Hepatitis C recurrence is virtually universal after liver

Transcription

1 GASTROENTEROLOGY 2012;142: Risk for Immune-Mediated Graft Dysfunction in Liver Transplant Recipients With Recurrent HCV Infection Treated With Pegylated Interferon JOSH LEVITSKY,* MARIA ISABEL FIEL, JOHN P. NORVELL,* EDWARD WANG,* KYMBERLY D. WATT, MICHAEL P. CURRY, SUMEET TEWANI, TIMOTHY M. MCCASHLAND, MAAROUF A. HOTEIT, # ABRAHAM SHAKED, # SAMUEL SAAB,** AMANDA C. CHI,** AMY TIEN, and THOMAS D. SCHIANO *Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois; The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York; Mayo Clinic Rochester, Rochester, Minnesota; Beth Israel-Deaconess Medical Center, Boston, Massachusetts; The University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska; # The University of Pennsylvania, Philadelphia, Pennsylvania; and **The University of California, Los Angeles, Pfleger Liver Institute, Los Angeles, California BACKGROUND & AIMS: Patients with recurrent hepatitis C virus infection treated with pegylated interferon (PEG) after liver transplantation can develop severe immune-mediated graft dysfunction (IGD) characterized by plasma cell hepatitis or rejection. METHODS: We conducted a multicenter case-control study of 52 liver transplant recipients with hepatitis C to assess the incidence of, risk factors for, and outcomes of PEG- IGD. Data from each patient were compared with those from 2 matched patients who did not develop PEG-IGD (n 104). We performed a multivariate analysis of risk factors and analyzed treatment and outcomes of graft dysfunction subtypes. RE- SULTS: Overall incidence of PEG-IGD during a 10-year study period was 7.2%. Risk factors included no prior PEG therapy (odds ratio 5.3; P.0001), therapy with PEG -2a (odds ratio 4.7; P.03), and immune features (mainly plasma cell hepatitis) on pre-peg therapy liver biopsies (odds ratio 3.9; P.005). The PEG-IGD group had lower long-term patient (61.5% vs 91.3% of controls) and graft (38.5% vs 85.6% of controls) survival and higher rates of retransplantation (34.6% vs 6.7% of controls) (all, P.0001), without increases in sustained virologic response. Variables associated with increased mortality included acute rejection as the PEG-IGD sub-type (hazard ratio [HR] 2.4; P.002), a high level of alkaline phosphatase at PEG initiation (HR 1.003; P.005), and lack of a sustained virologic response (HR 3.3; P.04). Variables associated with graft failure included a high level of alkaline phosphatase at PEG initiation (HR 1.002; P.04) and lack of a sustained virologic response (HR 2.1; P.04). CONCLUSIONS: PEG-IGD has high morbidity and mortality and is not associated with increased rates of virologic response. It is important to avoid PEG therapy in liver transplant recipients with specific clinical, biochemical, and histologic risk factors for PEG-IGD. Keywords: Organ Transplantation; Immune Response; Viral Hepatitis; Immunosuppression. Watch this article s video abstract and others at tiny.cc/j026c. Scan the quick response (QR) code to the left with your mobile device to watch this article s video abstract and others. Don t have a QR code reader? Get one at mobiletag.com/en/download.php. Hepatitis C recurrence is virtually universal after liver transplantation (LT), and the course of hepatitis C virus (HCV) graft disease is accelerated in transplant recipients in comparison with immunocompetent hosts. Approximately 10% 25% of patients develop bridging fibrosis and cirrhosis within 5 years of LT, resulting in lower patient and graft survival rates compared with HCV-negative recipients. 1 3 Interferon (IFN) alfa, either standard or pegylated (PEG) ribavirin, has been used to treat histological HCV recurrence (HCV-R) and delay the progression of fibrosis, although sustained virological responses (SVR) are low (24% 27%). 4 Recipients with recurrent HCV are difficult to treat with IFN, as they often have failed earlier therapy, are taking immunosuppression (IS), and have more side effects leading to discontinuation. 5 IFN has been noted to trigger autoimmune hepatitis and other immune disorders in nontransplant patients. 6,7 It has also been reported to lead to immune-mediated graft dysfunction (IGD), ie, acute rejection (AR), chronic rejection (CR), and plasma-cell hepatitis (PCH) after LT, resulting in graft failure in case series. 4,8 13 Development of PCH is thought to be a form of rejection associated with poor outcomes in HCV recipients With a large number of HCV recipients developing recurrence and receiving PEG therapy, PEG-IGD is an increasingly recognized phenomenon. 13 As patients can develop severe liver injury and require retransplantation, it would be important to have knowledge of overall outcomes and risk factors before PEG therapy to risk-stratify patients. We hypothesized that immunological and histological variables before or during PEG treatment are associated with an increased risk for PEG- IGD. We also postulated that PEG-IGD is associated with high morbidity and mortality, even in the setting of virological clearance. Abbreviations used in this paper: AR, acute rejection; CR, chronic rejection; HCV, hepatitis C virus; HCV-R, hepatitis C virus recurrence; HR, hazard ratio; IFN, interferon; IGD, immune-mediated graft dysfunction; IS, immunosuppression; LT, liver transplantation; PEG, pegylated interferon; PCH, plasma cell hepatitis; SVR, sustained virologic response by the AGA Institute /$36.00 doi: /j.gastro

2 May 2012 INTERFERON-INDUCED LIVER GRAFT DYSFUNCTION 1133 Methods Study Design This study is a multicenter case-control analysis of LT recipients with the diagnosis of PEG-IGD (ie, PCH, AR, CR). Our aims were to determine the overall incidence of PEG-IGD; to report the histological features of cases of PEG-IGD; to determine risk factors for PEG-IGD by comparing PEG-IGD patients with HCV LT controls who received PEG and did not develop IGD; and to describe management and outcomes after the PEG- IGD diagnosis in relation to controls. The protocol was approved by the Institutional Review Board at each center. Setting This study was performed at 7 US LT centers. Patients were considered eligible between January 15, 2000 (date of the first PEG therapy) and January 15, 2010 (last follow-up date for all patients). De-identified clinical data and follow-up were recorded in local electronic databases and grouped together into one database by the central site (J.L., E.W.) for analysis. Participants All adult (18 years of age and older) HCV-positive recipients who received PEG therapy post-lt were identified from each center s local transplant database. For IGD patient identification, the local investigator and pathologist reviewed biopsies that were performed during the time period in which PEG therapy was being administered to assess for evidence of PCH, AR, or CR. After the patients were locally identified, 2 HCV PEG-treated controls who did not have increased liver function tests requiring a biopsy on treatment were randomly selected and matched by year of LT. This matching was done to maintain homogeneity in length of follow-up from LT and in post-lt management (ie, IS regimens, HCV therapies), which can frequently change in LT centers. It was not required that the controls had liver biopsies on treatment, as this was not performed routinely at the study centers. The following were exclusion criteria for patients and controls: alternate etiology of graft dysfunction (ie, biliary/vascular/drug induced); lost to follow-up; lack of complete data on variables, outcomes, or histology. Once the patients and controls were identified, their de-identified pretreatment (immediately before therapy; patients and controls) and on-treatment (patients only; no controls had on-treatment biopsies) slides were sent to a central pathologist (M.I.F.) blinded to clinical and histological data. Finally, the principal investigator and statistician (J.L, E.W.) assembled and analyzed a unified database incorporating the separately established local clinical databases and the centrally read histological database. Variables The following clinical data were obtained by each center for all patients and controls (when relevant): 1. Pre-PEG treatment: baseline demographics, IS regimen, HCV characteristics (genotype, HCV RNA, pretransplantation IFN), liver histology, previous rejection, history of autoimmune disease, and PEG ribavirin regimen chosen. 2. During PEG treatment: mean PEG and ribavirin dosages, timing to graft dysfunction, clinical presentation and management of graft dysfunction, and liver histology. 3. Post PEG treatment: management of PEG-IGD, HCV RNA levels (end of treatment virological response, SVR), and outcomes (resolution, retransplantation, graft failure [either death or retransplantation], and death). A central blinded pathologist (M.I.F.) used standard published histological criteria for HCV-R and graft dysfunction diagnoses (ie, AR and CR). 14,15 Criteria for PCH followed those established from recent reports (Supplementary Table 1). 10,11 Biopsies reviewed were those performed immediately before PEG treatment (patients and controls) and those on PEG (patients) demonstrating the presence of PEG-IGD pathology. Statistical Methods Clinical characteristics between PEG-IGD patients and non- IGD controls were compared using the t test for continuous variables and 2 or Fisher exact test (for small number or highly imbalanced table cells) for categorical data. Data were summarized using descriptive statistics (ie, mean and standard deviation for continuous variables; count and frequency for categorical variables). Both univariate and multivariate analyses were conducted to determine the risk factors of PEG-IGD and graft and patient survival. Conditional logistic regression and stratified Cox models were used for the matched case control (1:2) data. Only variables with P.10 on univariate analysis were included in the subsequent multivariate model. Survival curves were estimated using the Kaplan Meier method and tested using the weighted-log-rank test; hazard ratios (HR) were estimated using stratified Cox proportional hazards models. The HR estimates were based on simultaneous analysis of all independent variables, and assumption of proportionality was met using log-minus-log plot. The power analysis was performed using PASS software (NCSS Inc, Kaysville, UT). With an anticipated event rate of 0.19 (overall mortality rate) during the 10 years of follow-up and a median survival of 8.75 years for the control group, a sample of 156 observations achieves 80% power at a 2-tailed.05 significance level to detect a minimum HR of 2.13 for any given covariate. 16 The HR of 2.13 was equivalent to the effect size of 35% (event 18/52) vs 11% (event 11/104) difference in patient mortality between PEG-IGD patients and non-igd controls. The study was powered to detect any HR 2.13 or 0.47 (1/2.13) between PEG-IGD patients and non-igd controls. The overall incidence of PEG-IGD was calculated by dividing the number of IGD patients by the cumulative number of all PEG-treated LT patients at the centers during the 10-year study time period. All P values were 2-sided, and a P value.05 was considered statistically significant. All analyses were conducted using SAS 9.2 (SAS Institute Inc, Cary, NC). Results Participants Seven LT centers comparable in size and clinical practice identified 57 PEG-IGD patients during the 10-year study time period (January 2000 January 2010). Two and three patients were excluded due to lack of follow-up and available histology, respectively. Thus, 52 PEG-IGD patients and 104 PEG-treated controls were included in the study. The overall 10-year incidence of PEG-IGD among all of the centers was 7.2% (52 patients/764 total PEG-treated LT recipients in the study time period). The incidence per center was as follows: Northwestern (16.3%), Beth Israel (12.5%), UCLA (10.7%), Mount Sinai (9.4%), Nebraska (6.2%), Mayo Clinic (5.3%), University of Pennsylvania (3.2%). Descriptive Data and Risk Factors Table 1 displays patient characteristics before and during PEG therapy. The time from LT to PEG therapy initiation was similar between the patients and controls. Compared with controls, patients were less often treated with IFN therapy before LT (31% vs 53%; P.009), had a

3 1134 LEVITSKY ET AL GASTROENTEROLOGY Vol. 142, No. 5 Table 1. Patient Characteristics and Risk Factors Variables IGD cases (n 52) Non-IGD controls (n 104) P value a Before PEG therapy Sex, male, n (%) 36 (69.2) 80 (76.9).39 Race, white, n (%) 37 (7.2) 78 (75.0).75 HCV genotype, n (%).14 Type 1 46 (88.5) 79 (75.9) Type 2 2 (3.9) 15 (14.4) Type 3 4 (7.7) 8 (7.7) Type 4 0 (0) 2 (1.9) Pre-LT IFN therapy, n (%) 16 (30.7) 55 (52.9).009 Living donor LT, n (%) 5 (9.6) 11 (10.7).92 History of autoimmune disease, n (%) 0 (0) 4 (3.8).37 Previous AR, n (%) 11 (21.2) 26 (25).74 2 episodes of previous AR, n (%) 1 (1.9) 3 (2.9).86 Previous steroid-refractory AR, n (%) 6 (11.5) 9 (9.5).78 Days from last AR to PEG therapy, mean SD At PEG therapy Age, mean SD Days from LT to PEG therapy initiation, mean SD Maintenance IS therapy, n (%) Tacrolimus 39 (75) 86 (82.7).36 Cyclosporine 11 (21.2) 14 (13.4).31 Sirolimus 2 (3.8) 7 (6.7).72 Mycophenolic acid 10 (19.2) 27 (25.9).46 Prednisone 12 (23.1) 23 (22.1).99 Reduction in IS 3 mo before PEG, n (%) 27 (51.9) 29 (27.9).003 Subtherapeutic IS level 3 mo before PEG, n (%) 11 (21.1) 11 (10.7).07 Laboratory values, mean SD HCV RNA, IU/mL Total bilirubin, mg/dl ALT, U/L Alkaline phosphatase, U/L Creatinine, mg/dl During PEG therapy PEG 2a used, n (%) 48 (92.3) 83 (79.8).04 Mean PEG 2a dosage, g/wk, mean SD Mean PEG 2b dosage, g/wk, mean SD Mean ribavirin dosage, mg/day, mean SD Reduction in IS during PEG therapy, n (%) 22 (42.3) 28 (26.9).05 a T test for continuous variables; 2 Fisher exact test for categorical variables. higher rate of reduction in IS therapy within 3 months of PEG initiation (52% vs 28%; P.003), and higher pre- PEG alkaline phosphatase levels ( vs U/L; P.003). During PEG treatment, patients were more often receiving PEG 2a (92% vs 80%; P.04) compared with 2b, had lower ribavirin dosages ( vs mg/day; P.01), and had a higher rate of reduction in IS during PEG therapy (42% vs 27%, P.05). Table 2 displays the histological findings of the pre- PEG biopsies, separated into overall immunological features and then by the component severity scores. Pre-PEG treatment biopsy immune features, defined by any evidence of PCH, AR, CR, were seen in a significantly higher percentage of patient who later developed IGD compared with controls (50% vs 18%; P.0001). By subgroup, PCH alone was the main pretreatment biopsy feature (37% vs 8%; P.0001), with higher severity scores for plasma cell infiltrates ( vs ; P.002) and percentage with centrizonal necrosis (25% vs 10%; P.03) in cases. The severity of features often associated with HCV-R, ie, portal inflammation, interface and zonal hepatitis, steatosis, and fibrosis, was not different. In the multivariate analysis, no IFN therapy treatment before LT (odds ratio 5.3; P.0001), use of PEG 2a (odds ratio 4.7; P.03), and immune features on pretreatment biopsy (odds ratio 3.9; P.005) were independently associated with a higher risk of developing IGD. Outcomes Data Table 3 lists the various outcomes for PEG-IGD patients and controls from the time of PEG therapy. Both had similar follow-up from initiation of PEG therapy. Patients demonstrated worse patient/graft survival and higher retransplantation rates vs controls from the time of PEG therapy, both numerically and on Kaplan Meier analysis (Figure 1A and B), as well as on multivariate Cox models controlling for variables shown in Table 1 (HR 2.91 and 4.18 for death and graft failure, respectively; P.01 for both). There was no difference

4 May 2012 INTERFERON-INDUCED LIVER GRAFT DYSFUNCTION 1135 Table 2. Liver Histology Immediately Before and During PEG Therapy Biopsy before PEG therapy Biopsy on PEG therapy Histology variables IGD cases (n 52) Non-IGD controls (n 104) P value a IGD cases only (n 52) Overall histology Immune features, n (%) 26 (50.0) b 19 (18.3) b /52 (100) PCH 19 (36.5) 8 (7.7) (54.8) PCH AR 1 (1.9) 3 (2.8).84 8 (15.3) PCH CR 0 0 NA 1 (1.9) AR 5 (9.6) 7 (6.7).79 7 (13.5) AR CR 0 1 (0.9).72 4 (7.7) CR 1 (1.9) (7.7) Component histology Portal inflammation (0 3), mean SD Interface hepatitis (0 3), mean SD Lobular activity (0 3), mean SD Plasma cell infiltrate (0 3), mean SD Centrizonal necrosis, n (%) c 13 (25.0) 10 (9.6) (59.6) Fibrosis (0 4), mean SD Steatosis (0 3), mean SD Rejection Activity Index (0 9), mean SD a T test for continuous variables; 2 or Fisher exact test for categorical variables. b Any degree of or combination of PCH, AR, or CR on pretreatment biopsy. c All biopsies with centrizonal necrosis had concurrent PCH. Centrizonal necrosis was not seen with AR or CR. in rates of virological clearance either at the end of (ie, end of treatment virological response) or 6 months after PEG therapy (SVR). However, the cohort of PEG-IGD patients without SVR had worse patient survival than all other groups (either patients with SVR or all controls with or without SVR) (Figure 1C; P.002; P.0001; P.0001, respectively). In addition, both patient cohorts (SVR or no SVR) had worse graft survival than either control group (Figure 1D; P.008; P.0001, respectively), primarily due to higher rates of retransplantation. All P values described here remained significant (P.05) after Bonferroni correction for multiple pairwise comparisons. Clinical and Histological Features of PEG-IGD Mean laboratory values at the time of IGD biopsy diagnosis are reported in Table 3. Divided by IGD etiology, PCH and AR patients had similar laboratory values at IGD diagnosis (alanine aminotransferase: vs U/L; P.92; total bilirubin: vs mg/dl; P.59; alkaline phosphatase: vs U/L; P.77). CR cases did not have different laboratory values (alanine aminotransferase: U/L; alkaline phosphatase: U/L) except for higher total bilirubin ( mg/dl; P.03) than AR patients. Figure 2 displays representative cases of AR, CR, and PCH developing on PEG. Table 2 (far right column) displays the histological presentations and severity scores for the PEG-IGD patients. More than 70% of the PEG-IGD patients had PCH, either alone or in combination with AR or CR. In addition, centrizonal necrosis was present only in the PCH biopsies, and not in AR or CR. Fourteen cases previously considered by the local pathologist as non-pch IGD Table 3. Biochemical Presentation and Outcomes of IGD Variable IGD cases (n 52) Non-IGD controls (n 104) P value a Total bilirubin, mg/dl, mean SD NA ALT, U/L, mean SD NA Alkaline phosphatase, U/L, mean SD NA INR, mean SD NA Creatinine, mg/dl, mean SD NA Days from PEG initiation to IGD, mean SD NA Days of follow-up after PEG initiation, mean SD ETVR, n (%) 30 (57.7) 50 (48.1).53 SVR, n (%) 21 (40.4) 34 (32.7).25 Graft failure, n (%) 32 (61.5) 15 (14.4).0001 Retransplant, n (%) 18 (34.6) 7 (6.7).0002 Death, n (%) 20 (38.5) 9 (8.7).0001 Graft failure after re-lt, n (%) 3 (5.7) 1 (0.9).56 Death after re-lt, n (%) 4 (7.7) 0.55 NOTE. Laboratory values were collected at the time of IGD diagnosis. Because multiple laboratory values are performed throughout the course of PEG therapy and are difficult to directly compare at similar time points with the IGD cases, they are not reported for the non-igd controls. ETVR, end-of-treatment virological response. a T test for continuous variables; 2 or Fisher exact test for categorical variables.

5 1136 LEVITSKY ET AL GASTROENTEROLOGY Vol. 142, No. 5 Figure 1. Kaplan Meier analyses of patient/graft survival (IGD patients vs non-igd controls). (A) Overall patient survival; (B) overall graft survival; (C) patient survival by SVR; (D) graft survival by SVR. diagnoses (2 mild AR, 5 moderate AR, 3 CR, 3 mixed mild AR/HCV-R, 1 mixed early CR, HCV-R) were considered to alternatively meet criteria for PCH by the central, blinded pathologist (M.I.F.). Twelve of these 14 were PCH with centrizonal necrosis. For clinical management after the IGD diagnosis, PEG was discontinued, prednisone was started, and baseline maintenance IS was augmented in 37 of 52 (71.2%), 41 of 52 (78.8%), and 40 of 52 (76.9%) patients, respectively. All clinical and histological variables (Tables 1 3) and the IGD management strategies were evaluated in a multivariate analysis to identify predictors of patient and graft survival. AR alone at IGD diagnosis (HR 2.4; P.002), higher alkaline phosphatase value at PEG therapy initiation (HR 1.003; P.005), and lack of SVR (HR 3.28; P.04) were associated with higher risk of patient mortality, while higher alkaline phosphatase value at PEG therapy initiation (HR 1.002; P.04) and lack of SVR (HR 2.1; P.04) were associated with greater risk of graft failure. Discussion Recurrent HCV after LT is a major problem leading to diminished patient and graft survival compared with other LT recipients. 3 This is compounded by the lower efficacy of IFN therapy in the post-transplantation setting, due to various factors including the presence of immunosuppressive therapy, higher chance of failure due to previous nonresponse, and higher adverse events resulting in suboptimal IFN and ribavirin dosages and/or early discontinuation of therapy. 4,17 However, the small percentage ( 25% 30%) who tolerate therapy and achieve SVR have superior long-term patient and graft survival to nonresponders, highlighting the need to identify more favorable patient characteristics before treatment and more tolerable therapies with higher potency. 18,19 In addition, a small but important subset as reported here can develop severe immune-mediated graft dysfunction likely related to the immunestimulating properties of IFN therapy. Our multicenter study reports the largest series of HCV LT recipients who developed IGD during the course of PEG therapy. This diagnosis was associated with significantly inferior patient and graft survival compared with controls without IGD on PEG therapy. In addition, similar end of treatment virological response and SVR rates in patients and controls do not support the hypothetical advantage of heightened viral clearance with immune-mediated injury. Although patients developing IGD without achieving SVR had both inferior patient and graft survival, those developing SVR still had diminished graft survival compared with all controls with or without SVR,

6 May 2012 INTERFERON-INDUCED LIVER GRAFT DYSFUNCTION 1137 Figure 2. Case examples of PEG-IGD. (A) Pre-PEG therapy recurrent hepatitis C and mild plasma cell infiltration: portal inflammation with increase in plasma cells (arrows, score of 2); (B) IGD: plasma cell hepatitis (arrows, score of 3) after 3 months of PEG; (C) pre-peg therapy recurrent hepatitis C with dense lymphocytic infiltrate, mild interface hepatitis; surrounding parenchyma shows foci of necroinflammation. (D) IGD: acute cellular rejection 2 months after PEG: portal tract with heavy infiltrate of inflammatory cells consisting of lymphocytes and eosinophils, endotheliitis, and bile duct damage (Rejection Activity Index 7); (E) pre-peg therapy recurrent hepatitis C: portal inflammation and interface hepatitis (no plasma cells or evidence of rejection); (F) IGD: ductopenic chronic rejection after 2 months of PEG: 2 portal tracts displaying absence of bile ducts; seen in 7 of 10 portal triads. (A, B) H&E, original magnification 100.(C, D) H&E, original magnification 200. (E, F) H&E, original magnification 40. due to a high percentage requiring retransplantation from IGD. As organ transplants are in low supply and high demand, any complications resulting in death or retransplantation have a substantial impact on transplantation outcomes, organ availability, and allocation. In addition, retransplantation for HCV recurrence is controversial because of the likelihood of recurrence in subsequent grafts, making the decision to retransplant IGD patients even more difficult because of the worse outcomes, particularly if SVR is not achieved. The significant morbidity and mortality of this subset underscores the need to identify this at-risk immunological group and avoid this complication. Utilizing a large cohort of patients, we were able to identify important variables and risk factors for IGD that may be useful in patient management. One strength of our study was having a single blinded pathologist review who confirmed each diagnosis and scored the degree and severity of each histological feature from pre- and on-treatment biopsies (341 biopsies reviewed in total). Immune features, most often PCH, in combination with histological features of HCV-R on pretreatment biopsy were seen in almost 50% of patients vs 20% of controls and might be the most important predictor of IGD. These immune features were reported by each center s local pathologist as histological abnormalities most consistent with HCV-R and led the treating hepatologist to initiate PEG therapy. This illustrates the clinical conundrum facing clinicians in identifying classic features of HCV recurrence, as plasma cell infiltrates can be seen in HCV infection (although generally to a minimal degree). As the predominant immune feature on the pretreatment biopsies was PCH with high plasma cell infiltrate scores and centrizonal necrosis, this form of immune injury is believed to be a distinct form of rejection associated with particularly poor outcomes in HCV patients and can predispose patients to IGD when treated with IFN. 10,11 In fact, centrizonal necrosis and perivenulitis are commonly seen in severe autoimmune hepatitis with acute liver injury or failure. 20,21 The combination of PCH with centrizonal necrosis promoted by IFN might be particularly severe and result in poor outcomes. 10 Whether IGD can be avoided if those with PCH or other immune features are not treated with IFN cannot be answered by this study, al-

7 1138 LEVITSKY ET AL GASTROENTEROLOGY Vol. 142, No. 5 though our data support strong consideration of this practice and, alternatively, optimization of IS therapy (rather than reduction). Interestingly, our central pathologist recorded 14 cases of PCH, often with centrizonal necrosis, that were previously read as AR, CR, or mixed HCV/rejection by the local pathologist. Although discrepancies between liver pathologists are well known, our results highlight the need to closely evaluate each biopsy for features of PCH and consider following specific criteria 10,11 to distinguish this etiology from HCV-R or classic forms of rejection, both before and during therapy. Other risk factors for PEG-IGD appear to have a parallel immunological basis, such as being naïve to IFN therapy, use of PEG 2a (which is associated with higher SVR, and potentially more immune-stimulating compared with PEG 2b 22 ) and high pretreatment alkaline phosphatase levels. Although alkaline phosphatase is not a specific marker for immune-mediated injury, it is nearly always elevated in patients with CR or ductulitis and less commonly increased in pure HCV-R. 23,24 Also associated with IGD was a reduction in IS before or during PEG therapy. The impetus for treating HCV recipients is to reduce IS therapy to slow down histological recurrence, although it might be preferable to maintain IS dosages/therapeutic levels in the time period before or during PEG therapy. 25 In fact, once HCV-R is established and treatment is considered, a period of time (1 3 months) involving stable IS therapy before PEG treatment initiation might be advisable, unless urgent treatment is required for clinical reasons (eg, cholestatic HCV). It is unclear if the presence of autoantibodies (eg, antinuclear, smooth-muscle, liver kidney microsomal) signifies an increased risk of IGD, as they were only available in a small percentage of all patients and controls, precluding analysis as a risk factor variable. However, there were no patients in the IGD group with known autoimmune diseases. The immunological properties of IFN provide mechanistic support for the induction of graft inflammation and injury. A tenet of IFN therapy is to promote HCV-specific CD4 and CD8 responses, which ultimately leads to prolonged virus-specific immune reconstitution and clearance, either before or after LT However, nonviral immune responses on IFN therapy can occur, resulting in either liver or non liver immune-mediated injury. 6,30 Type I interferons have profound effects on cytokine cascades involving induction of T helper 1 cytokines (IFN-, interleukin-2) and suppression of T helper 2 cytokines (ie, interleukin-4, interleukin-5). 31,32 In addition, IFN therapy can influence the terminal differentiation of alloactivated B cells to plasma cells, activated T cells and chemokines responsible for the lymphoplasmacytic (PCH) inflammation in the allograft. Our patients were likely either predisposed or made higher risk to develop such injury, based on their pretreatment history (new to IFN therapy), biochemical profile (alkaline phosphatase), histology, and immunosuppressive therapy reductions. Finally, we sought to determine variables associated with positive or negative outcomes to guide clinicians if IGD occurs on therapy. Interestingly, although PCH appeared to be most prevalent on pretreatment biopsies, AR features at IGD diagnosis were associated with worse patient survival. This might be speculatively due to progression of AR to refractory AR or irreversible CR. Not surprisingly, lack of SVR was highly associated with patient and graft loss. None of the management strategies at the time of IGD were associated with improved outcomes, such as augmentation of baseline IS therapy or PEG discontinuation, although the latter is advised given IFN appears to be the stimulus causing graft dysfunction. As such, new elevations in liver enzymes on PEG therapy should prompt a liver biopsy to diagnose IGD early and avoid progressive dysfunction. There are limitations of this study. First, this was a retrospective case-control study with the potential for patient selection bias. Because the patients represent a small but important percentage of PEG-treated recipients, they needed to be collected together from multiple centers to be able to perform statistical comparisons of risk factors and outcomes. Second, the data for IGD reflect those of the 7 centers and might not represent or estimate the true incidence, risk factors, and outcomes of this complication. In addition, as complete follow-up time was not available on all 764 PEG-treated patients, we were only able to report the overall 10-year incidence of PEG-IGD and not the incidence based on a more precise person time calculation. Also, there was some variability in the IGD incidence per center. The reasons for this are not known, as there were no obvious differences in patient populations, clinical variables, or case identification procedures among the centers. Given the retrospective design and associated biases, it is likely that other untested confounding variables might have accounted for the differences. Third, the controls were determined clinically as not having IGD and not by histological criteria, which might more accurately define the patients as controls. It is hypothetically possible that a portion of the controls with no biochemical abnormalities would have been found to have subclinical histological changes consistent with IGD if a biopsy was performed. Unfortunately, there were no patients to serve as controls who had normal liver biopsies on treatment, as it was not standard center practice to perform routine liver biopsies in patients with no biochemical abnormalities on treatment. We had to utilize clinical criteria (ie, no liver function test abnormalities requiring a biopsy on treatment) to accumulate enough controls (2:1) to appropriately analyze risk factors and outcomes. Finally, we were not able to obtain complete histology data from patients who died, were retransplanted, or had follow-up biopsies to determine the histological progression or regression of IGD. In conclusion, LT recipients who develop PEG-IGD are at high risk for graft failure and/or death and minimizing this complication is of the utmost importance. Our hope is that transplantation clinicians maintain IS dosages and do not initiate IFN in those with pretreatment biopsies showing significant immune features (particularly PCH), and consider consulting other liver transplant pathologists to help review indeterminate cases. Prospective trials investigating whether immune graft dysfunction, graft failure, and death can be avoided by not initiating IFN

8 May 2012 INTERFERON-INDUCED LIVER GRAFT DYSFUNCTION 1139 therapy in patients with clinical, immunological, and histological risks are of great interest and need. Supplementary Materials Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at and at doi: /j.gastro References 1. Gane EJ, Portmann BC, Naoumov NV, et al. Long-term outcome of hepatitis C infection after liver transplantation. N Engl J Med 1996;334: Prieto M, Berenguer M, Rayon JM, et al. High incidence of allograft cirrhosis in hepatitis C virus genotype 1b infection following transplantation: relationship with rejection episodes. Hepatology 1999; 29: Forman LM, Lewis JD, Berlin JA, et al. The association between hepatitis C infection and survival after orthotopic liver transplantation. Gastroenterology 2002;122: Wang CS, Ko HH, Yoshida EM, et al. 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Significant improvement in the outcome of HCV-infected transplant recipients by avoiding rapid steroid tapering and potent induction immunosuppression. J Hepatol 2006;44: Kamal SM, Fehr J, Roesler B, et al. Peginterferon alone or with ribavirin enhances HCV-specific CD4 T-helper 1 responses in patients with chronic hepatitis C. Gastroenterology 2002;123: Rosen HR, Hinrichs DJ, Gretch DR, et al. Association of multispecific CD4( ) response to hepatitis C and severity of recurrence after liver transplantation. Gastroenterology 1999;117: Tatsumi T, Takehara T, Miyagi T, et al. Hepatitis C virus-specific CD8 T cell frequencies are associated with the responses of pegylated interferon-alpha and ribavirin combination therapy in patients with chronic hepatitis C virus infection. Hepatol Res 2011;41: Weston SJ, Leistikow RL, Reddy KR, et al. Reconstitution of hepatitis C virus-specific T-cellmediated immunity after liver transplantation. Hepatology 2005;41: Tahan V, Ozseker F, Guneylioglu D, et al. Sarcoidosis after use of interferon for chronic hepatitis C: report of a case and review of the literature. Dig Dis Sci 2003;48: Tilg H. New insights into the mechanisms of interferon alfa: an immunoregulatory and anti-inflammatory cytokine. Gastroenterology 1997;112: Larrea E, Garcia N, Qian C, et al. Tumor necrosis factor alpha gene expression and the response to interferon in chronic hepatitis C. Hepatology 1996;23: Received July 8, Accepted January 15, Reprint requests Address requests for reprints to: Josh Levitsky, MD, MS, Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, 676 North Saint Clair Street, 19th Floor, Chicago, Illinois j-levitsky@northwestern.edu; fax: (312) Conflicts of interest These authors disclose the following: Josh Levitsky and Timothy M. McCashland are on the Speaker s Bureau for Genentech. Thomas D. Schiano is a consultant for Merck. The remaining authors disclose no conflicts. Funding This study was supported in part by an investigator-initiated grant (Josh Levitsky, principal investigator) from Schering-Plough/Merck Corporation. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

9 1139.e1 LEVITSKY ET AL GASTROENTEROLOGY Vol. 142, No. 5 Supplementary Table 1. Histological Scoring System for Plasma Cell Hepatitis 1,2 Overview Normal/other 0 HCV without features of PCH 1 Features suggestive of PCH 2 Features consistent with PCH 3 Portal inflammation Normal 0 Mild: sprinkling of cells 1 Moderate: lymphoid aggregates in some portal tracts 2 Severe: lymphoid aggregates in most portal tracts 3 Interface hepatitis None 0 Mild: focal, seen in few portal tracts 1 Moderate: focal in most portal tracts, continuous in few portal tracts 2 Severe: continuous in most portal tracts 3 Lobular activity None 0 Mild: scattered foci of parenchymal necrosis/acidophil bodies 1 Moderate: numerous foci of parenchymal necrosis with some bridging 2 Severe: bridging necrosis and/or centrilobular dropout 3 Plasma cells Nil 0 Occasional 1 Moderate ( 30% of the infiltrate) 2 Severe ( 30% or occurring in groups or clusters) 3 Centrizonal necrosis: Present Absent If present, are there inflammatory cells? Yes No Mixed type Mainly plasma cells Fibrosis (0 4) Score Steatosis (0 3) Score Rejection Activity Index (0 9) Score Incidental findings Score Supplementary References 1. Fiel MI, Agarwal K, Stanca C, et al. Posttransplant plasma cell hepatitis (de novo autoimmune hepatitis) is a variant of rejection and may lead to a negative outcome in patients with hepatitis C virus. Liver Transpl 2008;14: Ward SC, Schiano TD, Thung SN, Fiel MI. Plasma cell hepatitis in hepatitis C virus patients post-liver transplantation: case-control study showing poor outcome and predictive features in the liver explant. Liver Transpl 2009;15: