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liver allograft chronic rejection

Tuesday 13 April 2004

chronic hepatic allograft rejection; chronic rejection of liver allograft

Types

- ductopenic chronic hepatic allograft rejection
- hepatocytary chronic hepatic allograft rejection

Differential diagnosis

- Recurrent and infectious disorders associated with duct loss

  • A number of recurrent liver diseases post-transplant are associated with ductopenia (e.g., primary biliary cirrhosis and primary sclerosing cholangitis).
  • These conditions are associated with prominent portal lymphocytic infiltrates and in some instances (e.g., primary biliary cirrhosis) numerous portal plasma cells, with the majority having some degree of portal fibrosis as well. In addition, many of these liver diseases may eventually progress to a biliary cirrhosis.
  • Adenovirus infection in the pediatric population can also rarely be associated with duct injury and eventual duct loss; however, characteristic nuclear inclusions (smudge cells) are also present with this infection, and rarely a severe confluent parenchymal necrosis may also occur.
  • Chronic rejection, however, is associated with mild portal fibrosis, with occasional bridging fibrosis seen between terminal hepatic venules, without cirrhosis (rare cases reported) or significant lobular inflammation or necrosis.
  • In addition, portal inflammation diminishes as duct loss develops, with most portal tracts showing virtually no portal inflammation at the time of late stage chronic rejection.

- Drug-induced liver injury (e.g., chlorpromazine, chlorpropamide)

  • Certain drugs are associated with bile duct injury and ductopenia. Correlation with the timeframe of initiation of the drug and the onset of abnormal liver tests is important.
  • In drug-induced duct injury, after the drug is discontinued, the vast majority of cases will show eventual resolution of the duct damage; if the etiology is chronic rejection, however, duct damage will persist with eventual bile duct loss.

- Bile duct ischemia from hepatic artery thrombosis

  • Bile duct ischemia with eventual bile duct loss can also occur in partial or total hepatic artery occlusion from hepatic artery thrombosis.
  • The liver injury in this setting is acute and severe due to coexisting ischemic necrosis of the parenchyma, and arteriography confirms the appropriate diagnosis.

See also

- liver allograft

References

- Demetris A, Adams D, Bellamy C, Blakolmer K, Clouston A, Dhillon A, et al. Update of the International Banff Schema for Liver Allograft Rejection: working recommendations for the histopathologic staging and reporting of chronic rejection. An international panel. Hepatology 2000; 31: 792-799.

- Evans H, Kelly D, McKiernan P, Hubscher S. Progressive histological damage in liver allografts following pediatric liver transplantation. Hepatology 2006; 43: 1109-1117.

- Riva S, Sonzogni A, Bravi M, Bertani A, Alessio M, Candusso M, et al. Late graft dysfunction and auto-antibodies after liver transplantation in children: preliminary results of an Italian experience. Liver Transpl 2006; 12: 573-577.

- Sebagh M, Rifai K, Feray C, Yilmaz F, Falissard B, Roche B, et al. All liver recipients benefit from the protocol 10-year liver biopsies. Hepatology 2003; 37: 1293-1301.

- Neil D, Huebscher S. Histologic and biochemical changes during the evolution of chronic rejection in liver allografts. Hepatology 2002; 35: 639-651.

- Sebagh M, Blakolmer K, Falissard B, Roche B, Emile JF, Bismuth H, Samuel D, Reynes M. Accuracy of bile duct changes for the diagnosis of chronic liver allograft rejection: reliability of the 1999 Banff schema. Hepatology. 2002 Jan;35(1):117-25. PMID: 11786967

- Freese D, Snover D, Sharp H, Gross C, Savick S, Payne W. Chronic rejection after liver transplantation: a study of clinical histopathological and immunological features. Hepatology 1991; 13: 882-891.