LIVER TRANSPLANTATION 20:679–686, 2014
ORIGINAL ARTICLE
Recurrence of Primary Sclerosing Cholangitis in Pediatric Liver Transplant Recipients Veena L. Venkat,1 Sarangarajan Ranganathan,2 George V. Mazariegos,3 Qing Sun,3 and Rakesh Sindhi3 1 Division of Pediatric Gastroenterology, Hepatology, and Nutrition, 2Division of Pediatric Pathology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA; and 3Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
There is little detailed clinical information on recurrent primary sclerosing cholangitis (rPSC) after liver transplantation in children. Our purpose was to describe the characteristics of children who had experienced rPSC after liver transplantation so that we could identify potential risk factors for recurrence. Clinical information for pediatric patients undergoing transplantation for primary sclerosing cholangitis (PSC) was retrospectively reviewed, and variables related to the pretransplant diagnosis of PSC and posttransplant variables were abstracted. The studied variables included the following: cytomegalovirus/ Epstein-Barr virus status, early/late rejection, induction regimen, immunosuppression in the first year, steroid-resistant rejection, diagnosis of inflammatory bowel disease, and human leukocyte antigen markers commonly associated with PSC. A diagnosis of rPSC was made on the basis of radiographic features, histology, or both. Twelve patients underwent liver transplantation for PSC between 1993 and 2012. Patients received tacrolimus for maintenance immunosuppression after induction with steroids (n 5 6) or thymoglobulin (n 5 6). Three patients were diagnosed with rPSC 44, 60, and 62 months after transplantation. A fourth patient underwent retransplantation for graft failure with features of both hepatic artery stenosis and rPSC. This patient had distinct histological features of rPSC in the second graft. Three of the 4 patients were 7 years old or younger at the diagnosis of PSC. The patient and graft survival rates were similar for the steroid and thymoglobulin groups. All 4 children with rPSC received steroid-free thymoglobulin induction. In conclusion, our observation of an association between thymoglobulin, and age less than 10 years at the diagnosis of PSC, and rPSC adds to the existing suggestion of a link between the immune environment and the pathogenesis of rPSC. Defining the natural history of rPSC and searching for the etiology and risk factors of rPSC are important for the long-term outcomes of pediatric patients. Liver Transpl C 2014 AASLD. 20:679-686, 2014. V Received November 21, 2013; accepted March 9, 2014.
Abbreviations: ACR, acute cellular rejection; AIH, autoimmune hepatitis; CMV, cytomegalovirus; EBV, Epstein-Barr virus; ERCP, endoscopic retrograde cholangiopancreatography; HLA, human leukocyte antigen; IBD, inflammatory bowel disease; MRCP, magnetic resonance cholangiopancreatography; PSC, primary sclerosing cholangitis; rPSC, recurrent primary sclerosing cholangitis; SPLIT, Studies of Pediatric Liver Transplantation; SRTR, Scientific Registry of Transplant Recipients; UNOS, United Network for Organ Sharing. There were no grants or financial support associated with this study. The authors have no conflicts of interest to declare. This work was supported in part by the Health Resources and Services Administration (contract 234-2005-37011C). The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. Address reprint requests to Veena L. Venkat, M.D., Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224. Telephone: 412-692-5180; FAX: 412-692-7355; E-mail: [email protected] DOI 10.1002/lt.23868 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
25
28 35
7 (21.9) 11 (21) 9 (45) 9 (19.1) 61
18
32 52 20 47
Debray et al.8 (1994)‡
Wilschanski et al.7 (1995) Feldstein et al.5 (2003) Batres et al.4 (2005) Miloh et al.6 (2009) Miloh et al.9 (2011)
After institutional review board approval, clinical information for pediatric patients undergoing transplantation for PSC at the Children’s Hospital of Pittsburgh (University of Pittsburgh Medical Center) between 1993 and 2012 was retrospectively reviewed, and variables related to the pretransplant diagnosis of PSC and posttransplant variables were extracted. Histopathology was reviewed by a single pathologist (S.R.). A pretransplant diagnosis of PSC was confirmed with a review of laboratory studies and magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) reports and with a review of pretransplant biopsy and explant histology findings. Patients with overlapping features of PSC and autoimmune
Study (Year)
PATIENTS AND METHODS
*The data are presented as means and standard deviations. † The data are presented as medians and ranges. ‡ Total after the exclusion of patients with histiocytosis, immunodeficiency, and with a neonatal diagnosis that resolved spontaneously. n/a is not applicable or not reported.
18.7 6 13.8*
n/a No No No IBD n/a 40 (24–72)† 29 (192101)†
n/a (27) (33) (11) (10) 3/11 3/9 1/9 6/61
11 n/a n/a 0/5 (0)
3.5 6 3.3 (PSC)* 10.3 6 2.7 (PSC with IBD or AIH)* 13 (0.5-18)† 13.8 6 4.2* 14 (1.5-19.6)† 9.33 6 4.8 — (0.1-15)† 11 6 4.9* 12 (2-20)† 5 (27.8)
Features (%) Proposed for rPSC
Risk Factor Time From
Transplant to rPSC Diagnosis (Months) Patients With rPSC [n/N (%)] Recipients [n (%)] With PSC (n)
Age at PSC Diagnosis (Years) Liver
Transplant
Total
Patients
TABLE 1. Previously Published Studies of PSC in Children
Primary sclerosing cholangitis (PSC) is a chronic and progressive cholestatic liver disease. The incidence in children is 0.23/100,000 person-years, which is approximately 20% of the incidence reported for adults.1 The estimated 10-year survival rate for adults is 65%, with the endpoint of death or transplantation reached within 12 years of the diagnosis.2,3 According to available natural history studies in pediatrics, 19% to 45% of these children undergo liver transplantation with a median (50%) transplant-free survival time of 12.7 years.4-8 Recurrent primary sclerosing cholangitis (rPSC) in the graft has been reported by few pediatric groups. The available data on the incidence of rPSC in children and its risk factors are limited by small patient numbers and relatively short follow-up. Among pediatric patients, 0% to 33% have been described as having rPSC in the graft.4-6,9 (Table 1). The diagnosis of rPSC is made on the basis of histological and cholangiographic findings. However, similar features can be seen as a result of hepatic artery thrombosis, an ABO-incompatible allograft, chronic rejection, preservation injury, and a prolonged cold ischemia time. As such, the diagnostic criteria for rPSC include the confirmation of the pretransplant diagnosis of PSC and the careful exclusion of other potential injuries to the graft.10 The confirmation of the pretransplant diagnosis of PSC is particularly important for children, for whom other diseases (eg, immunodeficiency, cystic fibrosis, and Langerhans cell histiocytosis) can secondarily result in radiographic and histological features of sclerosing cholangitis but with very different outcomes. Our aims were to review our single-center experience with pediatric patients undergoing transplantation for a diagnosis of PSC, to describe their clinical features in detail, and to identify potential risk factors for our patients with PSC recurrence. United Network for Organ Sharing (UNOS)/Scientific Registry of Transplant Recipients (SRTR) data for patients with PSC were assessed to make comparisons and to gain perspective on a national scale.
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AIH Overlap/
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hepatitis (AIH; autoimmune sclerosing cholangitis) were excluded from this study. All posttransplant biopsy samples were reviewed for evidence of complications, including acute cellular rejection (ACR), hepatitis, and chronic rejection, and were evaluated for the recurrence of PSC. A diagnosis of rPSC was made on the basis of MRCP/ ERCP findings, histology, or both. The histological features used to diagnose recurrence included a predominantly biliary pathology with evidence of periductal edema and/or fibrosis in the absence of known biliary strictures due to vascular/surgical complications, ductular proliferation, cholangitis with intraepithelial neutrophils, and/or ductopenia in the presence of ductular proliferation. In patients with evidence of hepatic artery thrombosis, anastomotic strictures, or changes of chronic rejection, a diagnosis of primary disease recurrence was not made because of the overlapping histology of these complications. Clinical data for patients with documentation of rPSC were reviewed to ensure that the published criteria for a diagnosis of rPSC were met.10 ACR and chronic rejection were diagnosed with the Banff criteria.11,12 UNOS/SRTR data from September 30, 1987 to December 31, 2012 were reviewed for the patient and graft outcomes of patients undergoing transplantation for PSC. Comparisons of variables between groups were calculated with Fisher’s exact test. A P value of 0.05 was considered statistically significant. Survival outcomes were evaluated with Kaplan-Meier analyses. Statistical analyses were performed with SPSS 21 (IBM SPSS Statistics).
RESULTS Twelve patients underwent liver transplantation for PSC at the Children’s Hospital of Pittsburgh (University of Pittsburgh Medical Center) between 1993 and 2012. Sixty-seven percent were female. Among the patients undergoing isolated liver transplantation during this time frame, 2.2% (12/554) underwent transplantation for a diagnosis of PSC. The patient follow-up ranged from 1.25 to 8 years. Four patients were diagnosed with rPSC on the basis of histopathological findings. Three patients had coinciding findings on imaging: 2 on MRCP and/or ERCP and 1 with intrahepatic bile duct dilation on ultrasound. The histological features that were evaluated for the diagnosis of rPSC included portal edema with a mixed inflammatory infiltrate with neutrophils around and within bile ducts and the presence of concentric inflammation in the early stages and fibrosis in the later stages of the disease (Fig. 1). Plasma cells were present and were helpful for distinguishing between rPSC and other biliary complications. In the absence of plasma cells, the biliary changes overlapped with those seen in hepatic artery thrombosis and bile strictures/obstructive changes. There was no evidence of interface activity or pericentral venulitis at the time of
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the diagnosis of recurrence. A distinction from ACR could be made through the lack of biliary proliferation and the frequent presence of venulitis with lymphocyte-predominant injury to the ducts seen in ACR. Although progressive rPSC can lead to ductopenia, an assessment of sequential biopsy samples revealed accompanying cholangitis and ductular proliferation seen with a cytokeratin stain such as cytokeratin 7. This finding helped to differentiate this from chronic ductopenic rejection. Portal fibrosis, including bridging fibrosis, was a frequent accompaniment.
Pretransplant Clinical Characteristics The median age at the time of the initial presentation/diagnosis of PSC in the rPSC group was 5.5 years (range 5 3.9-15.3 years), whereas the median age was 10.9 years (range 5 3.9-15.3 years) for the group as a whole. Three of the 4 patients in the rPSC group were 7 years old or younger at the time of the initial pretransplant diagnosis of PSC. All patients included in this study had histological features of PSC confirmed by pretransplant biopsy and an evaluation of explants. Seven of the 12 patients (including 3 of the 4 patients with rPSC) had either MRCP or ERCP findings consistent with a pretransplant diagnosis of PSC. The remaining 5 patients were classified as having isolated small-duct disease before transplantation. Seven of the 12 patients had inflammatory bowel disease (IBD) before transplantation. Two patients were diagnosed with IBD after transplantation. All of the patients with recurrence had a diagnosis of IBD: 2 before transplantation and 2 after transplantation. One patient with rPSC received an immunomodulator for the treatment of IBD before transplantation. Only 1 patient underwent colectomy after the posttransplant development of fulminant colitis. Six of the 12 patients were anti-nuclear antibody– positive, and 1 patient (who developed rPSC) was smooth muscle actin–positive. Two of the 3 patients with rPSC were anti-nuclear antibody–positive. Serum total immunoglobulin G levels and immunoglobulin G4 levels were not available for the majority of the patients. No patient had evidence of features overlapping with AIH on available pretransplant or explant pathology.
Posttransplant Clinical Characteristics The median interval from the diagnosis of PSC to transplantation was 44.5 months (range 5 1-124 months) in this cohort, and there was no clear trend for the patients with rPSC versus those without rPSC. Patients received tacrolimus for maintenance immunosuppression either with steroids (n 5 6) or as a steroidfree regimen with thymoglobulin induction (n 5 6). After transplantation, 9 of the 12 patients received either azathioprine or mercaptopurine, and all 12 patients received ursodiol. Nine of 11 patients were
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Figure 1. (A) A trichrome stain of the original explanted liver shows peribiliary concentric fibrosis around a larger bile duct consistent with PSC (Masson’s trichrome, 3200). (B) An allograft biopsy image shows portal edema with a peribiliary concentric fibroinflammatory process consistent with recurrence in the allograft (hematoxylin and eosin, 3100). (C) A trichrome stain highlights the peribiliary concentric edema and loose fibrosis with interspersed inflammatory cells in this allograft biopsy sample (Masson’s trichrome, 3200). (D) A trichrome stain of the resected allograft shows peribiliary concentric fibrosis and a fibro-inflammatory process in the hilar region in this case of PSC recurrence in the allograft (Masson’s trichrome, 3100).
cytomegalovirus (CMV)-negative at the time of transplantation, 7 of 11 were treated for a CMV infection after transplantation, 4 of 11 were Epstein-Barr virus (EBV)–negative at the time of transplantation, 10 of 12 were diagnosed with early rejection, 4 of 10 were diagnosed with late rejection, 9 of 11 had IBD either before or after transplantation, 4 of 10 recipients and 2 of 10 donors were human leukocyte antigen B8 (HLA-B8)– positive, and 2 of 10 recipients were HLA-DR3/DQ2– positive (Table 2). Data were not available on some patients. Three patients were diagnosed with rPSC 62, 44, and 60 months after transplantation. A fourth patient underwent retransplantation for graft failure with features of both hepatic artery thrombosis and rPSC. Within the first 6 months after retransplantation, this patient had distinct histological features of rPSC in the second graft. A more detailed description of each rPSC case follows.
histology. He was referred to the transplant program at Children’s Hospital of Pittsburgh and underwent deceased donor liver transplantation 1 month later. He received steroid-free thymoglobulin induction and tacrolimus. He was diagnosed and treated with steroids for ACR 3 times within the first 3 months after transplantation. His rejection was responsive to steroids. He also received treatment with ganciclovir for CMV viremia. He presented with weight loss at 18 years of age, was subsequently diagnosed with ulcerative colitis, and was started on oral mesalamine as maintenance therapy. He had abnormal hepatic panel findings at the age of 20 years, and this led to a diagnosis of rPSC based on liver biopsy, MRCP, and ERCP findings. He was prescribed ursodiol at that time. He received 2 courses of steroids for flaring of ulcerative colitis at the ages of 20 and 23 years. He experienced disease progression in the graft and subsequently underwent retransplantation at the age of 24 years (9 years after his first transplant).
Case 1 The patient presented to his pediatrician at 15.3 years of age with nausea, vomiting, and jaundice. He was subsequently diagnosed with PSC on the basis of ERCP and
Case 2 The patient presented to his pediatrician at 7.0 years of age with abdominal pain and an abnormal hepatic
Yes
No Yes Yes Yes
Yes Yes Yes
No/Yes
profile. He was diagnosed with PSC on the basis of histology. His ERCP findings at diagnosis were normal. He subsequently underwent MRCP and repeat ERCP approximately 2 years later. These studies showed irregular intrahepatic ducts and narrowing of the common bile duct that required stent placement. He was referred to our transplant program and underwent deceased donor transplantation at 11.5 years of age. He received a steroid-free thymoglobulin induction regimen and tacrolimus for immunosuppression. He had findings of EBV viremia and EBV enteritis requiring a reduction in immunosuppression. He did not have any episodes of rejection in the first year after transplantation. At 12 years of age, he was diagnosed with ulcerative colitis and was treated with azathioprine. He was prescribed ursodiol at 13 years of age for an elevation of his gamma-glutamyltransferase level. No biopsy was performed at this time. He underwent biopsy for an abnormal hepatic profile (alanine aminotransferase and gamma-glutamyltransferase) at 15 years of age, and this showed rPSC. Because of concomitant findings of ACR, he received steroids, from which he was weaned over the course of 3 months. At 16 years of age, he had intrahepatic duct dilation on ultrasound. He did not undergo repeat liver biopsy as per his family’s preference.
15.9 15.7 13.0 14.5 15.5 13.8 13.3 10.2 8 9 10 11 12
Case 3
*Infection (EBV/CMV) treated after transplantation.
Steroid Steroid Thymoglobulin Steroid Steroid
Steroid Steroid 14.3 16.1 11.6 8.5 6 7
5
14.3
15.4 11.5 14.2 9.6 13.4 19.0
62 44 60 21 4
Thymoglobulin Thymoglobulin Thymoglobulin Thymoglobulin Steroid Thymoglobulin
Tacrolimus Azathioprine Tacrolimus Azathioprine Tacrolimus Azathioprine Tacrolimus 6-Mercaptopurine Tacrolimus 6-Mercaptopurine Tacrolimus/ Azathioprine rapamycin Tacrolimus Azathioprine Tacrolimus/ Azathioprine rapamycin Tacrolimus Azathioprine Tacrolimus Mycophenolate Tacrolimus Mycophenolate Tacrolimus Azathioprine Tacrolimus
Yes
Yes Yes Yes Yes Yes Yes No No
No No Yes No No
No/Yes No/Yes No No No No Yes No Yes No
Yes No
Yes/No Yes/No
No/Yes
Yes No Yes No Yes No No Yes No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes
No No Yes No Yes No
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15.3 7.0 3.9 4.0 1 2 3 4
Induction Immunosuppression
HLA Age at Months to Age at
rPSC Patient Diagnosis Transplant Number (Years) (Years) Diagnosis
TABLE 2. Clinical Features of Children Undergoing Transplantation for PSC
Third Early Late (B8 or DR3/DQ2): Agent IBD Rejection Rejection EBV* CMV* Donor/Recipient
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The patient was diagnosed with ulcerative colitis at 2 years of age. She was noted to have an abnormal liver profile, and a diagnosis of PSC was made on the basis of liver biopsy. A second pretransplant biopsy sample showed findings of PSC as well. Pretransplant ultrasound showed intrahepatic duct dilation. She developed ascites and varices and underwent living related liver transplantation at 14.2 years of age. She received steroid-free thymoglobulin induction and tacrolimus for immunosuppression. She was diagnosed with CMV viremia soon after transplantation and was treated with ganciclovir. She was also diagnosed and treated with steroids for 2 episodes of early rejection and 1 episode of late rejection. She developed fulminant colitis in the first year after transplantation and underwent colectomy. She continued to receive azathioprine for pouchitis and ileitis after her colectomy. She received ursodiol as well. She had features of recurrence on biopsy 5 years after transplantation.
Case 4 The patient was diagnosed with ulcerative colitis at 3 years of age after she had presented with diarrhea and bloody stools. At 4.0 years of age, she was diagnosed with PSC after liver biopsy and subsequent ERCP. She received 6-mercaptopurine for the treatment of her IBD and ursodiol for the treatment of her PSC before transplantation. These medications
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TABLE 3. UNOS/SRTR Baseline Data for Pediatric Patients With PSC: September 30, 1987 to December 31,
years. The use of living donor grafts was significantly higher in the pediatric population versus the adult population (10.6% versus 7.4%, P 5 0.03).
2012 Patients [n (%)] Sex: female [n (%)] Race [n (%)] White Black Hispanic Other Age at transplant (years) Mean 6 standard deviation Median (range) Donor type [n (%)] Deceased Living Retransplantation [n (%)]
339 128 (37.8) 238 (70.2) 55 (16.2) 28 (8.3) 18 (5.3) 14.4 6 5.2 16 (0-20) 363/406 43/406 101/406
were continued after transplantation. She underwent liver transplantation at 9.6 years of age. She received a steroid-free thymoglobulin induction regimen and tacrolimus. Her postoperative course was complicated by evidence of hepatic artery stenosis 3 months after transplantation and ACR. She was also treated for EBV hepatitis. Liver biopsies over the course of 3 years showed overlapping features of hepatic artery stenosis and rPSC, so a definitive diagnosis of rPSC could not be made, but it was suggested as a possibility. She underwent a second liver transplant at 13.4 years of age with steroids and tacrolimus. She continued to receive 6-mercaptopurine for her colitis, which was quiescent throughout much of her clinical course. Her immediate postoperative course after retransplantation was complicated by CMV hepatitis and EBV hepatitis. Biopsies within 4 months of her retransplantation showed evidence of rPSC in the second graft.
UNOS/SRTR Data Data from UNOS/SRTR for the period of September 30, 1987 to December 31, 2012 were obtained for both primary liver transplantation and retransplantation. Patients < 20 years of age were considered in the pediatric group. The baseline demographic data and clinical features are summarized in Table 3. The male/female distribution was 211/128 (62.2% were male). The 1-, 5-, and 10-year patient survival rates for this group were 94.4%, 88.2%, and 79.2%, respectively. The graft survival rates at 1, 5, and 10 years were 83.2%, 71.2%, and 55%, respectively. There was a significantly higher frequency of retransplantation (P < 0.001) for patients undergoing transplantation for the indication of PSC (101/406 or 24.9%) versus patients undergoing transplantation for biliary atresia (854/5060 or 16.9%), which is the most common indication for transplantation in children. The mean time to retransplantation for the PSC group was 4.1
DISCUSSION Twelve patients underwent liver transplantation for PSC between 1993 and 2012 at our center. Four of the 12 patients (33%) were diagnosed with disease recurrence in the allograft, and the median time to diagnosis was 52 months (range 5 4-62 months). The incidence of rPSC in our population fell within the ranges reported for series of adult patients (10%-55%) and pediatric patients (10%-33%).4-6,9,13-20 The median time to recurrence in the largest series of adult patients (n 5 230) was 55.2 months (range 5 6155 months), and this was similar to our findings.13 Recurrence was observed only in our patients who received thymoglobulin induction and steroid-free tacrolimus. This experience suggests that indiscriminate lymphocyte depletion by thymoglobulin, steroid avoidance, or both can contribute to recurrence. This finding supports results of previous studies in which steroid-resistant rejection and treatment with OKT3 or thymoglobulin were associated with recurrence.14,15,17 The short-term depletion of T cytotoxic cells with thymoglobulin, previously reported for our pediatric liver transplant population, may be useful in preventing early rejection. However, the accompanying depletion of CD4-positive T cells, which include CD4positive/CD25-positive/FOXP3–positive T regulatory cells, can last for several years and may contribute to unchecked antigraft cytotoxicity.21 The recurrence of PSC after transplantation in patients receiving a potent T cell–depleting agent further supports the need to evaluate the potential role of T regulatory cells in rPSC. The impact of steroids on rPSC has been inconsistently reported. Kugelmas et al.17 reported no difference in the frequency of recurrence with long-term steroid use. Steroid use for >3 months was described as predisposing to rPSC by Cholongitas et al.,16 and Brandsaeter et al.15 reported the use of low-dose maintenance steroids as their standard of care for all patients against a background of assessment of other risk factors. The association with excessive steroids could lead to the general conclusion that excessive immunosuppression, rather than T cell–depleting immunosuppression, is a risk factor; this highlights the limitations and sometimes inconsistent reporting of risk factors of recurrence. Mechanistic studies are needed to address these hypotheses. A majority of the patients (10/12) had evidence of ACR in the early posttransplant period, and 3 of these patients developed classic features of rPSC over time. One patient without an episode of histologically proven ACR developed rPSC. We infer from our series that the early occurrence of ACR does not influence recurrence. Similarly, although an association between rPSC and ACR has been suggested in some studies, the data presented for ACR as a risk factor
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are not robust, and they are found in univariate analyses only.14,16 It is also striking that 3 of the 4 patients with recurrence in our pediatric cohort were 7 years old or younger at the diagnosis of PSC. Two of these patients were approximately 4 years of age at the diagnosis of PSC. Secondary sclerosing cholangitis is a finding seen in children with immunodeficiency states. Although none of our patients exhibited signs or symptoms of immunodeficiency such as unusual or frequent infections before transplantation, the younger age at the diagnosis of PSC and the subsequent recurrence of disease could suggest a genetic predisposition, a congenital immune deficiency, or dysregulation. Autoantibody positivity is well recognized in patients with PSC, and we observed this in our cohort as well. Although the etiology of PSC and the reasons that PSC recurs in the allograft are not known, it is often considered an autoimmune disease on the basis of the presence of autoantibodies, the associations with autoimmune genetic loci, and the association with other immune-mediated diseases such as IBD. In comparison with other autoimmune processes, PSC paradoxically does not respond to immunosuppression. We were, however, careful to exclude patients with features of autoimmune sclerosing cholangitis because it may have a different clinical course both before and after transplantation.22 As in other pediatric and adult PSC series, the majority of our patients had a concomitant diagnosis of IBD. The only other pediatric series that has attempted to define risk factors for recurrence is the multicenter Studies of Pediatric Liver Transplantation (SPLIT) registry. As part of the analysis of transplant outcomes for patients with PSC, a survey instrument was used to capture data on rPSC. The diagnosis of IBD was associated with rPSC in this analysis.9 In series of adult patients, colectomy (when clinically indicated) before transplantation is suggested to be protective; however, the presence of IBD by itself has not been reported to be a significant risk factor for recurrence.13,16,17 In general, the proportion of patients undergoing liver transplantation with PSC as the indication at our institution (2.2%) is comparable to national data (UNOS/SRTR, 2.7%; SPLIT registry, 2.6%). As in adults, PSC in children is a male-predominant disease, with an average male-to-female ratio of 3:2 being described.4,5,7,9 In these pediatric series, the age at diagnosis and the age at transplant are in the second decade of life or later for the majority of patients.7,9 The pattern of referral to our center may have influenced the female sex predominance in our cohort, and this makes it difficult to compare the demographic and clinical variables of our local PSC patients. We found a significantly increased frequency of retransplantation in pediatric patients with PSC versus those with biliary atresia according to UNOS/ SRTR data. Only a small number of patients in the
VENKAT ET AL. 685
PSC group had data available for the reason for graft loss and/or the indication for retransplantation, and this precluded any further analysis of this group. In addition to medical and surgical complications, nonadherence to the medical regimen may be a factor in graft loss/retransplantation. The mean age at transplantation according to UNOS/SRTR data was 14.4 6 5.2 years. In our cohort, the median age at transplantation was 14.5 years (range 5 9.6-19.0 years). The impact of nonadherence on this largely adolescent population is difficult to quantify. The use of living donor grafts was also significantly higher in the pediatric population versus adults according to UNOS/SRTR data (10.6% versus 7.4%, P 5 0.03). Two of our 12 patients received a graft from a living donor. Our single-center study cohort is small and highlights the rarity of this indication for transplantation in children. As a result, our conclusions are speculative. Capturing the natural history of rPSC in children with standardized documentation of inclusion and exclusion criteria is needed to minimize complications in this patient population and to assess the long-term outcomes of pediatric patients undergoing transplantation for PSC. Our observation of an association between thymoglobulin use, a young age at presentation with PSC (diagnosis in the first decade), and rPSC adds to the existing suggestion of a link between the immune environment and the pathogenesis of rPSC. On the basis of our experience, steroid induction and tacrolimus maintenance are now our standard immunosuppression regimen for children undergoing liver transplantation for PSC. rPSC develops insidiously and may lead to morbidity and allograft failure well outside the 1- and 5-year posttransplant periods. The definition of the phenotype of PSC in pediatric patients < 10 years of age at the initial diagnosis, the effects of thymoglobulin-induced T cell depletion, and the role of regulatory T cells in PSC warrant further study.
REFERENCES 1. Kaplan GG, Laupland KB, Butzner D, Urbanski SJ, Lee SS. The burden of large and small duct primary sclerosing cholangitis in adults and children: a populationbased analysis. Am J Gastroenterol 2007;102:10421049. 2. Bambha K, Kim WR, Talwalkar J, Torgerson H, Benson JT, Therneau TM, et al. Incidence, clinical spectrum, and outcomes of primary sclerosing cholangitis in a United States community. Gastroenterology 2003;125:13641369. € f L, Bodemar G, Hultcrantz R, 3. Broom e U, Olsson R, L€ oo Danielsson A, et al. Natural history and prognostic factors in 305 Swedish patients with primary sclerosing cholangitis. Gut 1996;38:610-615. 4. Batres LA, Russo P, Mathews M, Piccoli DA, Chuang E, Ruchelli E. Primary sclerosing cholangitis in children: a histologic follow-up study. Pediatr Dev Pathol 2005;8: 568-576. 5. Feldstein AE, Perrault J, El-Youssif M, Lindor KD, Freese DK, Angulo P. Primary sclerosing cholangitis in children: a long-term follow-up study. Hepatology 2003;38:210217.
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6. Miloh T, Arnon R, Shneider B, Suchy F, Kerkar N. A retrospective single-center review of primary sclerosing cholangitis in children. Clin Gastroenterol Hepatol 2009;7: 239-245. 7. Wilschanski M, Chait P, Wade JA, Davis L, Corey M, St Louis P, et al. Primary sclerosing cholangitis in 32 children: clinical, laboratory, and radiographic features, with survival analysis. Hepatology 1995;22:1415-1422. 8. Debray D, Pariente D, Urvoas E, Hadchouel M, Bernard O. Sclerosing cholangitis in children. J Pediatr 1994;124: 49-56. 9. Miloh T, Anand R, Yin W, Vos M, Kerkar N, Alonso E; for Studies of Pediatric Liver Transplantation Research Group. Pediatric liver transplantation for primary sclerosing cholangitis. Liver Transpl 2011;17:925-933. 10. Graziadei IW. Recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2002;8:575-581. 11. Demetris A, Adams D, Bellamy C, Blakolmer K, Clouston A, Dhillon AP, et al. Update of the international Banff schema for liver allograft rejection: working recommendations for the histopathologic staging and reporting of chronic rejection. An international panel. Hepatology 2000;31:792-799. 12. Banff schema for grading liver allograft rejection: an international consensus document. Hepatology 1997;25: 658-663. 13. Alabraba E, Nightingale P, Gunson B, Hubscher S, Olliff S, Mirza D, Neuberger J. A re-evaluation of the risk factors for the recurrence of primary sclerosing cholangitis in liver allografts. Liver Transpl 2009;15:330-340. 14. Alexander J, Lord JD, Yeh MM, Cuevas C, Bakthavatsalam R, Kowdley KV. Risk factors for recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2008;14:245-251.
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15. Brandsaeter B, Schrumpf E, Bentdal O, Brabrand K, Smith HJ, Abildgaard A, et al. Recurrent primary sclerosing cholangitis after liver transplantation: a magnetic resonance cholangiography study with analyses of predictive factors. Liver Transpl 2005;11:1361-1369. 16. Cholongitas E, Shusang V, Papatheodoridis GV, Marelli L, Manousou P, Rolando N, et al. Risk factors for recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2008;14:138-143. 17. Kugelmas M, Spiegelman P, Osgood MJ, Young DA, Trotter JF, Steinberg T, et al. Different immunosuppressive regimens and recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2003;9: 727-732. 18. Khettry U, Keaveny A, Goldar-Najafi A, Lewis WD, Pomfret EA, Pomposelli JJ, et al. Liver transplantation for primary sclerosing cholangitis: a long-term clinicopathologic study. Hum Pathol 2003;34:1127-1136. 19. Egawa H, Ueda Y, Ichida T, Teramukai S, Nakanuma Y, Onishi S, Tsubouchi H. Risk factors for recurrence of primary sclerosing cholangitis after living donor liver transplantation in Japanese registry. Am J Transplant 2011; 11:518-527. 20. Campsen J, Zimmerman MA, Trotter JF, Wachs M, Bak T, Steinberg T, Kam I. Clinically recurrent primary sclerosing cholangitis following liver transplantation: a time course. Liver Transpl 2008;14:181-185. 21. Talukdar A, AshokKumar C, Farrar J, Wilson P, Janakiramanan A, Tregaskes M, Sindhi R. Lymphocyte subset reconstitution in pediatric liver recipients induced with steroid-free rabbit anti-human thymocyte globulin. Pediatr Transplant 2008;12:804-808. 22. Mieli-Vergani G, Vergani D. Paediatric autoimmune liver disease. Arch Dis Child 2013;98:1012-1017.
ORIGINAL ARTICLE
Recurrence of Primary Sclerosing Cholangitis in Pediatric Liver Transplant Recipients Veena L. Venkat,1 Sarangarajan Ranganathan,2 George V. Mazariegos,3 Qing Sun,3 and Rakesh Sindhi3 1 Division of Pediatric Gastroenterology, Hepatology, and Nutrition, 2Division of Pediatric Pathology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA; and 3Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
There is little detailed clinical information on recurrent primary sclerosing cholangitis (rPSC) after liver transplantation in children. Our purpose was to describe the characteristics of children who had experienced rPSC after liver transplantation so that we could identify potential risk factors for recurrence. Clinical information for pediatric patients undergoing transplantation for primary sclerosing cholangitis (PSC) was retrospectively reviewed, and variables related to the pretransplant diagnosis of PSC and posttransplant variables were abstracted. The studied variables included the following: cytomegalovirus/ Epstein-Barr virus status, early/late rejection, induction regimen, immunosuppression in the first year, steroid-resistant rejection, diagnosis of inflammatory bowel disease, and human leukocyte antigen markers commonly associated with PSC. A diagnosis of rPSC was made on the basis of radiographic features, histology, or both. Twelve patients underwent liver transplantation for PSC between 1993 and 2012. Patients received tacrolimus for maintenance immunosuppression after induction with steroids (n 5 6) or thymoglobulin (n 5 6). Three patients were diagnosed with rPSC 44, 60, and 62 months after transplantation. A fourth patient underwent retransplantation for graft failure with features of both hepatic artery stenosis and rPSC. This patient had distinct histological features of rPSC in the second graft. Three of the 4 patients were 7 years old or younger at the diagnosis of PSC. The patient and graft survival rates were similar for the steroid and thymoglobulin groups. All 4 children with rPSC received steroid-free thymoglobulin induction. In conclusion, our observation of an association between thymoglobulin, and age less than 10 years at the diagnosis of PSC, and rPSC adds to the existing suggestion of a link between the immune environment and the pathogenesis of rPSC. Defining the natural history of rPSC and searching for the etiology and risk factors of rPSC are important for the long-term outcomes of pediatric patients. Liver Transpl C 2014 AASLD. 20:679-686, 2014. V Received November 21, 2013; accepted March 9, 2014.
Abbreviations: ACR, acute cellular rejection; AIH, autoimmune hepatitis; CMV, cytomegalovirus; EBV, Epstein-Barr virus; ERCP, endoscopic retrograde cholangiopancreatography; HLA, human leukocyte antigen; IBD, inflammatory bowel disease; MRCP, magnetic resonance cholangiopancreatography; PSC, primary sclerosing cholangitis; rPSC, recurrent primary sclerosing cholangitis; SPLIT, Studies of Pediatric Liver Transplantation; SRTR, Scientific Registry of Transplant Recipients; UNOS, United Network for Organ Sharing. There were no grants or financial support associated with this study. The authors have no conflicts of interest to declare. This work was supported in part by the Health Resources and Services Administration (contract 234-2005-37011C). The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. Address reprint requests to Veena L. Venkat, M.D., Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224. Telephone: 412-692-5180; FAX: 412-692-7355; E-mail: [email protected] DOI 10.1002/lt.23868 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
25
28 35
7 (21.9) 11 (21) 9 (45) 9 (19.1) 61
18
32 52 20 47
Debray et al.8 (1994)‡
Wilschanski et al.7 (1995) Feldstein et al.5 (2003) Batres et al.4 (2005) Miloh et al.6 (2009) Miloh et al.9 (2011)
After institutional review board approval, clinical information for pediatric patients undergoing transplantation for PSC at the Children’s Hospital of Pittsburgh (University of Pittsburgh Medical Center) between 1993 and 2012 was retrospectively reviewed, and variables related to the pretransplant diagnosis of PSC and posttransplant variables were extracted. Histopathology was reviewed by a single pathologist (S.R.). A pretransplant diagnosis of PSC was confirmed with a review of laboratory studies and magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) reports and with a review of pretransplant biopsy and explant histology findings. Patients with overlapping features of PSC and autoimmune
Study (Year)
PATIENTS AND METHODS
*The data are presented as means and standard deviations. † The data are presented as medians and ranges. ‡ Total after the exclusion of patients with histiocytosis, immunodeficiency, and with a neonatal diagnosis that resolved spontaneously. n/a is not applicable or not reported.
18.7 6 13.8*
n/a No No No IBD n/a 40 (24–72)† 29 (192101)†
n/a (27) (33) (11) (10) 3/11 3/9 1/9 6/61
11 n/a n/a 0/5 (0)
3.5 6 3.3 (PSC)* 10.3 6 2.7 (PSC with IBD or AIH)* 13 (0.5-18)† 13.8 6 4.2* 14 (1.5-19.6)† 9.33 6 4.8 — (0.1-15)† 11 6 4.9* 12 (2-20)† 5 (27.8)
Features (%) Proposed for rPSC
Risk Factor Time From
Transplant to rPSC Diagnosis (Months) Patients With rPSC [n/N (%)] Recipients [n (%)] With PSC (n)
Age at PSC Diagnosis (Years) Liver
Transplant
Total
Patients
TABLE 1. Previously Published Studies of PSC in Children
Primary sclerosing cholangitis (PSC) is a chronic and progressive cholestatic liver disease. The incidence in children is 0.23/100,000 person-years, which is approximately 20% of the incidence reported for adults.1 The estimated 10-year survival rate for adults is 65%, with the endpoint of death or transplantation reached within 12 years of the diagnosis.2,3 According to available natural history studies in pediatrics, 19% to 45% of these children undergo liver transplantation with a median (50%) transplant-free survival time of 12.7 years.4-8 Recurrent primary sclerosing cholangitis (rPSC) in the graft has been reported by few pediatric groups. The available data on the incidence of rPSC in children and its risk factors are limited by small patient numbers and relatively short follow-up. Among pediatric patients, 0% to 33% have been described as having rPSC in the graft.4-6,9 (Table 1). The diagnosis of rPSC is made on the basis of histological and cholangiographic findings. However, similar features can be seen as a result of hepatic artery thrombosis, an ABO-incompatible allograft, chronic rejection, preservation injury, and a prolonged cold ischemia time. As such, the diagnostic criteria for rPSC include the confirmation of the pretransplant diagnosis of PSC and the careful exclusion of other potential injuries to the graft.10 The confirmation of the pretransplant diagnosis of PSC is particularly important for children, for whom other diseases (eg, immunodeficiency, cystic fibrosis, and Langerhans cell histiocytosis) can secondarily result in radiographic and histological features of sclerosing cholangitis but with very different outcomes. Our aims were to review our single-center experience with pediatric patients undergoing transplantation for a diagnosis of PSC, to describe their clinical features in detail, and to identify potential risk factors for our patients with PSC recurrence. United Network for Organ Sharing (UNOS)/Scientific Registry of Transplant Recipients (SRTR) data for patients with PSC were assessed to make comparisons and to gain perspective on a national scale.
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AIH Overlap/
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hepatitis (AIH; autoimmune sclerosing cholangitis) were excluded from this study. All posttransplant biopsy samples were reviewed for evidence of complications, including acute cellular rejection (ACR), hepatitis, and chronic rejection, and were evaluated for the recurrence of PSC. A diagnosis of rPSC was made on the basis of MRCP/ ERCP findings, histology, or both. The histological features used to diagnose recurrence included a predominantly biliary pathology with evidence of periductal edema and/or fibrosis in the absence of known biliary strictures due to vascular/surgical complications, ductular proliferation, cholangitis with intraepithelial neutrophils, and/or ductopenia in the presence of ductular proliferation. In patients with evidence of hepatic artery thrombosis, anastomotic strictures, or changes of chronic rejection, a diagnosis of primary disease recurrence was not made because of the overlapping histology of these complications. Clinical data for patients with documentation of rPSC were reviewed to ensure that the published criteria for a diagnosis of rPSC were met.10 ACR and chronic rejection were diagnosed with the Banff criteria.11,12 UNOS/SRTR data from September 30, 1987 to December 31, 2012 were reviewed for the patient and graft outcomes of patients undergoing transplantation for PSC. Comparisons of variables between groups were calculated with Fisher’s exact test. A P value of 0.05 was considered statistically significant. Survival outcomes were evaluated with Kaplan-Meier analyses. Statistical analyses were performed with SPSS 21 (IBM SPSS Statistics).
RESULTS Twelve patients underwent liver transplantation for PSC at the Children’s Hospital of Pittsburgh (University of Pittsburgh Medical Center) between 1993 and 2012. Sixty-seven percent were female. Among the patients undergoing isolated liver transplantation during this time frame, 2.2% (12/554) underwent transplantation for a diagnosis of PSC. The patient follow-up ranged from 1.25 to 8 years. Four patients were diagnosed with rPSC on the basis of histopathological findings. Three patients had coinciding findings on imaging: 2 on MRCP and/or ERCP and 1 with intrahepatic bile duct dilation on ultrasound. The histological features that were evaluated for the diagnosis of rPSC included portal edema with a mixed inflammatory infiltrate with neutrophils around and within bile ducts and the presence of concentric inflammation in the early stages and fibrosis in the later stages of the disease (Fig. 1). Plasma cells were present and were helpful for distinguishing between rPSC and other biliary complications. In the absence of plasma cells, the biliary changes overlapped with those seen in hepatic artery thrombosis and bile strictures/obstructive changes. There was no evidence of interface activity or pericentral venulitis at the time of
VENKAT ET AL. 681
the diagnosis of recurrence. A distinction from ACR could be made through the lack of biliary proliferation and the frequent presence of venulitis with lymphocyte-predominant injury to the ducts seen in ACR. Although progressive rPSC can lead to ductopenia, an assessment of sequential biopsy samples revealed accompanying cholangitis and ductular proliferation seen with a cytokeratin stain such as cytokeratin 7. This finding helped to differentiate this from chronic ductopenic rejection. Portal fibrosis, including bridging fibrosis, was a frequent accompaniment.
Pretransplant Clinical Characteristics The median age at the time of the initial presentation/diagnosis of PSC in the rPSC group was 5.5 years (range 5 3.9-15.3 years), whereas the median age was 10.9 years (range 5 3.9-15.3 years) for the group as a whole. Three of the 4 patients in the rPSC group were 7 years old or younger at the time of the initial pretransplant diagnosis of PSC. All patients included in this study had histological features of PSC confirmed by pretransplant biopsy and an evaluation of explants. Seven of the 12 patients (including 3 of the 4 patients with rPSC) had either MRCP or ERCP findings consistent with a pretransplant diagnosis of PSC. The remaining 5 patients were classified as having isolated small-duct disease before transplantation. Seven of the 12 patients had inflammatory bowel disease (IBD) before transplantation. Two patients were diagnosed with IBD after transplantation. All of the patients with recurrence had a diagnosis of IBD: 2 before transplantation and 2 after transplantation. One patient with rPSC received an immunomodulator for the treatment of IBD before transplantation. Only 1 patient underwent colectomy after the posttransplant development of fulminant colitis. Six of the 12 patients were anti-nuclear antibody– positive, and 1 patient (who developed rPSC) was smooth muscle actin–positive. Two of the 3 patients with rPSC were anti-nuclear antibody–positive. Serum total immunoglobulin G levels and immunoglobulin G4 levels were not available for the majority of the patients. No patient had evidence of features overlapping with AIH on available pretransplant or explant pathology.
Posttransplant Clinical Characteristics The median interval from the diagnosis of PSC to transplantation was 44.5 months (range 5 1-124 months) in this cohort, and there was no clear trend for the patients with rPSC versus those without rPSC. Patients received tacrolimus for maintenance immunosuppression either with steroids (n 5 6) or as a steroidfree regimen with thymoglobulin induction (n 5 6). After transplantation, 9 of the 12 patients received either azathioprine or mercaptopurine, and all 12 patients received ursodiol. Nine of 11 patients were
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Figure 1. (A) A trichrome stain of the original explanted liver shows peribiliary concentric fibrosis around a larger bile duct consistent with PSC (Masson’s trichrome, 3200). (B) An allograft biopsy image shows portal edema with a peribiliary concentric fibroinflammatory process consistent with recurrence in the allograft (hematoxylin and eosin, 3100). (C) A trichrome stain highlights the peribiliary concentric edema and loose fibrosis with interspersed inflammatory cells in this allograft biopsy sample (Masson’s trichrome, 3200). (D) A trichrome stain of the resected allograft shows peribiliary concentric fibrosis and a fibro-inflammatory process in the hilar region in this case of PSC recurrence in the allograft (Masson’s trichrome, 3100).
cytomegalovirus (CMV)-negative at the time of transplantation, 7 of 11 were treated for a CMV infection after transplantation, 4 of 11 were Epstein-Barr virus (EBV)–negative at the time of transplantation, 10 of 12 were diagnosed with early rejection, 4 of 10 were diagnosed with late rejection, 9 of 11 had IBD either before or after transplantation, 4 of 10 recipients and 2 of 10 donors were human leukocyte antigen B8 (HLA-B8)– positive, and 2 of 10 recipients were HLA-DR3/DQ2– positive (Table 2). Data were not available on some patients. Three patients were diagnosed with rPSC 62, 44, and 60 months after transplantation. A fourth patient underwent retransplantation for graft failure with features of both hepatic artery thrombosis and rPSC. Within the first 6 months after retransplantation, this patient had distinct histological features of rPSC in the second graft. A more detailed description of each rPSC case follows.
histology. He was referred to the transplant program at Children’s Hospital of Pittsburgh and underwent deceased donor liver transplantation 1 month later. He received steroid-free thymoglobulin induction and tacrolimus. He was diagnosed and treated with steroids for ACR 3 times within the first 3 months after transplantation. His rejection was responsive to steroids. He also received treatment with ganciclovir for CMV viremia. He presented with weight loss at 18 years of age, was subsequently diagnosed with ulcerative colitis, and was started on oral mesalamine as maintenance therapy. He had abnormal hepatic panel findings at the age of 20 years, and this led to a diagnosis of rPSC based on liver biopsy, MRCP, and ERCP findings. He was prescribed ursodiol at that time. He received 2 courses of steroids for flaring of ulcerative colitis at the ages of 20 and 23 years. He experienced disease progression in the graft and subsequently underwent retransplantation at the age of 24 years (9 years after his first transplant).
Case 1 The patient presented to his pediatrician at 15.3 years of age with nausea, vomiting, and jaundice. He was subsequently diagnosed with PSC on the basis of ERCP and
Case 2 The patient presented to his pediatrician at 7.0 years of age with abdominal pain and an abnormal hepatic
Yes
No Yes Yes Yes
Yes Yes Yes
No/Yes
profile. He was diagnosed with PSC on the basis of histology. His ERCP findings at diagnosis were normal. He subsequently underwent MRCP and repeat ERCP approximately 2 years later. These studies showed irregular intrahepatic ducts and narrowing of the common bile duct that required stent placement. He was referred to our transplant program and underwent deceased donor transplantation at 11.5 years of age. He received a steroid-free thymoglobulin induction regimen and tacrolimus for immunosuppression. He had findings of EBV viremia and EBV enteritis requiring a reduction in immunosuppression. He did not have any episodes of rejection in the first year after transplantation. At 12 years of age, he was diagnosed with ulcerative colitis and was treated with azathioprine. He was prescribed ursodiol at 13 years of age for an elevation of his gamma-glutamyltransferase level. No biopsy was performed at this time. He underwent biopsy for an abnormal hepatic profile (alanine aminotransferase and gamma-glutamyltransferase) at 15 years of age, and this showed rPSC. Because of concomitant findings of ACR, he received steroids, from which he was weaned over the course of 3 months. At 16 years of age, he had intrahepatic duct dilation on ultrasound. He did not undergo repeat liver biopsy as per his family’s preference.
15.9 15.7 13.0 14.5 15.5 13.8 13.3 10.2 8 9 10 11 12
Case 3
*Infection (EBV/CMV) treated after transplantation.
Steroid Steroid Thymoglobulin Steroid Steroid
Steroid Steroid 14.3 16.1 11.6 8.5 6 7
5
14.3
15.4 11.5 14.2 9.6 13.4 19.0
62 44 60 21 4
Thymoglobulin Thymoglobulin Thymoglobulin Thymoglobulin Steroid Thymoglobulin
Tacrolimus Azathioprine Tacrolimus Azathioprine Tacrolimus Azathioprine Tacrolimus 6-Mercaptopurine Tacrolimus 6-Mercaptopurine Tacrolimus/ Azathioprine rapamycin Tacrolimus Azathioprine Tacrolimus/ Azathioprine rapamycin Tacrolimus Azathioprine Tacrolimus Mycophenolate Tacrolimus Mycophenolate Tacrolimus Azathioprine Tacrolimus
Yes
Yes Yes Yes Yes Yes Yes No No
No No Yes No No
No/Yes No/Yes No No No No Yes No Yes No
Yes No
Yes/No Yes/No
No/Yes
Yes No Yes No Yes No No Yes No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes
No No Yes No Yes No
VENKAT ET AL. 683
15.3 7.0 3.9 4.0 1 2 3 4
Induction Immunosuppression
HLA Age at Months to Age at
rPSC Patient Diagnosis Transplant Number (Years) (Years) Diagnosis
TABLE 2. Clinical Features of Children Undergoing Transplantation for PSC
Third Early Late (B8 or DR3/DQ2): Agent IBD Rejection Rejection EBV* CMV* Donor/Recipient
LIVER TRANSPLANTATION, Vol. 20, No. 6, 2014
The patient was diagnosed with ulcerative colitis at 2 years of age. She was noted to have an abnormal liver profile, and a diagnosis of PSC was made on the basis of liver biopsy. A second pretransplant biopsy sample showed findings of PSC as well. Pretransplant ultrasound showed intrahepatic duct dilation. She developed ascites and varices and underwent living related liver transplantation at 14.2 years of age. She received steroid-free thymoglobulin induction and tacrolimus for immunosuppression. She was diagnosed with CMV viremia soon after transplantation and was treated with ganciclovir. She was also diagnosed and treated with steroids for 2 episodes of early rejection and 1 episode of late rejection. She developed fulminant colitis in the first year after transplantation and underwent colectomy. She continued to receive azathioprine for pouchitis and ileitis after her colectomy. She received ursodiol as well. She had features of recurrence on biopsy 5 years after transplantation.
Case 4 The patient was diagnosed with ulcerative colitis at 3 years of age after she had presented with diarrhea and bloody stools. At 4.0 years of age, she was diagnosed with PSC after liver biopsy and subsequent ERCP. She received 6-mercaptopurine for the treatment of her IBD and ursodiol for the treatment of her PSC before transplantation. These medications
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TABLE 3. UNOS/SRTR Baseline Data for Pediatric Patients With PSC: September 30, 1987 to December 31,
years. The use of living donor grafts was significantly higher in the pediatric population versus the adult population (10.6% versus 7.4%, P 5 0.03).
2012 Patients [n (%)] Sex: female [n (%)] Race [n (%)] White Black Hispanic Other Age at transplant (years) Mean 6 standard deviation Median (range) Donor type [n (%)] Deceased Living Retransplantation [n (%)]
339 128 (37.8) 238 (70.2) 55 (16.2) 28 (8.3) 18 (5.3) 14.4 6 5.2 16 (0-20) 363/406 43/406 101/406
were continued after transplantation. She underwent liver transplantation at 9.6 years of age. She received a steroid-free thymoglobulin induction regimen and tacrolimus. Her postoperative course was complicated by evidence of hepatic artery stenosis 3 months after transplantation and ACR. She was also treated for EBV hepatitis. Liver biopsies over the course of 3 years showed overlapping features of hepatic artery stenosis and rPSC, so a definitive diagnosis of rPSC could not be made, but it was suggested as a possibility. She underwent a second liver transplant at 13.4 years of age with steroids and tacrolimus. She continued to receive 6-mercaptopurine for her colitis, which was quiescent throughout much of her clinical course. Her immediate postoperative course after retransplantation was complicated by CMV hepatitis and EBV hepatitis. Biopsies within 4 months of her retransplantation showed evidence of rPSC in the second graft.
UNOS/SRTR Data Data from UNOS/SRTR for the period of September 30, 1987 to December 31, 2012 were obtained for both primary liver transplantation and retransplantation. Patients < 20 years of age were considered in the pediatric group. The baseline demographic data and clinical features are summarized in Table 3. The male/female distribution was 211/128 (62.2% were male). The 1-, 5-, and 10-year patient survival rates for this group were 94.4%, 88.2%, and 79.2%, respectively. The graft survival rates at 1, 5, and 10 years were 83.2%, 71.2%, and 55%, respectively. There was a significantly higher frequency of retransplantation (P < 0.001) for patients undergoing transplantation for the indication of PSC (101/406 or 24.9%) versus patients undergoing transplantation for biliary atresia (854/5060 or 16.9%), which is the most common indication for transplantation in children. The mean time to retransplantation for the PSC group was 4.1
DISCUSSION Twelve patients underwent liver transplantation for PSC between 1993 and 2012 at our center. Four of the 12 patients (33%) were diagnosed with disease recurrence in the allograft, and the median time to diagnosis was 52 months (range 5 4-62 months). The incidence of rPSC in our population fell within the ranges reported for series of adult patients (10%-55%) and pediatric patients (10%-33%).4-6,9,13-20 The median time to recurrence in the largest series of adult patients (n 5 230) was 55.2 months (range 5 6155 months), and this was similar to our findings.13 Recurrence was observed only in our patients who received thymoglobulin induction and steroid-free tacrolimus. This experience suggests that indiscriminate lymphocyte depletion by thymoglobulin, steroid avoidance, or both can contribute to recurrence. This finding supports results of previous studies in which steroid-resistant rejection and treatment with OKT3 or thymoglobulin were associated with recurrence.14,15,17 The short-term depletion of T cytotoxic cells with thymoglobulin, previously reported for our pediatric liver transplant population, may be useful in preventing early rejection. However, the accompanying depletion of CD4-positive T cells, which include CD4positive/CD25-positive/FOXP3–positive T regulatory cells, can last for several years and may contribute to unchecked antigraft cytotoxicity.21 The recurrence of PSC after transplantation in patients receiving a potent T cell–depleting agent further supports the need to evaluate the potential role of T regulatory cells in rPSC. The impact of steroids on rPSC has been inconsistently reported. Kugelmas et al.17 reported no difference in the frequency of recurrence with long-term steroid use. Steroid use for >3 months was described as predisposing to rPSC by Cholongitas et al.,16 and Brandsaeter et al.15 reported the use of low-dose maintenance steroids as their standard of care for all patients against a background of assessment of other risk factors. The association with excessive steroids could lead to the general conclusion that excessive immunosuppression, rather than T cell–depleting immunosuppression, is a risk factor; this highlights the limitations and sometimes inconsistent reporting of risk factors of recurrence. Mechanistic studies are needed to address these hypotheses. A majority of the patients (10/12) had evidence of ACR in the early posttransplant period, and 3 of these patients developed classic features of rPSC over time. One patient without an episode of histologically proven ACR developed rPSC. We infer from our series that the early occurrence of ACR does not influence recurrence. Similarly, although an association between rPSC and ACR has been suggested in some studies, the data presented for ACR as a risk factor
LIVER TRANSPLANTATION, Vol. 20, No. 6, 2014
are not robust, and they are found in univariate analyses only.14,16 It is also striking that 3 of the 4 patients with recurrence in our pediatric cohort were 7 years old or younger at the diagnosis of PSC. Two of these patients were approximately 4 years of age at the diagnosis of PSC. Secondary sclerosing cholangitis is a finding seen in children with immunodeficiency states. Although none of our patients exhibited signs or symptoms of immunodeficiency such as unusual or frequent infections before transplantation, the younger age at the diagnosis of PSC and the subsequent recurrence of disease could suggest a genetic predisposition, a congenital immune deficiency, or dysregulation. Autoantibody positivity is well recognized in patients with PSC, and we observed this in our cohort as well. Although the etiology of PSC and the reasons that PSC recurs in the allograft are not known, it is often considered an autoimmune disease on the basis of the presence of autoantibodies, the associations with autoimmune genetic loci, and the association with other immune-mediated diseases such as IBD. In comparison with other autoimmune processes, PSC paradoxically does not respond to immunosuppression. We were, however, careful to exclude patients with features of autoimmune sclerosing cholangitis because it may have a different clinical course both before and after transplantation.22 As in other pediatric and adult PSC series, the majority of our patients had a concomitant diagnosis of IBD. The only other pediatric series that has attempted to define risk factors for recurrence is the multicenter Studies of Pediatric Liver Transplantation (SPLIT) registry. As part of the analysis of transplant outcomes for patients with PSC, a survey instrument was used to capture data on rPSC. The diagnosis of IBD was associated with rPSC in this analysis.9 In series of adult patients, colectomy (when clinically indicated) before transplantation is suggested to be protective; however, the presence of IBD by itself has not been reported to be a significant risk factor for recurrence.13,16,17 In general, the proportion of patients undergoing liver transplantation with PSC as the indication at our institution (2.2%) is comparable to national data (UNOS/SRTR, 2.7%; SPLIT registry, 2.6%). As in adults, PSC in children is a male-predominant disease, with an average male-to-female ratio of 3:2 being described.4,5,7,9 In these pediatric series, the age at diagnosis and the age at transplant are in the second decade of life or later for the majority of patients.7,9 The pattern of referral to our center may have influenced the female sex predominance in our cohort, and this makes it difficult to compare the demographic and clinical variables of our local PSC patients. We found a significantly increased frequency of retransplantation in pediatric patients with PSC versus those with biliary atresia according to UNOS/ SRTR data. Only a small number of patients in the
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PSC group had data available for the reason for graft loss and/or the indication for retransplantation, and this precluded any further analysis of this group. In addition to medical and surgical complications, nonadherence to the medical regimen may be a factor in graft loss/retransplantation. The mean age at transplantation according to UNOS/SRTR data was 14.4 6 5.2 years. In our cohort, the median age at transplantation was 14.5 years (range 5 9.6-19.0 years). The impact of nonadherence on this largely adolescent population is difficult to quantify. The use of living donor grafts was also significantly higher in the pediatric population versus adults according to UNOS/SRTR data (10.6% versus 7.4%, P 5 0.03). Two of our 12 patients received a graft from a living donor. Our single-center study cohort is small and highlights the rarity of this indication for transplantation in children. As a result, our conclusions are speculative. Capturing the natural history of rPSC in children with standardized documentation of inclusion and exclusion criteria is needed to minimize complications in this patient population and to assess the long-term outcomes of pediatric patients undergoing transplantation for PSC. Our observation of an association between thymoglobulin use, a young age at presentation with PSC (diagnosis in the first decade), and rPSC adds to the existing suggestion of a link between the immune environment and the pathogenesis of rPSC. On the basis of our experience, steroid induction and tacrolimus maintenance are now our standard immunosuppression regimen for children undergoing liver transplantation for PSC. rPSC develops insidiously and may lead to morbidity and allograft failure well outside the 1- and 5-year posttransplant periods. The definition of the phenotype of PSC in pediatric patients < 10 years of age at the initial diagnosis, the effects of thymoglobulin-induced T cell depletion, and the role of regulatory T cells in PSC warrant further study.
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