Surgical Pathology Criteria

Acute Rejection of Transplanted Liver

Differential Diagnosis

Acute Rejection of Liver Chronic Rejection of Liver
1 week to 1 year post-transplant Presents > 6-12 months post-transplant
Bile duct lymphocytic infiltrate Bile duct loss in at least 50% of portal tracts
No cholestasis unless extensive bile duct damage Centrilobular cholestasis
No hepatocyte swelling Centrilobular hepatocyte swelling
No apoptotic bodies in lobules Scattered apoptotic bodies may be present

Acute Rejection of Liver Preservation / Reperfusion Injury of Transplanted Liver
Mixed portal and/or perivenular infiltrate Lacks perivenular infiltrate
Bile duct lymphocytic infiltrate Neutrophilic pericholangitis and bile ductular proliferation
Endotheliitis Lacks endotheliitis
1 week to 1 year post-transplant Less than 3 weeks post-transplant
Cholestasis absent to mild Centrilobular cholestasis

Acute Rejection

Acute Rejection and

Hepatitis C
Hepatitis C
Endotheliitis prominent Endotheliitis prominent Endotheliitis infrequent
Bile duct damage frequent Bile duct damage frequent Bile duct damage infrequent
Eosinophils frequent Eosinophils frequent Eosinophils few or rare
Steatosis infrequent Steatosis occasional Steatosis occasional
Acidophil bodies absent Acidophil bodies frequent Acidophil bodies frequent
Serum HCV RNA absent Serum HCV RNA present Serum HCV RNA present
Both may show a lymphocytic portal infiltrate, but acute rejection has a mixed infiltrate

Infectious processes in transplanted liver may present clinically or histologically in the differential diagnosis of acute rejection


Acute rejection of liver versus recurrence of original disease

Acute Rejection of Liver Bile Duct Obstruction
Mixed infiltrate frequently with eosinophils Eosinophils infrequent
Bile duct lymphocytic infiltrate Bile ductular proliferation with cholestasis and bile plugs, neutrophilic pericholangitis
Endotheliitis Lacks endotheliitis

Acute Rejection of Liver Acute Vascular Anastomotic Problems
Mixed infiltrate frequently with eosinophils No significant inflammation even in preserved parenchyma
No hepatocyte necrosis or infarction Extensive areas of infarction, with or without congestion
Endotheliitis Lacks endotheliitis

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