Rejection in Liver Transplantation Recipients

Abstract

Rejection following liver transplantation continues to impact transplant recipients although rates have decreased over time with advances in immunosuppression management. The diagnosis of rejection remains challenging with liver biopsy remaining the reference standard for diagnosis. Proper classification of rejection type and severity is imperative as this guides management and ultimately graft preservation. Future areas of promise include non-invasive testing for detection of rejection to reduce the morbidity associated with invasive testing and further advances in immunosuppression management to reduce toxicities associated with immunosuppression while minimizing rejection related morbidity.

Keywords: Banff criteria; immunosuppression; rejection.

Figure 1

Acute cellular rejection and plasma cell rich rejection. A to D. Hematoxylin and Eosin, light microscopy. A, 100×, acute cellular rejection: moderate portal inflammation composed of lymphocytes and some eosinophils with ductulitis (long arrows) and endotheliitis (short arrow). B, 200×, acute cellular rejection, endotheliitis: expansion of portal tracts by a mixed infiltrate of predominantly lymphocytes and some eosinophils is noted. Endotheliitis is subendothelial lymphocytic infiltration in the portal venules, short arrows. C, 200×, acute cellular rejection, ductulitis: expansion of portal tracts by a mixed infiltrate of predominantly lymphocytes and some eosinophils is noted. Ductulitis is bile ducts cuffed and infiltrated by inflammatory cells, long arrows. D, 400×, plasma cell rich rejection: moderate periportal and perivenular inflammation is rich in plasma cells, short arrow.

Figure 2

Chronic rejection and antibody mediated rejection. A to D. Hematoxylin and Eosin, light microscopy. A, 100×, antibody mediated rejection: perivenular hepatocyte dropout and inflammation is noted, arrow. B, 100×, chronic rejection: ductopenia or absence of bile ducts is noted in the two portal tracts noted in this field, arrow. C, 100×, chronic rejection: senescent or dystrophic changes in bile ducts include nuclear pleomorphism, enlargement, and loss of polarity, arrow. D, 400×, chronic rejection: sinusoidal aggregated of foamy histiocytes is one of the features of chronic rejection, arrow.