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Orthotopic Liver Transplants in Children: Change in Hepatic Venous Doppler Wave Pattern as an Indicator of Acute Rejection¹

¹ From the Departments of Pediatric Radiology (S.J., J.C.J., S.H.), Pediatric Surgery (C.L.C.), and Pediatric Gastroenterology (D.C.B.), Children’s Hospital, University Hospital of Geneva, 6 rue Willy Donzé, 1112 Geneva, Switzerland. Received July 23, 2001; revision requested September 24; final revision received May 1, 2002; accepted May 14. Address correspondence to S.J. (e-mail: sigrid.jequier@hcuge.ch).

View larger version (69K): [in a new window]   Figure 1. Transverse US image of the middle hepatic vein depicts normal hepatic venous Doppler US wave pattern: The flow wave is directed toward the ICV during diastole (d), reverses toward the liver during atrial systole (p), then proceeds back toward the heart and reverses again to a lesser degree toward the liver during contraction of the right ventricle (v). * = baseline.

View larger version (129K): [in a new window]   Figure 2a. Doppler US images depict findings of transplant rejection in a girl aged 9 years 2 months with a reduced left liver graft; her liver failure had been caused by Langerhans cell histiocytosis complicated by sclerosing cholangitis. (a) Sagittal image of the left hepatic vein shows a triphasic flow pattern; this was observed at US during each of the first 4 days after surgery. Arrows point to reversion of flow during atrial systole. (b) Sagittal image obtained during the 5th day after surgery shows a change to a monophasic flow pattern. Results of liver biopsy confirmed acute cellular graft rejection. (c) Sagittal image of the same vein on day 13. With treatment, return to a well-modulated biphasic hepatic venous flow pattern has occurred. Arrows point to reversion of flow during atrial systole.

View larger version (118K): [in a new window]   Figure 2b. Doppler US images depict findings of transplant rejection in a girl aged 9 years 2 months with a reduced left liver graft; her liver failure had been caused by Langerhans cell histiocytosis complicated by sclerosing cholangitis. (a) Sagittal image of the left hepatic vein shows a triphasic flow pattern; this was observed at US during each of the first 4 days after surgery. Arrows point to reversion of flow during atrial systole. (b) Sagittal image obtained during the 5th day after surgery shows a change to a monophasic flow pattern. Results of liver biopsy confirmed acute cellular graft rejection. (c) Sagittal image of the same vein on day 13. With treatment, return to a well-modulated biphasic hepatic venous flow pattern has occurred. Arrows point to reversion of flow during atrial systole.

View larger version (103K): [in a new window]   Figure 2c. Doppler US images depict findings of transplant rejection in a girl aged 9 years 2 months with a reduced left liver graft; her liver failure had been caused by Langerhans cell histiocytosis complicated by sclerosing cholangitis. (a) Sagittal image of the left hepatic vein shows a triphasic flow pattern; this was observed at US during each of the first 4 days after surgery. Arrows point to reversion of flow during atrial systole. (b) Sagittal image obtained during the 5th day after surgery shows a change to a monophasic flow pattern. Results of liver biopsy confirmed acute cellular graft rejection. (c) Sagittal image of the same vein on day 13. With treatment, return to a well-modulated biphasic hepatic venous flow pattern has occurred. Arrows point to reversion of flow during atrial systole.

View larger version (149K): [in a new window]   Figure 3a. Doppler US images in a boy aged 5 years 3 months who had received an entire liver at age 3 years 3 months for congenital biliary atresia and a failed Kasai operation. (a) Transverse image of the middle hepatic vein of the transplant shows that the hepatic venous flow wave is triphasic. (b) In an image obtained 1 month later in the same view as a, hepatic venous flow is now monophasic. Biopsy revealed lymphoid infiltration of the liver in the context of lymphoproliferative disease. These images represent a false-positive Doppler US result.

View larger version (153K): [in a new window]   Figure 3b. Doppler US images in a boy aged 5 years 3 months who had received an entire liver at age 3 years 3 months for congenital biliary atresia and a failed Kasai operation. (a) Transverse image of the middle hepatic vein of the transplant shows that the hepatic venous flow wave is triphasic. (b) In an image obtained 1 month later in the same view as a, hepatic venous flow is now monophasic. Biopsy revealed lymphoid infiltration of the liver in the context of lymphoproliferative disease. These images represent a false-positive Doppler US result.

View larger version (34K): [in a new window]   Figure 4. Graph shows results of statistical analysis of the value of Doppler US examinations in the identification of instances of acute liver graft rejection. These results were based on two levels of analysis. The first level, all information (AI), involved an analysis of Doppler US results as compared with clinical findings and biopsy findings. The second level involved the analysis of Doppler US results as compared with biopsy findings (B) only. Intermediate computations needed for comparison of results of the two levels of analysis—that is, the difference between the two levels (AI-B) and the 2 value ([AI-B]**2/B) for the two levels—are presented graphically. The difference is highly significant overall (2 = 63.12 with three degrees of freedom, P < .001). This result is almost entirely due to the group of false-positive Doppler US images (2 = 60.75 with one degree of freedom, P < .001). The difference between the frequencies observed in the categories of false-negative and true-negative results is zero; the difference between the frequencies observed in the categories of false-positive and true-positive results is negligible and not statistically significant.