Pediatric Nephrology
Pediatr Nephrol (1992) 6:407 - 411 9 IPNA 1992
Original article Glomerular abnormalities in children undergoing orthotopic liver transplantation Simon E. Chin1, Roy A. Axelsen3, Darrell H. G. Crawford5, Zoltan H. Endre5, 6 Stephen V. Lynch4, Glenda A. Balderson4, Russell W. Strong 4, Ross W. Shepherd1, John R. Burke 2, and Simon J. Fleming6 Departments of 1Gastroenterology and Nutrition and 2 Nephrology, Royal Children's Hospital, Queensland, Australia Departments of 3 Pathology and 4 Surgery, Princess Alexandra Hospital, Queensland, Australia 5 Department of Medicine, University of Queensland, Queensland, Australia 6 Department of Renal Medicine, Royal Brisbane Hospital, Herston, Queensland 4029, Australia Received November 26, 1991; received in revised form and accepted March 19, 1992
Abstract. A prospective study of renal function was undertaken on an unselected group of 8 children with chronic progressive liver disease on whom a renal biopsy was performed subsequently at the time of orthotopic liver transplantation. Two patients had abnormal urinalyses and 2 elevated urinary albumin/creatinine ratios. The remainder had no clinical evidence of renal dysfunction. All had normal serum creatinine concentrations. Glomerular abnormalities were present in all renal biopsies and were of two types: hepatic glomerulosclerosis (n = 5) and minor glomerular abnormalities (n = 3). IgM immunofluorescence was present in all biopsies and IgA in 6. Elevated serum immunoglobulin levels were observed in all patients, with IgM elevation in 6, IgA in 4 and IgG in 6. C3 and/or C4 were reduced in 5 patients and increased circulating immune complexes containing IgM were noted in 4. The clinical significance of these cirrhosis-associated glomerular abnormalities can only be established by longterm follow-up studies after orthotopic liver transplantation.
Key words: Glomerulonephritis - Liver cirrhosis - Orthotopic liver transplantation
Introduction Orthotopic liver transplantation has become an established therapeutic option for children with end-stage liver disease, with 1-year survival rates of 70% or more [1, 2]. A variety of functional renal abnormalities, such as the hepatorenal syndrome and disturbances in salt and water metabolism, frequently complicate end-stage liver disease, and renal failure occurs frequently both before or immediately after orthotopic liver transplantation, possibly contributing to mortality [3 - 5]. Correspondence to: S. J. Fleming
Morphological glomerular changes including hepatic glomerulosclerosis (HGS) and IgA nephropathy also occur in liver disease [6-12]. While the abnormalities have largely been described in adults, there is evidence for similar glomemlar lesions occurring in children with cirrhosis [13], but detailed prospective morphological studies have not been carried out. As pre-existing glomerular disease could potentially contribute to the development of renal complications in children with end-stage liver disease, a prospective study of renal function and pathology was undertaken in a consecutive series of these children undergoing liver transplantation.
Methods Between March 1990 and January 1991, 14 children (median age 1.3 years, range 0.58-4.25 years) were accepted by the Queensland Liver Transplant Service for orthotopic liver transplantation. The cause of their chronic liver disease was biliary atresia (n = 13) and Alagille's syndrome (n = 1). Prior to transplantation, the children were maintained on a high-carbohydrate diet supplemented with branched-chain amino acids and vitamins. All were on diuretics and periodically some received trimethoprim-sulphamethoxazole as prophylaxis against cholangitis. None received immunosuppression or total parenteral nutrition. Informed consent was obtained from the parents of 13 children for the study which had been approved by the Royal Children's Hospital Ethics Committee. Renal biopsies were not obtained from 4 children because of technical difficulties related to previous abdominal surgery. The biopsy of another patient contained no glomeruli and this child was also excluded from data analysis leaving 8 patients in the study group. Prior to transplantation, details of past and present renal symptomatology were obtained for each patient and a complete physical examination performed. Detailed laboratory investigations were undertaken including: serum creatinine, urea, liver function tests, immunogtobulins, complement and hepatitis B serology. Serum was also tested for antinuclear antibodies, cryoglobulins and circulating immune complexes. Results were compared with the normal range obtained for age-matched laboratory controls. Microscopy of freshly passed urine and renal ultrasound were performed on all patients, and urinary albumin and creatinine concentration ratios were measured from random urine samples. The glomerular filtration rate (GFR) was estimated from the formula: GFR = [k x length (cm)] divided by serum creatinine (mg/dl), where k = 0.45 for infants aged less than 1 year and k = 0.55 for older children [14, 15].
408 Ultratome V (LKB-Produkter AB, Bromma, Sweden) and examined in a Jeol JEM-100 s (Jeol, Tokyo, Japan) electron microscope.
Results
Clinical features (Table i) All 8 biopsied patients had biliary atresia with chronic progressive hepatic failure and derangement o f liver function tests. Abnormal urinalyses were present in 2 patients. Patient 1 had 65,000 dysmorphic erythrocytes/ml urine and patient 2 13,000 erythrocytes]ml. In patient 1 the erythrocytes were accompanied by granular and cellular casts. Serum creatinine and urea levels and G F R estimations were all within the normal rar~ge for age [16]. Urinary albumin/creatinine ratios were outside the normal reference range [17] in 2 patients. The abnormal ratios were 0.25 in patient 4 and 0.16 in patient 6 (normal range 0 . 0 3 0.11 for children of their weight). No renal abnormalities were seen on abdominal ultrasound and all tests for hepatitis B surface antigen and antibody were negative. Fig. 1. Hepatic glomerulosclerosis with segmental thickening of the glomerular capillary wall with double contours (arrow)and moderate expansion of the mesangial matrix. Periodic acid-Schiff, x 690
During the liver transplant operation, a Tru-Cut (Travenol Laboratories, Deerfield, Ill., USA) needle biopsy of the kidney was performed under direct vision by the operating surgeon. All biopsies were examined by light, immunofluorescent and electron microscopy. For light microscopy, tissue was fixed in formal-subfimate. Paraffin sections (3 g thick) were then stained with haematoxylin and eosin and periodic acid-Schiff (PAS). Sections 1 g thick were stained with PAS and Gomori's periodic acid methemanime silver. Tissue for immunofluorescence was transported and stored for 24 h in a neutral, citrate-buffered solution containing 3.12 M ammonium sulphate. It was then snap frozen in liquid nitrogen and frozen sections were cut and subjected to direct immunofluorescence with antiserum to IgG, IgA, IgM, Clq, C3 and fibrinogen. Tissue for electron microscopy was diced and fixed in 3% glutaraldehyde in 0.1 M sodium cacodylate buffer, pH 7.2. The tissue was post-fixed in 1% osmium tetroxide, stained en bloc with 5% uranyl acetate and embedded in an Epon/Araldite mixture. Ultrathin sections were cut on an LKB
Pathology (Table 2) All 8 biopsies yielded material satisfactory for light microscopy and immunofluorescence, and glomeruli were present in 7 of the 8 specimens submitted for electron microscopy. In the paraffin sections for light microscopy the m a x i m u m number of glomeruli per section varied f r o m 3 to 30. Glomerular abnormalities were present in all biopsies. There were 7 cases of HGS [7], characterised on light microscopy by expansion o f mesangial matrix, double contours of capillary walls and varying degrees of mesangial hypercellularity (Fig. 1). All biopsies showed diffuse I g M in the m e s a n g i u m and/or glomerular capillary wails, while I g A and I g G were present in most. Ultrastructural findings were available on 4 specimens. The abnormalities (Fig. 2) consisted o f an increase in mesangial cells and matrix, electron-dense mesangial deposits (1 case), hypertrophy of the endothelium, thickening of capillary walls due to
Table 1. Clinical details of children with end-stage liver disease undergoing liver transplantation in whom renal biopsies were performed (n = 8) Patient
Age (years)
Sex
GFR (ml/min per 1.73 m2)
Urinary albumin/creatinine a (mg/ml)/(mg/ml)
Serum bilirubin (gmol/1)
Serum AST units/1
Serum GGT units/1
1 2 3 4 5 6 7 8
1.3 0.6 1.6 1.3 1.6 0.6 3.2 1.2
F F M M F M F F
118 82 107 92 118 73 112 89
0.01 0.06 0.25 0.12 0.16 0.04 0.10
522 564 164 251 402 175 114 268
354 534 240 257 264 208 404 262
192
Pediatr Nephrol (1992) 6:407 - 411 9 IPNA 1992
Original article Glomerular abnormalities in children undergoing orthotopic liver transplantation Simon E. Chin1, Roy A. Axelsen3, Darrell H. G. Crawford5, Zoltan H. Endre5, 6 Stephen V. Lynch4, Glenda A. Balderson4, Russell W. Strong 4, Ross W. Shepherd1, John R. Burke 2, and Simon J. Fleming6 Departments of 1Gastroenterology and Nutrition and 2 Nephrology, Royal Children's Hospital, Queensland, Australia Departments of 3 Pathology and 4 Surgery, Princess Alexandra Hospital, Queensland, Australia 5 Department of Medicine, University of Queensland, Queensland, Australia 6 Department of Renal Medicine, Royal Brisbane Hospital, Herston, Queensland 4029, Australia Received November 26, 1991; received in revised form and accepted March 19, 1992
Abstract. A prospective study of renal function was undertaken on an unselected group of 8 children with chronic progressive liver disease on whom a renal biopsy was performed subsequently at the time of orthotopic liver transplantation. Two patients had abnormal urinalyses and 2 elevated urinary albumin/creatinine ratios. The remainder had no clinical evidence of renal dysfunction. All had normal serum creatinine concentrations. Glomerular abnormalities were present in all renal biopsies and were of two types: hepatic glomerulosclerosis (n = 5) and minor glomerular abnormalities (n = 3). IgM immunofluorescence was present in all biopsies and IgA in 6. Elevated serum immunoglobulin levels were observed in all patients, with IgM elevation in 6, IgA in 4 and IgG in 6. C3 and/or C4 were reduced in 5 patients and increased circulating immune complexes containing IgM were noted in 4. The clinical significance of these cirrhosis-associated glomerular abnormalities can only be established by longterm follow-up studies after orthotopic liver transplantation.
Key words: Glomerulonephritis - Liver cirrhosis - Orthotopic liver transplantation
Introduction Orthotopic liver transplantation has become an established therapeutic option for children with end-stage liver disease, with 1-year survival rates of 70% or more [1, 2]. A variety of functional renal abnormalities, such as the hepatorenal syndrome and disturbances in salt and water metabolism, frequently complicate end-stage liver disease, and renal failure occurs frequently both before or immediately after orthotopic liver transplantation, possibly contributing to mortality [3 - 5]. Correspondence to: S. J. Fleming
Morphological glomerular changes including hepatic glomerulosclerosis (HGS) and IgA nephropathy also occur in liver disease [6-12]. While the abnormalities have largely been described in adults, there is evidence for similar glomemlar lesions occurring in children with cirrhosis [13], but detailed prospective morphological studies have not been carried out. As pre-existing glomerular disease could potentially contribute to the development of renal complications in children with end-stage liver disease, a prospective study of renal function and pathology was undertaken in a consecutive series of these children undergoing liver transplantation.
Methods Between March 1990 and January 1991, 14 children (median age 1.3 years, range 0.58-4.25 years) were accepted by the Queensland Liver Transplant Service for orthotopic liver transplantation. The cause of their chronic liver disease was biliary atresia (n = 13) and Alagille's syndrome (n = 1). Prior to transplantation, the children were maintained on a high-carbohydrate diet supplemented with branched-chain amino acids and vitamins. All were on diuretics and periodically some received trimethoprim-sulphamethoxazole as prophylaxis against cholangitis. None received immunosuppression or total parenteral nutrition. Informed consent was obtained from the parents of 13 children for the study which had been approved by the Royal Children's Hospital Ethics Committee. Renal biopsies were not obtained from 4 children because of technical difficulties related to previous abdominal surgery. The biopsy of another patient contained no glomeruli and this child was also excluded from data analysis leaving 8 patients in the study group. Prior to transplantation, details of past and present renal symptomatology were obtained for each patient and a complete physical examination performed. Detailed laboratory investigations were undertaken including: serum creatinine, urea, liver function tests, immunogtobulins, complement and hepatitis B serology. Serum was also tested for antinuclear antibodies, cryoglobulins and circulating immune complexes. Results were compared with the normal range obtained for age-matched laboratory controls. Microscopy of freshly passed urine and renal ultrasound were performed on all patients, and urinary albumin and creatinine concentration ratios were measured from random urine samples. The glomerular filtration rate (GFR) was estimated from the formula: GFR = [k x length (cm)] divided by serum creatinine (mg/dl), where k = 0.45 for infants aged less than 1 year and k = 0.55 for older children [14, 15].
408 Ultratome V (LKB-Produkter AB, Bromma, Sweden) and examined in a Jeol JEM-100 s (Jeol, Tokyo, Japan) electron microscope.
Results
Clinical features (Table i) All 8 biopsied patients had biliary atresia with chronic progressive hepatic failure and derangement o f liver function tests. Abnormal urinalyses were present in 2 patients. Patient 1 had 65,000 dysmorphic erythrocytes/ml urine and patient 2 13,000 erythrocytes]ml. In patient 1 the erythrocytes were accompanied by granular and cellular casts. Serum creatinine and urea levels and G F R estimations were all within the normal rar~ge for age [16]. Urinary albumin/creatinine ratios were outside the normal reference range [17] in 2 patients. The abnormal ratios were 0.25 in patient 4 and 0.16 in patient 6 (normal range 0 . 0 3 0.11 for children of their weight). No renal abnormalities were seen on abdominal ultrasound and all tests for hepatitis B surface antigen and antibody were negative. Fig. 1. Hepatic glomerulosclerosis with segmental thickening of the glomerular capillary wall with double contours (arrow)and moderate expansion of the mesangial matrix. Periodic acid-Schiff, x 690
During the liver transplant operation, a Tru-Cut (Travenol Laboratories, Deerfield, Ill., USA) needle biopsy of the kidney was performed under direct vision by the operating surgeon. All biopsies were examined by light, immunofluorescent and electron microscopy. For light microscopy, tissue was fixed in formal-subfimate. Paraffin sections (3 g thick) were then stained with haematoxylin and eosin and periodic acid-Schiff (PAS). Sections 1 g thick were stained with PAS and Gomori's periodic acid methemanime silver. Tissue for immunofluorescence was transported and stored for 24 h in a neutral, citrate-buffered solution containing 3.12 M ammonium sulphate. It was then snap frozen in liquid nitrogen and frozen sections were cut and subjected to direct immunofluorescence with antiserum to IgG, IgA, IgM, Clq, C3 and fibrinogen. Tissue for electron microscopy was diced and fixed in 3% glutaraldehyde in 0.1 M sodium cacodylate buffer, pH 7.2. The tissue was post-fixed in 1% osmium tetroxide, stained en bloc with 5% uranyl acetate and embedded in an Epon/Araldite mixture. Ultrathin sections were cut on an LKB
Pathology (Table 2) All 8 biopsies yielded material satisfactory for light microscopy and immunofluorescence, and glomeruli were present in 7 of the 8 specimens submitted for electron microscopy. In the paraffin sections for light microscopy the m a x i m u m number of glomeruli per section varied f r o m 3 to 30. Glomerular abnormalities were present in all biopsies. There were 7 cases of HGS [7], characterised on light microscopy by expansion o f mesangial matrix, double contours of capillary walls and varying degrees of mesangial hypercellularity (Fig. 1). All biopsies showed diffuse I g M in the m e s a n g i u m and/or glomerular capillary wails, while I g A and I g G were present in most. Ultrastructural findings were available on 4 specimens. The abnormalities (Fig. 2) consisted o f an increase in mesangial cells and matrix, electron-dense mesangial deposits (1 case), hypertrophy of the endothelium, thickening of capillary walls due to
Table 1. Clinical details of children with end-stage liver disease undergoing liver transplantation in whom renal biopsies were performed (n = 8) Patient
Age (years)
Sex
GFR (ml/min per 1.73 m2)
Urinary albumin/creatinine a (mg/ml)/(mg/ml)
Serum bilirubin (gmol/1)
Serum AST units/1
Serum GGT units/1
1 2 3 4 5 6 7 8
1.3 0.6 1.6 1.3 1.6 0.6 3.2 1.2
F F M M F M F F
118 82 107 92 118 73 112 89
0.01 0.06 0.25 0.12 0.16 0.04 0.10
522 564 164 251 402 175 114 268
354 534 240 257 264 208 404 262
192
