Liver transplantation: Diagnosis of acute cellular rejection
- K Rajender Reddy, MD
K Rajender Reddy, MD
- Ruimy Family President's Distinguished Professor of Medicine
- Professor of Medicine in Surgery
- Director of Hepatology
- Director, Viral Hepatitis Center
- Medical Director of Liver Transplantation
- University of Pennsylvania School of Medicine
- Section Editor
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
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 . 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 . 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".)
EPIDEMIOLOGY AND OUTCOMES
Acute rejection in liver transplant recipients is an important clinical event and identification of risk factors for rejection may permit a more individualized approach to immunosuppressive therapy.
In a study of two large cohorts of liver transplant recipients, at least one biopsy-proven acute rejection episode occurred in 27 percent recipients in the Adult to Adult Living Donor Liver Transplantation (A2ALL) cohort and in 15.6 percent recipients in Scientific Registry of Transplant Recipients (SRTR) cohort .
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- EPIDEMIOLOGY AND OUTCOMES
- Risk factors for acute rejection
- CLINICAL PRESENTATION
- LIVER BIOPSY
- DIFFERENTIAL DIAGNOSIS
- Recurrent hepatitis C virus
- Functional cholestasis
- Cyclosporine toxicity
- Massive hemorrhagic necrosis
- Alloimmune hemolysis
- APPROACH TO THE PATIENT
- SUMMARY AND RECOMMENDATIONS