Liver biopsy post liver transplantation for HCV-related end stage liver disease: Clinical value and risk factors for graft hepatitis and rejection
Background and aim: Hepatitis C-related end stage liver disease (HCV-ESLD) is the leading primary indication for liver transplantation (LT). Recurrent HCV infection after LT is universal and most patients show manifested graft hepatitis. Accurate diagnosis is important in acute rejection in HCV-infected patients, as increased immunosuppression accelerates HCV-induced liver damage and shortens graft and patient survival. Aim of our study was to investigate the safety and the clinical value of this procedure in a large academic referral European LT center.
Patients and methods: Between January 2000 and October 2011, 138 patients were liver transplanted for hepatitis C-related end stage liver disease (HCV-ESLD) in Hannover Medical School and 96 of them received 196 representative liver biopsies. Comparison between graft rejection and hepatitis was achieved. Modifications in the recipient's management according to the biopsy result, as well as the biochemical trend four weeks following the biopsy were analyzed.
Results: From 211 biopsies, we collected 196 (93%) representative biopsies among them, five patients (2.5%) developed biopsy-related complications. The biopsies showed 35% rejection, 31% graft hepatitis and 34% other diagnoses. In comparison to patients with recurrence, graft rejection was independently associated with lower albumin (p = 0.025) and higher bilirubin (p = 0.011) in the multivariate analysis. In 25% of occasions, corresponding treatment was received. In the follow-up, serum ALT, GGT and bilirubin improved in 41%, 25% and 31% of cases respectively; mostly without treatment modification. There was a significant improvement in ALT values of rejection cases irrespective of treatment modification.
Conclusion: Despite the altered anatomical status and immunosuppression, liver biopsy post HCV-ESLD transplants is safe in 97.5% and representative in 93% of cases. Two thirds of cases developed either graft rejection or recurrence of the graft hepatitis C. Graft rejection is independently associated with lower albumin and higher bilirubin. According to the biopsy, only 1/4 of cases were in need of treatment modifications. ALT values showed significant improvement four weeks after the biopsy in cases of rejection with or without therapy modifications.