Liver
transplant Rejection
Epidemiology and
Etiology:
- <
5% of liver transplant recipients
Common sites:
Gross features:
Histologic
features:
- Acute
cellular rejection ( < 6wks):
- Mixed
portal tract inflammation
- Lymphocytes
- Plasma
cells
- Neutrophils
- Eosinophils (often abundant, very
helpful)
- Large
lymphoid cells (occasionally)
- Bile duct
injury
- Surrounded
and infiltrated by inflammatory cells
- Damage
to epithelium
- Variation
in nuclear size
- Vacuolation of cytoplasm
- Regions
of cell stratification
- Cell
loss and irregularity of duct outlines
- Hepatocyte injury
- Near
central vein endotheliitis
- Endotheliitis (maybe)
- Attachment
of lymphoid cells to the endothelium of portal vein branches or
terminal hepatic venules
- Endothelial
damage
- Subendothelial inflammation
- Lifting
off of endothelial cells from the underlying vein wall
- Banff
grading scheme (rejection activity index – RAI):
- Portal
inflammation:
- 1
– mosly lymphocytic inflammation involving
but not expanding a minority of the triads
- 2
– expansion of most or all triads by mixed infiltrate
- 3
– marked expansion of most or all triads by mixed infiltrate
containing numerous blasts and eosinophils
- Bile
duct inflammation:
- Venous
endothelial inflammation:
- Chronic
(ductopenic) rejection (60d or longer):
- Severe
obliterative arteritis
of small and larger arteries
- Loss
of portal tract arterioles maybe
- Ischemic
changes and necrosis of hepatocytes in perivascular liver parenchyma
- Small
duct “dystrophy”:
- Atrophy
- Nuclear
pleomorphism
- Pyknosis
- Ductopenia over time (>50% of
portal tracts required)
- Sparse
portal inflammation over time
- Acute
rejection may also be present
- Cholestasis in late stage
- Fibrosis
(but usually not cirrhosis) in late stage
Immunophenotype:
Marker:
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Sensitivity:
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Specificity:
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Molecular features:
Other features:
- Chronic
rejection usually leads to irreversible graft failure
References:
- Robbins
& Cotran Pathologic Basis of Disease (2005)
- Scheuer & Lefkowitch Liver Biopsy Interpretation (2006)