Pathology of Recurrent Hepatitis C
Diagnostic Problems and Differential Diagnosis:
Are there Predictors of Graft Outcome?
Stefan Hübscher, School of Cancer Sciences, University of Birmingham
and Department of Cellular Pathology, Queen Elizabeth Hospital,
Birmingham. U.K.
Hepatitis C in the Liver Allograft
• HCV cirrhosis commonest indication for liver transplantation
• Re-infection is universal
– begins within few hours of reperfusion
– HCV-RNA >> pre-transplant levels
• Most cases (70-90%) result in graft inflammation
• Many progress to cirrhosis
– 20-30% by 5 years, up to 50% at 10 years
• 10-30% develop graft failure (Roche 2010, Ponziani 2011)
– most common indication for late retransplantation
Hepatitis C in the Liver Allograft
Histological Features
Typical Histological Features
- as seen in the non-transplanted liver
Atypical Histological Features
- modified by immunosuppression
- interaction with other complications
• Many post-transplant biopsies have features reflecting more than one process
• Liver biopsy may help to identify main cause of graft damage
Hepatitis C in the Liver Allograft
Histological Features
Typical Histological Features
- as seen in the non-transplanted liver
Atypical Histological Features
- modified by immunosuppression
- interaction with other complications
Hepatitis C in Liver Allografts - Evolution of Histological Changes
Phase
(time post-transplant)
Early infection
(0-2 months)
Histology
Mild non-specific
changes
Established infection
(2-6 months)
Acute hepatitis
Progressive damage
(> 6 months)
Chronic hepatitis
Comments
Lobular disarray
Acidophil bodies
Lack of inflammation
Steatosis
Lobular inflammation (usually mild)
Portal/periportal inflammation
Fibrosis/cirrhosis
Hepatitis C in Liver Allografts - Evolution of Histological Changes
Phase
(time post-transplant)
Early infection
(0-2 months)
Histology
Mild non-specific
changes
Established infection
(2-6 months)
Acute hepatitis
Progressive damage
(> 6 months)
Chronic hepatitis
Comments
Lobular disarray
Acidophil bodies
Lack of inflammation
Steatosis
Lobular inflammation (usually mild)
Portal/periportal inflammation
Fibrosis/cirrhosis
Recurrent HCV –5 weeks post-OLT
Early Recurrent HCV
lobular disarray, variation in cell size
Hepatitis C in Liver Allografts - Evolution of Histological Changes
Phase
(time post-transplant)
Early infection
(0-2 months)
Histology
Mild non-specific
changes
Established infection
(2-6 months)
Acute hepatitis
Progressive damage
(> 6 months)
Chronic hepatitis
Comments
Lobular disarray
Acidophil bodies
Lack of inflammation
Steatosis
Lobular inflammation (usually mild)
Portal/periportal inflammation
Fibrosis/cirrhosis
Recurrent HCV – 3 months post-OLT
spotty lobular inflammation (mild)
Hepatitis C in Liver Allografts - Evolution of Histological Changes
Phase
(time post-transplant)
Early infection
(0-2 months)
Histology
Mild non-specific
changes
Established infection
(2-6 months)
Acute hepatitis
Progressive damage
(> 6 months)
Chronic hepatitis
Comments
Lobular disarray
Acidophil bodies
Lack of inflammation
Steatosis
Lobular inflammation (usually mild)
Portal/periportal inflammation
Fibrosis/cirrhosis
Recurrent Hepatitis C – 6 months post-OLT
Chronic Hepatitis
Chronic Hepatitis C in the Liver Allograft
Role of Protocol Liver Biopsies
Most centres still obtain protocol annual review biopsies from
HCV-positive patients
•
e.g. 65% in recent survey of 35 LT centres (vs 25% for nonHCV patients) (Mells & Neuberger 2008)
•
Histological abnormalities frequently present in HCV-positive
patients with normal LFTs (Berenguer 2001, Sebagh 2003)
Chronic Hepatitis C in the Liver Allograft
Role of Protocol Liver Biopsies
Mainly used to assess disease severity (especially fibrosis)
•
Implications for prognosis (e.g. presence/severity of fibrosis at 1 year predicts
subsequent progression to fibrosis/cirrhosis/graft failure)
•
May influence treatment (anti-viral therapy to prevent fibrosis progression)
Scoring systems (e.g. METAVIR, Ishak) should be used with caution and only
in patients with “pure” HCV infection.
Non-invasive methods (serum markers, transient elastography) increasingly
used to assess fibrosis in post-transplant HCV
•
Mainly useful to identify mild/early fibrosis versus advanced fibrosis/cirrhosis
•
May also help to predict fibrosis progression
Hepatitis C in the Liver Allograft
Differences Compared with HCV in the Native Liver
1.
More aggressive disease
–
More severe inflammatory activity
–
more rapid progression to fibrosis and cirrhosis
(20- 30% cirrhotic by 5 years, up to 50% by 10 years)
2.
Atypical features
–
Cholestatic features (“fibrosing cholestatic hepatitis”)
–
Autoimmune features ( de novo AIH / “plasma cell hepatitis”)
3.
Interaction with other graft complications
–
Rejection (acute and chronic)
–
Non-alcoholic fatty liver disease
Hepatitis C in the Liver Allograft
Differences Compared with HCV in the Native Liver
1.
More aggressive disease
–
More severe inflammatory activity
–
more rapid progression to fibrosis and cirrhosis
(20- 30% cirrhotic by 5 years, up to 50% by 10 years)
2.
Atypical features
–
Cholestatic features (“fibrosing cholestatic hepatitis”)
–
Autoimmune features ( de novo AIH / “plasma cell hepatitis”)
3.
Interaction with other graft complications
–
Rejection (acute and chronic)
–
Non-alcoholic fatty liver disease
Recurrent Hepatitis C – Liver Biopsy 12 months post-transplant
prominent lobular inflammation with zone 3 necrosis (central perivenulitis)
•
Are these changes related to HCV alone?
or
•
Is this HCV + another graft complication?
-
Late acute rejection
-
De novo AIH
Recurrent Hepatitis C – Liver Biopsy 12 months post-transplant
prominent lobular inflammation with zone 3 necrosis (central perivenulitis)
•
Are these changes related to HCV alone?
or
•
•
Is this HCV + another graft complication?
-
Late acute rejection
-
De novo AIH
Histological distinction often difficult
-
Clinical context (e.g. recent changes in immunosuppression and/or antiviral therapy)
-
Results of other investigations (e.g. HCV-RNA levels, auto-antibodies)
Aggressive Recurrent HCV
•
•
•
•
Male, age 52. 21 months post-LT for HCV
Antiviral therapy recently stopped because of nephric abscess
Presented with acutely deranged LFTs (AST 650)
Became HCV-RNA positive
Hepatitis C in the Liver Allograft
Differences Compared with HCV in the Native Liver
1.
More aggressive disease
–
More severe inflammatory activity
–
more rapid progression to fibrosis and cirrhosis
(20- 30% cirrhotic by 5 years, up to 50% by 10 years)
2.
Atypical features
–
Cholestatic features (“fibrosing cholestatic hepatitis”)
–
Autoimmune features ( de novo AIH / “plasma cell hepatitis”)
3.
Interaction with other graft complications
–
Rejection (acute and chronic)
–
Non-alcoholic fatty liver disease
Hepatitis C with Cholestatic Features (“Fibrosing Cholestatic Hepatitis”)
Pathogenesis
Most cases present within first 12 months post-transplant (peak 2-6 months)
High viral RNA levels (serum and intra-hepatic)
Impaired HCV-specific immune response
High viral load in hepatocytes may result in:
• Direct cytopathic injury to hepatocytes (ballooning, cholestasis)
• Replicative senescence in hepatocytes
– Stimulus for progenitor cell activation & ductular reaction
– Hepatic stellate cell activation
Fibrosis
Hepatitis C with Cholestatic Features (“Fibrosing Cholestatic Hepatitis”)
Prevalence & Clinical Features
Prevalence
• Reported frequency varies (2-13%)
• May reflect different diagnostic criteria
• Higher frequency in HIV co-infected patients (up to 20% - Antoni 2011)
Clinical Features
• Jaundice and cholestatic liver biochemistry
– Other causes of cholestasis should be excluded (e.g. biliary
obstruction, drug toxicity)
• Severe cases progress rapidly to graft failure
Hepatitis C with Cholestatic Features (“Fibrosing Cholestatic Hepatitis”)
Histological Features
Early Features
•
Hepatocyte ballooning and cholestasis, mainly perivenular
•
Lobular disarray, little inflammation
•
Perisinusoidal fibrosis (? related to hepatic stellate cell activation)
Later Changes
•
Portal expansion with marginal ductular reaction
•
Progressive fibrosis (periportal and bridging)
•
Severe cases progressing rapidly to graft failure may be associated with
multi-acinar necrosis and collapse
Hepatitis C with Cholestatic Features - Histological Features
Differences Compared with Fibrosing Cholestatic Hepatitis B
•
Cholestatic features frequently co-exist with more typical hepatitic
changes
•
Fibrosis less prominent (cholestatic hepatitis C)
•
Clinico-pathological severity variable
–
Mild/early cases may respond to reduction in
immunosuppression +/- anti-viral therapy
–
Overall mortality 50% (Narang 2010)
Cholestatic Hepatitis C – Lobular Changes
Ballooning, lobular disarray
Bilirubinostasis
Cholestatic Hepatitis C – Portal &Periportal Changes
Cholestatic Hepatitis C – Portal &Periportal Changes
Ductular reaction
Also seen in:
•
Biliary obstruction
•
Acute rejection
Leads to periportal fibrosis
keratin 7
Cholestatic Hepatitis C –
Fibrosis - Periportal and Perisinusoidal
Hepatitis C with “Autoimmune Features”
( de novo autoimmune hepatitis, “plasma cell hepatitis”)
1.
Following Interferon Therapy
(Cholongitas 2006,Kontorinis 2006,Berardi 2007,Merli 2009)
•
14 cases – all had biochemical, serological and histological features
compatible with autoimmune hepatitis (“de novo AIH”)
•
Prevalence 20% (9/44) in largest study
•
12/14 were HCV-RNA negative
•
10/14 responded to treatment with immunosuppression
(Berardi 2006)
Chronic Hepatitis in the Liver Allograft
Features favouring an autoimmune aetiology
Portal inflammation with plasma cells
Interface hepatitis
Lobular inflammation (plasma cell rich)
Confluent necrosis
(Central perivenulitis)
Hepatitis C with “Autoimmune Features”
( de novo autoimmune hepatitis, “plasma cell hepatitis”)
2. Unrelated to Interferon Therapy
(Khettry 2007, Fiel 2008)
•
47 patients (prevalence 10%) - plasma cell rich portal and lobular infiltrates
(“plasma cell hepatitis”)
•
Centrilobular necro-inflammatory changes (“central perivenulitis”) in 43/47
•
Worse outcome than cases of “typical” recurrent HCV
Pathogenesis
•
75% had increased serum immunoglobulins and/or autoantibodies (Khettry 2007)
•
•
In keeping with DNAIH
82% had suboptimal immunosuppression, auto-antibodies only in low titre (Fiel 2008)
•
Probably a form of rejection
•
40% of patients with plasma cell hepatitis post-LT had plasma cell-rich infiltrates in native
liver at transplantation (versus 18% in control group) (Ward 2009)
Increasing evidence to suggest that DNAIH and late rejection are part of an overlapping
spectrum of immune-mediated graft injury (pathogenesis and histological features)
Hepatitis C in the Liver Allograft
Differences Compared with HCV in the Native Liver
1.
More aggressive disease
–
More severe inflammatory activity
–
more rapid progression to fibrosis and cirrhosis
(20- 30% cirrhotic by 5 years, up to 50% by 10 years)
2.
Atypical features
–
Cholestatic features (“fibrosing cholestatic hepatitis”)
–
Autoimmune features ( de novo AIH / “plasma cell hepatitis”)
3.
Interaction with other graft complications
–
Rejection (acute and chronic)
–
Non-alcoholic fatty liver disease
Hepatitis C and Rejection
Rejection/immunosuppression = risk factors for severe/progressive HCV
• Immunosuppression allows increased viral replication
• Predisposes to more severe inflammation when immunosuppression reduced
Higher incidence of acute and chronic rejection in HCV-positive patients
• HCV-associated changes may augment alloimmune-mediated lesions
•
Common patterns of liver injury (e.g.portal inflammation, bile duct damage)
• Effects of anti-viral therapy (interferon)
•
Stimulation of immune system
•
Improved hepatocellular metabolism of immunosuppressive drugs after viral
clearance from hepatocytes
Hepatitis C
versus
Rejection
Hepatitis C and Acute Rejection
(Demetris Am J Surg Pathol 2004, Banff Working Party 2006)
•
AR and recurrent HCV have overlapping histological features (portal inflammation,
bile duct inflammation, venous endothelial inflammation) and may occur at the same
time
•
In most cases the pattern of inflammation enables the main cause of graft dysfunction
to be identified
•
Cases in which distinction between HCV and AR is difficult probably have a dual
pathology
– In most of these cases rejection changes are mild
– HCV best considered as the primary diagnosis
– No additional immunosuppression required
•
Increased immunosuppression should be considered as a treatment option if
– rejection changes moderate or severe
– features suggest progression to (early) chronic rejection
Late Cellular Rejection - Different Histological Features
(Snover 1988, Kemnitz 1989, Cakaloglu 1995, Pappo 1995)
• Portal inflammation predominantly mononuclear
• Inflammation of bile ducts and venular endothelium less conspicuous
• More prominent interface hepatitis and lobular inflammation
• Overall features resemble chronic hepatitis (e.g. viral or autoimmune)
“Idiopathic” chronic hepatitis
“Idiopathic” Chronic Hepatitis
Cirrhosis 5 years post-transplant
Common(est) histological diagnosis in late post-transplant biopsies
•
10-50% of biopsies > 1yr have unexplained inflammation (mainly portal, usually
mild) that could be classified as “idiopathic” CH (Shaikh & Demetris 2007)
In cases where viral and autoimmune causes have been excluded:
•
May be a form of rejection (late rejection with hepatitic features)
•
A potentially important cause of graft fibrosis
– 50-70% of children with CH have bridging fibrosis/cirrhosis, 10 year post-transplant
(Evans 2006, Herzog 2008)
Hepatitis C versus Acute Rejection - Other Approaches
Immunostaining for HCV Antigens (Grassi 2006, Errico-Grigioni 2008, Sadamori 2009)
•
Higher frequency of staining and greater proportion of positively staining
hepatocytes in HCV than rejection.
Immunostaining for C4d
•
(Schmeding, 2006, Lorho, 2006,Jain, 2006, Bellamy 2007)
Higher frequency of C4d positivity in acute rejection (45-80%) than in recurrent
HCV infection (0-12%)
Immunostaining for cell cycle entry protein mcm-2 (Unitt 2009)
•
More mcm-2 positive portal lymphocytes in rejection than HCV
Immunostaining for MxA protein – marker of type 1 IFN activation (MacQuillan 2010)
•
More hepatocellular expression in HCV than rejection
Hepatitis C versus Acute Rejection - Other Approaches
Applications & Limitations of Immunohistochemistry
•
Most studies have looked at “typical” cases of acute rejection and HCV,
which are clearly distinguishable by routine microscopy.
•
Problems with reproducibility (HCV tissue detection)
•
Problems with specificity (C4d immunostaining)
•
May help to identify main cause of graft damage in some cases where
routine histological findings inconclusive
•
High tissue expression of HCV antigens confirmed diagnosis of HCV
hepatitis in 16 patients with inconclusive histological diagnosis (Grassi 2006)
•
Mcm-2 expression pointed to correct diagnosis in 11 HCV infected patients
with uncertain diagnosis – 7 HCV, 4 superimposed ACR (Unitt 2009)
Recurrent Hepatitis C
Are there predictors of graft outcome?
•
Can one identify risk factors that predispose to more
severe disease (rapid progression to
fibrosis/cirrhosis/graft failure) ?
•
May have implications for donor/ patient selection
prior to transplantation and for post-transplant
management (e.g. selecting patients for anti-viral
therapy)
Recurrent HCV – Risk Factors for Severe/Progressive Disease
Viral Factors
HCV genotype (1b or 4)
HCV-RNA levels (pre- and post-transplant)
Recipient Factors
Age, female gender
Non-white race
Co-infection with HIV
IL-28b polymorphism
TGF beta-1 polymorphism
Donor factors
Age
White race
HLA mis-matching
Hepatic iron concentration
Steatosis (controversial)
Donation after cardiac death (DCD) (controversial)
Transplant-related
factors
Perioperative
 warm and cold ischaemic times, preservation/reperfusion injury
Acute rejection
 severity and number of episodes
Immunosuppression
 amount/type of immunosuppression given
 rapid withdrawal of cortiocosteroids
Co-infection with herpesviruses (CMV, HHV-6)
Metabolic syndrome/NAFLD
Biliary complications
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
1.
Steatosis
2.
Necro-inflammatory activity
3.
Hepatocyte apoptosis/replicative senescence
4.
Hepatic stellate cell activation
5.
Early fibrosis
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
1.
Steatosis
•
Presence/severity during 1st month (Pelletier 2000)
•
Presence at 1 year (Ghabril 2011)
•
May reflect viral factors (genotype 3) or host factors (NAFLD)
•
Risk factor for poor response to anti-viral therapy (Testino 2011)
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
2.
Necro-inflammatory activity
•
Severity at time of first presentation with HCV hepatitis
(during 1st 6 months)
•
(Sreekumar 2000 , Guido 2003)
Severity in protocol biopsies at 4-12 months also
predictive (Gane 1996, Prieto 1999, Firpi 2004)
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
3.
Hepatocyte apoptosis/replicative senescence
•
Amount of hepatocyte apoptosis in stage F0 biopsies
•
Hepatocellular expression of senescence-associated beta
galacosidase in biopsies during 1st year (Trak-Smyra 2004)
•
Hepatocellular expression of cell cycle entry protein Mcm-2 in
early biopsies (median 3 months) (Marshall 2005)
•
Initial cell cycle entry
(Meriden 2010)
Subsequent cell cycle arrest
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
4.
Hepatic stellate cell activation
Marker
Predictive value/other comments
“Slow
fibroser”
Smooth
muscle actin
“Rapid fibroser”
Numbers of SMA-positive
cells in protocol biopsies (3-6
months) predicts development of fibrosis at 1-2 years
(Guido 1997, Carpino 2005,
Gawrieh 2005, Russo 2005)
GFA P
(Carotti 2008)
Vimentin
(Meriden 2010)
GFAP – marker of early HSC activation
% of GFAP-positive cells in early biopsies correlates with
rate of fibrosis progression
Numbers
of -vimentin
positiveforcells
4 month
biopsy
immunostaining
SMAin stage F0 biopsies
2005) to F3/F4 fibrosis
predicts (from
rapid Russo
progression
Mainly portal/periportal , associated with ductular reaction
(CK 19 positive cells)
Hepatitis C In Liver Allografts
Histological Factors Predictive For Severe/Progressive Disease
(rapid progression to advanced fibrosis/cirrhosis)
5.
Early fibrosis
•
Fibrosis stage (Ishak 2-3/6) at 1 year predicts progression to cirrhosis at 5
years (Firpi 2004)
•
Fibrosis stage (Ishak > 2) at 1 year predicts progression to graft failure
(Gallegos-Orozco 2009)
•
Digital image analysis to measure collagen proportionate area (CPA)
in Sirius red stained sections (Manousou 2011)
•
CPA at one year strongly predictive for subsequent hepatic
decompensation (better than Ishak stage or HVPG)
Pathology of Recurrent Hepatitis C – Summary & Conclusions
1.
Liver biopsy continues to play an important role in the management of
post-transplant HCV.
2.
In most cases with typical features, biopsy mainly used to assess disease
severity (fibrosis stage).
3.
Cases with atypical features (e.g cholestatic HCV, HCV with
“autoimmune features”) are more challenging and require careful clinicopathological correlation. Implications for prognosis and treatment.
4.
Hepatitis C and rejection frequently co-exist. Liver biopsy helps to
identify the predominant cause of graft damage.
5.
Some features seen in early biopsies (protocol or clinically-indicated)
appear to be predictive of rapidly progressive graft injury . These may also
have therapeutic implications (e.g. early use of anti viral therapy)
Monday 28 April 2008