Are posttransplantation protocol liver biopsies useful in the long term?

Controversy exists about the usefulness of yearly protocol liver biopsies after liver transplantation, mainly among patients with normal transaminase levels. The aim of this study is to determine (1) the prevalence and cause of histological liver injury in transplant recipients with a minimum histological follow-up of 1 year (n = 254), and (2) the correlation between histological findings and transaminase values. The main indication for liver transplantation was viral-related cirrhosis (61%; 86% caused by hepatitis C virus [HCV]). Protocol liver biopsies were performed yearly for the first 5 years in HCV-infected transplant recipients and at 1 and 5 years in the remaining patients. Histological liver injury included several categories of liver damage (hepatitis, rejection, steatohepatitis, cholangitis, and Budd-Chiari-like lesions). Among biopsy specimens categorized as hepatitis, severe hepatitis was defined as the presence of stage 3 or greater fibrosis. The prevalence of liver injury increased significantly with time (42% v 56% at 1 and 5 years, respectively; P =.09) and was significantly greater in patients who underwent transplantation for HCV-related cirrhosis than in those who underwent transplantation for other reasons (P =.0001). The most frequent category of liver injury was hepatitis (97% and 96% at 1 and 5 years, respectively). Although a proportion of patients with liver injury (12% to 29%) had normal transaminase values, this percentage was almost null in patients with severe hepatitis. Normal histological characteristics were found in the vast majority of non-HCV-infected transplant recipients with normal transaminase values. Given the high prevalence of abnormal histological findings, particularly the increase over time of those defined as severe, protocol liver biopsies are clearly justified in HCV-infected transplant recipients. Conversely, given the rarity of abnormal histological findings, protocol liver biopsies should be questioned in non-HCV-infected transplant recipients with normal transaminase values.