Liver biopsy interpretation for causes of late liver allograft dysfunction

Abstract

Evaluation of needle biopsies and extensive clinicopathological correlation play an important role in the determination of liver allograft dysfunction occurring more than 1 year after transplantation. Interpretation of these biopsies can be quite difficult because of the high incidence of recurrent diseases that show histopathological, clinical, and serological features that overlap with each other and with rejection. Also, more than one insult can contribute to allograft injury. In an attempt to enable centers to compare and pool results, improve therapy, and better understand pathophysiological disease mechanisms, the Banff Working Group on Liver Allograft Pathology herein proposes a set of consensus criteria for the most common and problematic causes of late liver allograft dysfunction, including late-onset acute and chronic rejection, recurrent and new-onset viral and autoimmune hepatitis, biliary strictures, and recurrent primary biliary cirrhosis and primary sclerosing cholangitis. A discussion of differential diagnosis is also presented. (HEPATOLOGY 2006;44:489-501.)

Current views on rejection pathology in liver transplantation

“…Congestion or haemorrhage may also be present in these areas. Rarely, early AR presents with centrilobular inflammatory changes in the absence of the typical portal triad, termed ICP [7].…”

“…ICP is generally preceded by at least one episode of CP occurring in conjunction with portal features of rejection [8,9,14,15], occurs in around 30% of protocol biopsies [8,9,16] and is more commonly seen more than 1 year post-transplant [9,17], often with no or mild abnormalities in liver function tests [9]. A grading system for CP proposed by the Banff group [7] appears to correlate with adverse outcomes [9]. Rejection is the usual cause of ICP, but other causes of centrilobular injury such as ischaemia, drug toxicity, viral hepatitis (recurrent or acquired) and AIH (recurrent or acquired) should also be considered [18].…”

Immunology of Transplant Protocols

“…Small arteriolar vasculopathy and glomerulopathy occur in kidney, small airway fibrosis in lung (bronchiolitis obliterans), biliary duct loss and obstructive vasculopathy in liver, and coronary artery disease with concentric intravascular occlusion in heart transplant [9,13,[21][22][23]. Chronic rejection leads to ischemia and irreversible fibrosis with ultimate graft loss.…”

Idiopathic Post Liver-Transplant Hepatitis Remains Obscure with Respect to Its Etiology and Relationship with Immunosuppressiona

“…A histological pattern of chronic hepatitis (CH) characterized by lymphocytic inflammation with necro-inflammatory activity is often observed after liver transplantation (LT) and is linked to various causes such as viral infections and autoimmune disorders [1][2][3][4] . Some histological features may indicate particular causes.…”

“…The presence of ground-glass hepatocytes and positive immunostaining for Hepatitis B virus (HBV) antigens are pathognomonic of HBV infection. Lymphocytic cholangitis may be observed in Hepatitis E (HEV) [5] and Hepatitis C (HCV) infection [1][2][3] . Severe centrilobular necroinflammatory activity and plasma cell-rich infiltrate best correlated with the diagnosis of de novo autoimmune hepatitis (AIH) [6] .…”