Hepatic venous pressure gradient identifies patients at risk of severe hepatitis C recurrence after liver transplantation

Abstract

Liver biopsy is essential in the follow-up of HCV-infected liver transplant recipients. The aim of this study was to prospectively compare percutaneous (PLB) versus transjugular liver biopsy (TLB) in the assessment of liver damage. We also explored the diagnostic value of hepatic venous pressure gradient (HVPG) to identify patients at risk of severe HCV disease recurrence after liver transplantation (LT). One hundred sixteen paired PLB and TLB (with HVPG measurement) were performed 3 or 12 months after LT in 80 patients. Concordance for necroinflammation and fibrosis was fair or good, particularly 1 year after LT (kappa > 0.6). At this point, a significant positive association was seen between the median HVPG and the fibrosis stage C hronic hepatitis C virus (HCV) infection leading to liver cirrhosis and hepatocellular carcinoma is the main indication for liver transplantation (LT) in Western countries and Japan. 1 Regretfully, recurrence of HCV infection is universal after LT, 2 and disease progression is significantly faster in immunosuppressed than in immunocompetent individuals. In liver transplant recipients, chronic HCV infection may lead to cirrhosis in as much as 30% of individuals only 5 years after LT. [3][4][5] Once liver cirrhosis is established, the cumulative probability of developing clinical decompensation is close to 50% 1 year after diagnosis and, more importantly, survival after decompensation is extremely short. 6 As a result of this accelerated course of HCV infection, longterm graft and patient survival are significantly reduced in patients undergoing LT for HCV-related cirrhosis compared with other groups. 7 Frequent liver biopsies are essential to monitor HCV-induced liver damage and are part of the routine follow-up of HCV-infected liver transplant recipients. Early histological damage after transplantation correlates with long-term outcome; in fact, the presence of significant liver fibrosis in 1-year liver biopsies identifies patients at high risk of graft loss. 3,8 In addition, assessment of liver damage is relevant to adopt therapeutic decisions, particularly because of the low efficacy and high incidence of adverse events of current antiviral therapy in this group of patients. 3,9,10

Hepatic venous pressure gradient to assess fibrosis and its progression after liver transplantation for HCV cirrhosis

“…There were 25 pressure evaluations (18 patients) that fulfilled our definition of potentially discrepant results with respect to the expected fibrosis stage or HVPG. The median biopsy length of the entire "discrepant" group was 22 mm (range, [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] and the number of fragments was 3.5 (range, 2-8) similar to the population as a whole. In the discrepant group, 56% of biopsies did not show severe nodularity/cirrhosis with 4 (range, 1-9) complete portal tracts and 8 (range, 2-13) partial portal tracts.…”

“…The potential utility of HVPG as a hemodynamic marker related to HCV progression can be assessed providing due attention is paid to sampling of liver biopsies, as poor samples can lead staging and grading errors, particularly in HCV infection. 24 A recent study did not evaluate HVPG in relation to TJB specimens (average length was only 1 cm, 25 ) whereas HVPG was correlated with percutaneous liver biopsies taken 12 months after transplantation, with an average length of 1.5 cm. The latter is below the optimum for grading and staging.…”

Noninvasive tests in the post–liver transplantation setting

“…The average length of TJLB was only 10 mm and 15 mm for PLB, with an average of 7 and 9 (summation of complete and partial) portal tracts, respectively. 2 Blasco et al 2 could not correlate HVPG with the TJLB because of the inferior quality of the LB, but these represent 61% of the biopsies in the current study. 1 We submit that if they found their TJLB suboptimal to correlate histology with HVPG in the previous study, 2 then they are suboptimal in comparison with HVPG in this study 1 and with transient elastography.…”

“…4 Specifically, a single-pass TJLB is insufficient; at least 3 passes are needed. 4 There may also be differences between TJLB performed with Menghini needles (used by Blasco et al 2 and, we assume, in any added patients that may have undergone biopsy in the study by Carrion et al 1 ) compared with Trucut needles.…”

“…Clearly, neither HVPG nor transient elastography had an adequate histological reference standard in either study. 1,2 Moreover, given that transient elastography cannot be a surrogate for other histological features such as inflammation and steatosis, which are reported to have good predictive value for the progression of fibrosis, 6,7 LB will still be needed to assess recurrent HCV disease after liver transplantation. Because LB will need to be performed, and because measurement of HVPG has independent prognostic value, 2 the transjugular route offers the most efficient route to perform both biopsy and HVPG measurement at the same time, and it allows multiple passes to enable better, often optimal liver samples to be obtained.…”