Post-transplant Recurrent Bile Salt Export Protein (BSEP) Disease: A Form of Antibody-mediated Graft Dysfunction and Utilization of C4d.

Recurrent Bile Salt Export Protein (rBSEP) disease has been reported in PFIC2 patients following liver transplantation (LT), and is often refractory to standard anti-cellular rejection immunosuppressants. The mechanism of rBSEP disease is proposed to be a form of type II hypersensitivity reaction with de novo anti-BSEP antibodies blocking the function of allograft BSEP. Utilization of C4d has not been evaluated in rBSEP. We describe a girl with 3 episodes of rBSEP with severe pruritus at 8.9, 10.3, and 11.0 years post-LT, respectively. Patient's serum reacted with normal liver canaliculi by indirect immunofluorescence (IF), while patient's liver showed canalicular IgG deposition. The histologic features of all three liver biopsies recapitulate PFIC2 with cholestatic giant cell hepatitis. Canalicular BSEP expression was not detected in areas of feathery degeneration by immunohistochemistry; but was retained in morphologically normal liver. By direct IF, C4d showed diffuse sinusoidal staining in the 3rd biopsy. Patient responded well to Rituximab with or without intravenous immunoglobulin with subsiding symptoms and normalization of serum bile acid levels. In conclusion, rBSEP disease should be considered in the differential diagnosis when evaluating for rejection in a PFIC2 patient post-LT presenting with pruritus. A portion of liver core may be snap frozen in OCT medium for possible direct IF for C4d, that can serve as a surrogate marker for complement activation and antibody mediated graft dysfunction. (C) 2017 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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