NODULAR REGENERATIVE HYPERPLASIA OF THE LIVER GRAFT AFTER LIVER-TRANSPLANTATION

Nodular regenerative hyperplasia has not previously been reported in p atients who have undergone orthotopic liver transplantation. In this r eport we describe the clinical, biochemical and histologic findings in nine liver transplant recipients in whom nodular regenerative hyperpl asia developed between 6 and 144 mo (median, 64 mo) after transplantat ion. Six of the patients manifested features of portal hypertension (v ariceal bleeding, ascites, severe intractable peripheral edema), where as three patients were asymptomatic at the time of diagnosis. All pati ents had elevated serum alkaline phosphatase (median, 269 IU; range, 1 59 to 1182 IU) and gamma-glutamyl transferase levels (median, 247 IU; range 104 to 1513 IU). Other liver function tests remained normal. In five patients, earlier biopsies had identified histological features o f venous outflow block, consistent with azathioprine hepatotoxicity. A h nine patients had been taking azathioprine up to the time of present ation. After withdrawal of azathioprine, liver function tests improved appreciably in five patients and histologic improvement was documente d in four of these who underwent follow-up liver biopsies. In the rema ining four patients progressive graft failure ensued and all subsequen tly underwent repeat liver retransplantation. At a certain stage, nodu lar regenerative hyperplasia, in the context of a liver graft, becomes an irreversible lesion, emphasizing the need for early identification and withdrawal of the agent.