Pretransplant Biopsies and Outside Slides
Cirrhosis developing on a background of chronic inflammatory liver disease is the most common indication for liver replacement. A thorough pretransplantation workup is aimed at correctly identifying the cause of liver injury, and providing data to assess the usefulness of transplantation for particular disease indications. It also helps to determine if special treatment is needed; whether liver tissue destined for research purposes will require special handling and whether the original disease might influence the clinical course after transplantation. For the pathologist, the pretransplant workup often includes evaluation of consultation slides prepared elsewhere. A brief clinical history and referral pathology report including correct identification of the patient, must accompany the slides. Mention of any previous surgical procedures, treatment for liver disease, or remote liver biopsies performed before the onset of cirrhosis are generally helpful. At other times, liver biopsies are obtained just prior to hepatic replacement at the transplant center. Failure to obtain a tissue diagnosis of irreversible liver injury prior to transplantation in patients with chronic disease, will occasionally lead to inappropriate frozen section request when a donor organ becomes available. Such practice is strongly discouraged.
On occasion, patients with fulminant liver failure may be referred
for transplantation without a definitive diagnosis or thorough
pretransplant work-up. We have successfully utilized a transjugular
approach to obtaining biopsies in such patients(1-3), who are
stable enough to wait for the time required to prepare a permanent
section. In critically ill patients, frozen sections have provided
crucial diagnostic information, which has greatly influenced the
decision to proceed or abort a transplant procedure in some cases(1, 2). Knowledge that
will facilitate the processing of the information gained from the biopsy includes:
familiarity with the pattern of injury associated with particular
etiologic agents; the prognostic implications of the extent
of the injury; and presence or absence of significant regenerative activity.
Reference to a standard liver pathology
text is suggested for this information (4). Ultimately, the decision to proceed or
delay transplantation rests with the recipient surgeon. S/he is
responsible for collation of the information and advice provided
by a patient management team that includes a hepatologist, critical
care specialist, pathologist and anesthesiologist. The team combines
information gained from the biopsy histopathology with patient
demographic data, disease etiology, liver injury and synthetic
function tests and clinical profile (5).