negative before the development of autoimmune stigmata. It could be hypothesized that concomitant to the loss of the viral target for the immune system some mechanisms may lead to aberrant antigen presentation, or provide costimulatory signals leading to the breaking of tolerance versus
M. Merli et al. / Digestive and Liver Disease 41 (2009) 345–349
the transplanted graft. This phenomenon does not seem to be influenced by the time interval from transplantation, since it occurred in two patients (cases 1 and 2) who had been transplanted more than 3 years earlier. The development of this disease during the treatment with calcineurin inhibitors supports the opinion held by most AIH specialists that these drugs, although effective in the acute phase, are not of help in the management of autoimmune liver diseases [16]. It may also be questioned if the reported immune-mediated liver dysfunction should be considered different from a typical acute rejection. Actually, the presence of plasma cell infiltrates seems peculiar to this condition but not of acute rejection; moreover, the typical endothelialitis/venulitis and the signs of biliary damage were lacking [8]. A further characteristic in these patients was the presence of circulating autoantibodies, not present during acute rejection. Finally, similarly to AIH, it has been reported that these patients respond to a combined immunosuppressive therapy with prednisolone and azathioprine [3]. In our cases, azathioprine could not be always introduced due to leucopaenia; the steroid treatment at lower doses than those used in acute rejection was however helpful, although it probably contributed to the HCV viraemia relapse. Finally, unlike AIH in non-transplanted patients, it may be argued if the immune reaction versus a non-self organ can be defined as an autoimmune process. However, we do not know if the immune response, in this case, is directed against alloantigens, neoantigens in the liver, or self-antigens, possibly shared by donor and host cells. It is very likely that the inflammatory milieu due to alloreactive cells in the transplanted organ contributes to the disease process.
[2]
[3] [4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
Conflict of interest statement None declared.
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