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Liver transplantation: Diagnosis of acute cellular rejection

K Rajender Reddy, MD
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Despite improvements in immunosuppressive therapy, hepatic allograft rejection remains an important cause of morbidity and late graft loss in patients undergoing liver transplantation [1-6].

At one end of the spectrum, graft function may remain stable in many patients found to have focal or mild histologic features of rejection on a protocol liver biopsy, even when no treatment is provided [7]. Such lymphocyte trafficking through the allograft has been hypothesized to contribute to the development of a degree of immunological tolerance. On the other hand, approximately 5 to 10 percent of liver transplantation recipients who develop acute cellular rejection progress to severe ductopenic rejection despite antirejection therapy [8]. These patients may require retransplantation.

The clinical manifestations and diagnosis of acute cellular liver transplantation rejection are described below. The treatment of this complication and a review of transplantation immunobiology are discussed separately. (See "Treatment of acute cellular rejection in liver transplantation" and "Transplantation immunobiology".)


Early acute cellular rejection mostly occurs within 90 days of the liver transplantation. Early acute rejection episodes do not adversely affect graft or patient outcomes, except in patients transplanted for hepatitis C virus, who have worse outcomes in the setting of bolus glucocorticoid therapy [9-11]. Late cellular rejection episodes are often associated with low blood cyclosporine or tacrolimus concentrations and have been associated with reduced graft survival [2,12-14]. The following examples illustrate the range of findings in the largest series:

In a cohort of 762 consecutive adult liver transplantation recipients, 490 (64 percent) developed at least one episode of rejection, most occurring during the first six weeks after transplantation [15]. Approximately 20 percent of these patients developed a second rejection episode within one year of transplantation.


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Literature review current through: Mar 2017. | This topic last updated: Jun 04, 2015.
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