Dig Liver Dis. 2013 Jun;45(6):505-9.

The meaning of tissue and serum HCV RNA quantitation in hepatitis C recurrence after liver transplantation: a retrospective study.

Vasuri F, Morelli MC, Gruppioni E, Fiorentino M, Ercolani G, Cescon M, Pinna AD, Grigioni WF, D’Errico-Grigioni A.

Pathology Unit, F. Addarii Institute of Oncology and Transplantation Pathology, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy.



BACKGROUND: While the role of serum HCV RNA quantitation in hepatitis C virus recurrence after liver transplantation is well established, the meaning of HCV RNA tissue quantitation is largely unclear, and no correlations with recipient outcome have been investigated yet.

AIMS: To assess the predictive value, and a possible prognostic role, of tissue and serum HCV RNA in first post-transplant biopsies.

METHODS: We retrospectively reviewed the first post-transplant biopsies of 83 recipients. Tissue and serum HCV RNA was quantitated by RT-PCR, and compared with serum, clinical and histological data.

RESULTS: HCV RNA quantitation allowed us to categorise recipients into three different risk groups: (1) tissue HCV RNA ≤ 1.5 IU/ng with any serum HCV RNA; (2) tissue HCV RNA>1.5 IU/ng and serum HCV RNA < 40 × 10(6)copies/mL; (3) tissue HCV RNA>1.5 IU/ng and serum HCV RNA ≥ 40 × 10(6)copies/mL. Hepatitis C virus recurrence rates in the three groups were 68%, 91% and 100% (P=0.004); hepatitis C virus-related mortality was 0%, 14% and 45% respectively (P<0.001).

CONCLUSIONS: This preliminary study on serum and tissue HCV RNA quantitation allows recipient “stratification” in prognostic groups, which could be applicable in the future for timely antiviral treatment and/or immunosuppression modulation.

Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd.

PMID: 23317815



Liver cirrhosis due to hepatitis C virus (HCV) infection is the first indication for orthotopic liver transplantation (OLT) in the Western Countries. HCV re-infection after OLT is virtually universal, and histopathological HCV recurrent hepatitis is recorded in most recipients, representing the major cause of overall post-transplant mortality. Liver tissue HCV RNA (tHCV RNA) evaluated with both real-time quantitative polymerase chain reaction (RT-PCR) and immunohistochemistry were seen to be significantly higher in recipients with histologically-proven HCV recurrence than in other recipients, but a validated laboratoristic cut-off value for RT-PCR, with a prognostic meaning in addition to a diagnostic usefulness, was still lacking.

The aims of our retrospective study were to compare tHCV RNA and serum HCV RNA (sHCV RNA) in a series of 83 HCV-positive OLT recipients who clinically needed a first liver biopsy after OLT (early phases of acute HCV recurrence), and to combine these values with clinical and pathological data in order to assess their predictive value in the natural history of HCV recurrence.

To study HCV-positive recipients in a reproducible fashion, we chose to analyse the first post-transplant liver biopsies of each recipient. The premise is that there is no consensus among transplant centres concerning the usefulness of scheduled biopsies, and also in our Institution performing liver biopsies in recipients with normal transaminase levels and good clinical conditions raises ethical considerations. Thus, the first post-OLT liver biopsy is performed for specific clinical indications. In our series the first liver biopsy was performed after 3 months from OLT on average, and the total number of recipients with HCV recurrence was 71 (85%). After a median follow-up time of nearly 3 years, 29 recipients died, among which 13 died from graft failure related to HCV recurrent hepatitis. This means that we recorded a 15.7% of overall HCV-related mortality, an additional evidence of how HCV recurrent hepatitis still represents a major topic in transplantation.

Diagnostic usefulness of HCV RNA quantitation. Mean tHCV RNA at first biopsy was 26.35 IU/ng and 1.55 IU/ng among the recurrent and non-recurrent recipients respectively (P<0.001, Mann-Whitney test). A cut-off value of 0.85 IU/ng, showed a sensitivity of 89% and a specificity of 71% towards the histological diagnosis of HCV recurrent hepatitis. We realize that this cut-off value is very low, but it reflects the fact that only OLT recipients with tHCV RNA close to 0 can be reasonably considered free from HCV active replication in the very early post-transplant stages (see Figure 1 for a case with very low tissue HCV RNA). Moreover, we recommend the use of RT-PCR as a diagnostic tool supporting (and not replacing) the histopathological diagnosis: indeed, the diagnosis of HCV recurrent hepatitis must be based on a histopathological picture at least compatible and (then) confirmed by RT-PCR.

Prognostic usefulness of HCV RNA quantitation. Interestingly, no HCV-related deaths were recorded among patients with tHCV RNA less than 1.5 IU/ng at first biopsy. On the other hand, among the recipients with tHCV RNA ≥1.5 IU/ng, HCV-related outcome was strongly related to sHCV RNA. Thus, we were able to sort the recipients into three risk groups, basing on both tissue and serum HCV RNA quantitation at the time of the first post-transplant liver biopsy:

Group 1 (34%, Figure 1): tHCV RNA ≤1.5 IU/ng, any sHCV RNA. Nineteen (68%) recipients of this group had a histological HCV recurrence with no cases of HCV-related deaths.

Group 2 (42%): tHCV RNA >1.5 IU/ng, sHCV RNA <40 x106 copies/mL. Thirty-two (91%) recipients of this group had a HCV recurrent hepatitis, 4 (11%) died from HCV-related disease.

Group 3 (24%, Figure 2): tHCV RNA >1.5 IU/ng, sHCV RNA ≥40 x106 copies/mL. All recipients of this group had a diagnosis of HCV recurrence, and 9 (45%) died from HCV-related disease.

From group 1 to group 3, there is an increasing incidence in HCV recurrent hepatitis rates (from 68% to 100%), a diminished recurrence time, and an increasing HCV-related mortality, from 0% to 45%, which means that recipients of group 1 are likely to be virtually protected from disease progression, while nearly half recipients from group 3 will die from HCV recurrent hepatitis.

Also the severity of the histopathological picture increased from group 1 to 3, with an increasing number of Councilman bodies, which reflected a more active viral replication with lobular necrosis (see also Figure 2). Of note, a cholestatic hepatitis, which is a well-known variant of HCV recurrent hepatitis with worse prognosis, was seen in the first biopsy in 35% on group 3 recipients (and in none of the group 1, as quite expected).

A very interesting observation came from the comparison with clinical data, which showed that 30% of group 3 recipients experienced post-transplant biliary complications before biopsy, versus 7-9% of groups 1 and 2. Moreover, the occurrence of biliary complications was likely to be specifically related to HCV-related mortality, and not to overall mortality, reinforcing the correlation between biliary complications and HCV replication. The link between HCV replication and biliary complications has already been reported in the literature, but it has not been clarified yet.

Implications and possible applications of the study. Our results indicate that the first post-transplant liver biopsy is a reliable model for the study of HCV-positive recipients, at least in settings where the scheduled biopsies are not performed. Furthermore, in these critical patients all serological analyses as well as liver biopsies should always be performed at the time of the first clinical “event”, in order to analyze both serum and tissue HCV RNA and therefore study the HCV-related risk. The early recognition of group 3 recipients should imply a more aggressive antiviral therapy and/or an adequate immunomodulation.



1. D’Errico-Grigioni A, Fiorentino M, Vasuri F, Gruppioni E, Fabbrizio B, Zucchini N, Ballardini G, Morelli C, Pinna AD, Grigioni WF. Tissue hepatitis C virus RNA quantification and protein expression help identify early hepatitis C virus recurrence after liver transplantation. Liver Transpl 2008;14:313-20
2. Gruppioni E, Vasuri F, Fiorentino M, Capizzi E, Altimari A, Pirini MG, Grazi GL, Malvi D, Grigioni WF, D’Errico-Grigioni A. Real-time quantitative assay for routine testing of HCV RNA in formalin-fixed, paraffin-embedded liver samples. Diagn Mol Pathol 2009;18:232-8


Prof. Antonia D’Errico-Grigioni, MD.
“F. Addarii” Institute of Oncology and Transplantation Pathology,
Department of Experimental, Diagnostic and Specialty Medicine (DIMES),
S. Orsola-Malpighi Hospital, Bologna University.
V.le Ercolani 4/2, 40138, Bologna, Italy.

figure-11Figure 1. A case with not-specific post-transplant alterations, with mild portal infiltrate (a) and no major lobular involvement (b). At real-time PCR (c) the HCV RNA curve from the specimen was 5 copies, below the reference standard curve 10.

figure-21Figure 2. A case of early HCV recurrent hepatitis, showing marked portal infiltrate with piecemeal necrosis (a) and lobular Councilman’s bodies (arrows) with hepatocytic polymorphism (b). At real-time PCR (c) the HCV RNA curve from the specimen was 3.26 x 10^4 copies, between the reference standard curve 10^5 and the reference standard curve 10^4.


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