Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
With great interest we read the article by Pappo et al. (1) about the clinicopathological features of liver allograft dysfunction occurring more than 5 years after transplantation. In our opinion, this is important work in the pathology of liver transplantation for two reasons: (a) it shows the significance of long-term changes after transplantation; and (b) it raises the question of the problem of chronic rejection in liver grafts.
This formulation of the question is of great significance because of the increasing number of successful liver transplantations with constantly increasing survival rates. The pathology of liver transplants more than 5 years after transplantation can be roughly divided into three groups: (a) the problem of chronic rejection; (b) recurrence of the original disease; and finally, (c) failure of the liver graft for other reasons, most not directly related to transplantation.
The publication of Pappo and colleagues shows that recurrence of the original disease is of great importance. In our opinion, however, this is not the most important problem with long-term survival after transplantation of a solid organ. Our experiences are based on the results of other transplant centers. The separate data at our disposal from various work-places show great variations; for example, the results of the Essen Transplant Group show 61.5% allograft survival after 5 years from a total of 222 patients with 261 transplants. The survival of allografts changes, moreover, in different groups of original diseases, with malignant tumors totalling 29.9%; transplantations for emergency reasons, 51.2%; and elective transplantation (with defined disorder of the liver, e.g., cirrhosis on the basis of hepatitis), 71%. A recurrence 5 years after transplantation occurs in about 30.2% of benign elective transplantations, that is, the group with an elective indication; the maximum is due to hepatitis B with hepatitis B virus-DNA positivity and, interestingly, the minimum due to so-called cryptogenic cirrhosis and alcoholic liver damage. The recurrence in primary biliary cirrhosis is about 10%.
The principal unanswered question is interpretation of the recurrence of the original disease and of changes after transplantation as a result of a patient's individual situation. For example, it is very difficult to interpret the recurrence of an original disease in so-called social alcoholics who drink only sporadically on social occasions and in whom the indication for a transplant was, for example, because of liver failure due to advanced cirrhosis on the basis of hepatitis B. It is very difficult, in fact virtually impossible, to estimate the effect of such influences in interpreting a recurrence of original disease. Furthermore, as with the transplantation of other solid organs, the problems of chronic rejection seem to us to be underestimated. In our opinion, as with other transplants of solid organs (e.g. in the heart) (2), defined changes of a chronic rejection also exist in the liver (3,4). In detailed histopathological analysis, one finds the changes above all in bioptical material, which could be defined as the changes in the framework of a chronic rejection. Three grades of severity of chronic rejection can be defined in our system of the so-called Hannover Classification of Chronic Rejection:
At the same time, with regard to the entire organ, one speaks of a parenchymal type, a vascular type, or a ductular type of chronic rejection. With the exception of vascular rejection, with the equivalent of a graft vasculopathy, all other types of rejection can be diagnosed in the bioptical material. Nevertheless, one should not underestimate recurrence of the original disease on the basis of chronic rejection. The analyses are possible only through a complete review of the clinical files, above all, the laboratory results, in comparison with the histopathology.
