The Role of the Pathologist in Liver Transplantation

Effective management of solid organ transplantation recipients requires a team of physicians, familiar with complications unique to immunosuppressed allograft recipients. An anatomical pathologist with a special interest in transplantation pathobiology can be an invaluable member of such a team. He/she can significantly contribute to almost every aspect of a large transplantation program, including recipient selection, evaluation of donor organs and post-transplant follow-up, as well as research into new therapeutic approaches and the understanding of disease processes. In addition, because of the specialization required, transplant centers tend to be regionalized. Therefore, some of the follow-up care will often occur at smaller facilities and pathologists not familiar with post-transplant, will at times encounter biopsies from liver allograft recipients. In some instances, complications that arise are relatively straightforward and can be easily handled at a non-transplant center. However, other complications are difficult to recognize and therefore, require considerable experience. In such cases, close contact with experts at the regional transplant center can be helpful. This is made easier with the advent of electronic communications, such as e-mail and the internet. This site is but one example.

To effectively deal with transplantation pathology, it is desirable that the pathologist has an adequate working knowledge of four basic areas: 1) liver pathophysiology; 2) familiarity with clinical management problems and terminology; 3) opportunistic infections and immunodeficiency-associated malignancies and 4) immunopathology. These help the pathologist to correctly diagnose the histopathological changes seen on light microscopy and effectively communicate this information to the clinical managment team. In addition, transplantation pathology is more "medical" or "inflammatory" pathology rather than tumor pathology, which comprises a significant proportion of most surgical pathology practices. Thus, one may be asked to render an "opinion" rather than an absolute diagnosis. For example, a patient may develop a post-transplant lymphoproliferative disorder(PTLD) because of over-immunosuppression. Subsequently, the immunosuppressive therapy may be substantially reduced or withdrawn. Rejection of the allograft may then appear, and these changes may overlap with those seen with Epstein-Barr virus(EBV) hepatitis. The pathologist may be asked to render an opinion whether the rejection is "severe enough" to require therapy today, or can the treatment be delayed until all evidence of EBV reactivity or PTLD has resolved. Willingness to answer a question like this, and participate in the decision-making process, requires experience with similar situations in the past, and an understanding that the pathologist will at times, be proven wrong. These types of situations may be unconfortable to some, because pathologists are often thought of as the "final check point", where the "correct" diagnosis is rendered.

Nevertheless, I have found this type of pathology practice to be particularly rewarding. The feedback on the correctness of diagnoses is very quick and One can significantly contribute to an efficient and effective management of patients who have been given a "second chance" at life, being rescued from endstage organ disease.

Please mail comments, corrections or suggestions to the TPIS administration at the UPMC.

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