Acute Rejection Grading

Pretransplant Biopsies and Outside Slides

Cirrhosis developing on a background of chronic inflammatory liver disease is the most common indication for liver replacement. A thorough pretransplantation workup is aimed at correctly identifying the cause of liver injury, and providing data to assess the usefulness of transplantation for particular disease indications. It also helps to determine if special treatment is needed; whether liver tissue destined for research purposes will require special handling and whether the original disease might influence the clinical course after transplantation. For the pathologist, the pretransplant workup often includes evaluation of consultation slides prepared elsewhere. A brief clinical history and referral pathology report including correct identification of the patient, must accompany the slides. Mention of any previous surgical procedures, treatment for liver disease, or remote liver biopsies performed before the onset of cirrhosis are generally helpful. At other times, liver biopsies are obtained just prior to hepatic replacement at the transplant center. Failure to obtain a tissue diagnosis of irreversible liver injury prior to transplantation in patients with chronic disease, will occasionally lead to inappropriate frozen section request when a donor organ becomes available. Such practice is strongly discouraged.

On occasion, patients with fulminant liver failure may be referred for transplantation without a definitive diagnosis or thorough pretransplant work-up. We have successfully utilized a transjugular approach to obtaining biopsies in such patients(1-3), who are stable enough to wait for the time required to prepare a permanent section. In critically ill patients, frozen sections have provided crucial diagnostic information, which has greatly influenced the decision to proceed or abort a transplant procedure in some cases(1, 2). Knowledge that will facilitate the processing of the information gained from the biopsy includes: familiarity with the pattern of injury associated with particular etiologic agents; the prognostic implications of the extent of the injury; and presence or absence of significant regenerative activity. Reference to a standard liver pathology text is suggested for this information (4). Ultimately, the decision to proceed or delay transplantation rests with the recipient surgeon. S/he is responsible for collation of the information and advice provided by a patient management team that includes a hepatologist, critical care specialist, pathologist and anesthesiologist. The team combines information gained from the biopsy histopathology with patient demographic data, disease etiology, liver injury and synthetic function tests and clinical profile (5).


  1. Demetris AJ. The pathology of liver transplantation. [Review]. Curr Probl Surg 1990;27(3):117-178.
  2. Donaldson BW, Gopinath R, Wanless IR, et al. The role of transjugular liver biopsy in fulminant liver failure: relation to other prognostic indicators. Hepatology 1993;18(6):1370-1376.
  3. Lee RG. Diagnostic Liver Pathology. St. Louis: Mosby-Yearbook, Inc., 1994.
  4. Demetris AJ, Tsamandas AC, Delaney CP, et al. Pathology of Liver Transplantation. In: Transplantation of the Liver, (Busuttil RW and Klintmalm GB eds). Philadelphia: W. B. Saunders Company, 1996:681-723.

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Last Modified: Thu Jun 18 10:14:08 EDT 2009


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