Chronic Rejection of Transplanted Liver

Definition

Consequence of severe chronic immunologic injury to bile duct epithelium (loss of ducts) and endothelium (obliterated arteries)

Two types: bile duct loss and obliterative arteriopathy
- Usually occur together
- Only one site affected in about 15% of cases
Bile duct loss (ductopenia, vanishing bile duct syndrome)
- At least 50% of portal tracts lack bile ducts
  - Need at least 4-5 complete portal tracts to evaluate
  - Preferably 20 tracts to evaluate
- Absence of bile ductular proliferation
- Cholestasis in zone 3 (pericentral)
- Pericentral hepatocyte ballooning and dropout
- Due to chronic injury
  - Acute bile duct loss after acute rejection may be reversible
Obliterative arteriopathy
- Requires hepatectomy for diagnosis
  - Occluded arteries due to concentric intimal thickening and lipid rich macrophages
  - Biliary strictures may occur
- Centrilobular hepatocyte dropout

Neeraja Kambham MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342