Chapter 18: Hepatic Complications of Organ or Bone Marrow Transplantation

Question 1

The use of transplantation for bone marrow, renal, hepatic and other organ disorders has
generated a challenging group of hepatic complications.

The liver may be damaged by what?

Answer 1

toxic drugs or graft-versus-host disease in patients undergoing bone marrow transplantation,
whereas patients receiving a liver transplant may have graft failure or rejection, and may develop sinusoidal obstruction syndrome, as already discussed.

Although the clinical settings
are obviously different for each patient population, the common themes of toxic or immunologically mediated liver damage, infection of immunosuppressed hosts, recurrent disease, and post-transplant lymphoproliferative disorder are readily apparent.

The following
focuses on post-transplant graft-versus-host disease and liver rejection.

Question 2

The liver has the unenviable position of being attacked by graft-versus-host and host-versusgraft
mechanisms, in the setting of what respectively?

Answer 2

bone marrow transplantation and liver transplantation,

These processes are discussed in detail in Chapter 6 .

More than other solid
organs, liver transplants are reasonably well tolerated by recipients.

That being said, the
hepatic morphologic features that are peculiar to immunological attack after transplantation
deserve comment.

Question 3

Liver damage after bone marrow transplantation is the consequence of what?

Answer 3

acute or chronic graft-versus-host disease.

In acute graft-versus-host disease, which occurs
10 to 50 days after bone marrow transplantation, donor lymphocytes attack the epithelial cells
of the liver.

This results in hepatitis with necrosis of hepatocytes and bile duct epithelial cells,
and inflammation of the parenchyma and portal tracts.

In chronic hepatic graft-versushost
disease (usually more than 100 days after transplantation), there is portal tract
inflammation, selective bile duct destruction, and eventual fibrosis.

Portal vein and hepatic vein radicles may show endothelitis, a process in which a subendothelial lymphocytic infiltrate lifts the endothelium from its basement membrane.

Cholestasis may be observed in both
acute and chronic graft-versus-host disease

Question 4

In transplanted livers, acute rejection is characterized what?

Answer 4

by infiltration of a mixed population
of inflammatory cells that include eosinophils into portal tracts, bile duct and hepatocyte injury,
and endothelitis ( Fig. 18-41 ).

The severity of the rejection is graded according to the BANFF scheme, which is important for clinical management. [67]

Question 5

With chronic rejection of transplanted liver, what happens?

Answer 5

a severe obliterative arteritis of small and larger arterial vessels (arteriopathy) results in ischemic
changes in the liver parenchyma.

Alternatively, bile ducts are progressively destroyed,
because of either direct immunological attack or obliteration of their arterial supply, resulting
in loss of the graft.

Question 6

Answer 6

FIGURE 18-41 Transplanted liver with acute cellular rejection.

Note the mixed
inflammatory cell infiltration including eosinophils in portal tracts, bile duct damage, and
endotheliitis.
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