Acute and Chronic Rejection in Liver Transplantation

Advances in immunosuppression have improved the outcome of transplantation. Although early cellular rejection does not adversely impact transplantation outcome, late cellular rejection appears to behave differently from both a clinical and a histologic point of view, potentially resulting in poor outcomes. Histologic assessments continue to play an important role in the diagnosis and management of liver allograft rejection. Former conditions known as “de novo autoimmune hepatitis” and “idiopathic posttransplantation chronic hepatitis” are currently labeled “atypical cases of rejection” and late T cell–mediated rejection. There is increasing evidence to suggest that central perivenulitis may be an important manifestation of these immune conditions. In addition, although the liver appears relatively resistant to donor-specific antibody–mediated injury, alloantibody-mediated adverse consequences are increasingly being recognized, including cases of acute and chronic antibody-mediated rejection and the potential implication of atypical immune-mediated manifestations of rejection, particularly late and chronic rejection. Judicious immunosuppression appears to be a common protective factor against these complications. This review contains 5 figures, 5 tables, and 72 references. Key words: antibody-mediated rejection, chronic rejection, de novo autoimmune hepatitis, fibrosis, idiopathic posttransplantation hepatitis, late rejection, liver transplantation, plasma cell–rich rejection, T cell–mediated rejection