1. Post-transplant centrilobular hepatitis - rejection or autoimmune-like? Andrew Clouston & Catherine Campbell Princess Alexandra Hospital, Australia University of Queensland, Australia

2. Outline introduction pathology of CLH evolution possible pathogenesis

3. Centrilobular hepatitis Acute rejection Chronic rejection Vascular Autoimmune hepatitis “Central venulitis”

4. Centrilobular hepatitis Acute rejectionportal changes Chronic rejectionduct changes Vascularimaging Autoimmune hepatitishisto & autoAb “Central venulitis”

5. Allo- vs Auto-immunity

8. De novo AIH post-OLT elevated transaminases typical histology –interface hepatitis ++ –plasma cells

9. De novo AIH post-OLT elevated transaminases typical histology –interface hepatitis ++ –plasma cells late – median 24 months autoantibodies response to pred / aza

14. 40 - 50% Salcedo Hepatology 2002

15. CV

16. Allo- vs Auto-immunity

19. Late centrilobular hepatitis Tsamandas 1997 –AR -- prognosis good Nakazawa 2000 –hepatitis -- prognosis OK Hassoon 2004 –AR (50%) – prognosis poor –>> evolution into CR IS THIS A FORM OF AR or AIH?

20. Case 28 yr old man previous farm worker 1994 cryptogenic cirrhosis March 2003 OLTx ; uneventful post op course

21. Case 28 yr old man previous farm worker 1994 cryptogenic cirrhosis March 2003 OLTx ; uneventful post op course June 2004 abnormal LFTs –Transaminitis, BR normal Immunosuppression stable –prednisolone 5mg, tacrolimus Biopsy ?AR

27. No treatment

30. “Darrell”

31. 2005 Draft statement on late liver allograft dysfunction (Banff working group) “Central venulitis” “Centrilobular inflammation +/- hepatocyte necrosis/dropout” –Peri-venular inflammation –Peri-venular hepatocyte necrosis/dropout –Haemorrhage –Pigmented macrophages

32. Ddx “central venulitis” (Banff) Acute rejection as isolated central venulitis –Perivenular inflammation with hepatocyte dropout and haemorrhage –Grading system provided –“severe” – damage of >3 hepatocyte layers in some central veins –Variable outcome

33. Hypothesis – centrilobular hepatitis ? Pure centrilobular form of AR ? Form of autoimmune- like hepatitis

34. Aims 1.Characterise “centrilobular hepatitis” -Nature of the histological changes -Associated clinical features 2.Document the natural history 3.Investigate possible mechanism

35. Methods Prospectively accrued cases from 1999 Prominent “centrilobular hepatitis” on biopsy No portal tract changes of AR or CR Clinical details –baseline, biopsy and follow up LFTs –baseline immunosuppression –change in treatment –auto-antibody status

36. Methods Histological assessment

37. CLportal

38. Results Seen in 24 pts (182 transplants) – 13% 30 - 2850 days post-OLT Mean 1066 days (~ 3 years) i.e. “late allograft dysfunction”

39. n=24 Autoimmune-like hepatitis Centrilobular hepatitis n=13 Recurrent AIH n=5 Denovo AI-like hepatitis n=5 Moderate interface hepatitis & typical autoAb Rejection n= 1 Original disease

40. **

44. p=0.063

45. ns

46. *

47. * p=0.051

48. ns

49. Histology - summary Milder portal infiltrates Milder interface hepatitis Fewer portal plasma cells Minimal duct injury PT

50. Histology - summary Milder portal infiltrates Milder interface hepatitis Fewer portal plasma cells Minimal duct injury Milder degree of CL dropout Similar inflammatory infiltrate (↓ PC) Overall lobular scores similar Minimal endothelialitis PT Lob

51. CLportal

54. HCV

56. Clinical features No differences in LFTs between 3 groups LFT pattern variable –BR usually normal –raised transaminases or cholestatic enzymes Autoantibodies –Recurrent 5/5 –De-novo 5/5 –CLH7/13

57. Treatment De-novo AI-like hepatitis Recurrent AIH AIH protocol

58. Treatment De-novo AI-like hepatitis Recurrent AIH CLH AIH protocol 5 - AIH protocol 8 - no change 4-HCV+2-fluctuate2-resolve No episodes CR or VOD

59. CLH on biopsy

60. pred / aza

61. Evolution (n=8 multiple biopsies) De-novo AI-like hepatitis Recurrent AIH CLH 1 1 2 + 3 1

62. Centrilobular hepatitis & AI-like hepatitis 1. Histological overlap CLH & AIH-DN & AIH-R 2. Similar clinical presentation 3. Histological evolution between the lesions 4. No episodes CR or VOD

63. Centrilobular hepatitis & AI-like hepatitis 1. Histological overlap CLH & AIH-DN & AIH-R 2. Similar clinical presentation 3. Histological evolution between the lesions 4. No episodes CR or VOD ? Does CLH represent a form of de novo autoimmune-like hepatitis with no or mild portal tract changes

64. Issues De-novo AI-like hepatitis AR Recurrent AIH CLH

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66. Do AutoAb mean AIH? NO Animal models of Tx 71% OLT recipients –2/3 patients by 3 years –M > F Salcedo J Hepatol 2001 Abstr. 30% non-OLT cirrhotics

67. AutoAb - classical AIH %AgeAutoAb Type 1 80%AdultANA, aSMA Type 2 4-20%Childanti-LKM-1 Type 310-20%Adultanti-SLA/LP

68. Autoantibodies variable late – 6 mo after hepatitis atypical anti-LKM –cytosolic antigen Salcedo 2002 Hepatology –anti-GST-T1 Aguilera 2001 Clin Exp Immunol

69. Autoantibodies variable late – 6 mo after hepatitis atypical LKM –cytosolic antigen Salcedo 2002 Hepatology –anti-GST-T1 Aguilera 2001 Clin Exp Immunol

70. Denovo AI-like hepatitis GSTT1 detoxification enzyme preferentially expressed liver and kidney cells (centrilobular hepatocytes) 20% pop n deletion GSTT1 gene  non- expression Potential for organ mismatch Aguilera I et al, Liver Transplantation 2004; 10: 1166-1172

71. Denovo AI-like hepatitis Aguilera I et al, Liver Transplantation 2004; 10: 1166-1172

72. Denovo AI-like hepatitis Aguilera I et al, Liver Transplantation 2004; 10: 1166-1172 110 OLT patients 15 pos  neg recipient 12/15 anti-GSTT1 Ab 6/15  de-novo AIH

73. Denovo AI-like hepatitis Aguilera I et al, Liver Transplantation 2004; 10: 1166-1172 Immune response to GSST1 in donor liver Targeted peptide not a self-Ag Immune response oligo-specific

74. GSTT-1 expression – PAH cohort Recipient negative GSTT1 Controls0/15 AIH-R3/5 AIH-DN2/4 CLH4/12 ns p = 0.004

75. Allo- vs Auto-immunity

76. Conclusions - CLH Common late finding in OLTx biopsies (13%) Shares clinical and histological features that overlap with autoimmune type hepatitis (milder) Responds to re-introduction of steroids Untreated may resolve or persist No progression to CR or VOD Shares potential pathogenic mechanism with de novo AI-like hepatitis (GSTT-1 mismatch)

77. Conclusions - CLH ? re-consider “isolated central venulitis” as form of acute rejection (Banff 2005) “Autoimmune-like centrilobular hepatitis”

78. Acknowledgments Dr Catherine Campbell Ms Glenda Balderson Ms Alba Vanelli-Rees Dr Julie Jonsson Dr Darrell Crawford