Are protocol graft biopsies after pediatric liver transplantation useful? Experience in a single center over 20 years

Abstract

Background:The role of protocol liver biopsies (PLB) in the follow-up of pediatric liver transplant recipients remains questionable. This single-center retrospective study aimed to evaluate their clinical impact on the long-term management of pediatric liver transplant recipients. Methods:We described histopathological lesions and clinical consequences for patient management of PLB performed 1, 5, 10, 15, 20, and 25 years after pediatric liver transplantation (LT).Results: A total of 351 PLB performed on 133 patients between 1992 and 2021 were reviewed. PLB found signs of rejection in 21.7% of cases (76/351), and moderate to severe fibrosis in 26.5% of cases (93/351). Overall, 264 PLB (75.2%) did not cause any changes to patient care. Immunosuppression was enhanced after 63 PLB, including 23 cases of occult rejection. The 1-year PLB triggered significantly more changes, while biopsies at 15, 20, and 25 years produced the lowest rates of subsequent modifications.PLB had a significantly higher probability of inducing therapeutic changes if the patient had abnormal biological or imaging results (odds ratio [OR] 2.82 and 2.06), or a recent history of rejection or bacterial infection (OR 2.22 and 2.03). Conclusion:Our results suggest that, although it often does not prompt any treatment changes, PLB could be performed because of its ability to detect silent rejection requiring an increase in immunosuppression. PLB could be carried out 1, 5, and 10 years after LT and then every 10 years in patients with normal biological and imaging results and no recent complications, while other patients could be kept on a 5-year protocol.

Progress in the diagnosis and treatment of graft fibrosis after liver transplantation

“…It has become a practical tool for evaluating the fibrosis stage of LT grafts in children. In long‐term follow‐up, it is recommended that recipients with normal laboratory and imaging examination results without complications undergo surveillance liver biopsy at 1, 5, and 10 years after LT, followed by a repeat biopsy every 10 years after that 3 . Although liver biopsy can identify the etiology of fibrosis and guide the modification of immunosuppression regimens, the measurement results are susceptible to sample errors and differences between pathological observers, which emphasizes the need for the development of noninvasive diagnostic techniques 26,27 …”

“…Ten years post‐LT, 29% (16/55) of patients had severe graft fibrosis, and 56% (9/16) of them had portal hypertension. Another long‐term study of PLT recipients performed by Wischlen et al 3 showed that more than half of the children showed only mild fibrosis at 10 years after LT but that several patients were found to have cirrhosis at the 15 years or longer follow‐up. Currently, no cohort study has focused solely on liver fibrosis in adult LT recipients.…”