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Acute/Active Antibody-Mediated Liver Allograft Rejection and Scoring of Components
Diagnosis of Acute/Active AMR |
Category
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Criteria for Diagnosis |
1. Histopathology |
2. DSA (Donor-specific antibody) |
3. C4d Immunostain |
4. Other
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5. Overall Scores
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Definite for AMR
(criteria 1-4 required, criterion 5 derives from these)
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(See below for component scoring: overall h-score =2-3)
Usually present: a. Portal microvascular endothelial cell hypertrophy b. Dilatation of portal capillaries and inlet venules c. Portal microvasculitis (monocytic, eosinophilic and/or neutrophilic) d. Portal edema e. Ductular reaction
Other features: f. Cholestasis (usually present but variable) g. Edema with periportal necrosis (more common/prominent with ABO mismatch) h. Lymphocytic and/or necrotizing arteritis (variable)
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Positive serum DSA
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(See below for component scoring) Diffuse microvascular C4d deposition (score=3) on frozen or formalin fixed-paraffin-embedded tissue in ABO-compatible graft
OR Portal stromal C4d deposition in ABO-incompatible graft
(Assumes optimized C4d staining with adequate positive control)
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Reasonably exclude other insults causing similar injury pattern
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Most cases will have C4d score of 3 and h-score of 2-3 for total of 5-6.
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Suspicious for AMR (criteria 1, 2 and 5 required) |
h-score >0 |
Positive serum DSA |
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C4d score + h-score = 3-4
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Indeterminate for AMR (criteria 2, 3 and 5 OR 2, 4 and 5 required) |
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DSA negative, equivocal or not available |
C4d stain negative (score=0), equivocal or not available |
Coexisting insult might be contributing to injury |
C4d score + h-score =2 or greater
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h score (Histopathology Score) for Acute/Active AMR Components
Score
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Components |
Portal Microvascular Endothelial Cells |
Microvasculitis |
Microvascular Dilatation |
Portal Edema |
Microvascular Injury |
1
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Portal microvascular endothelial cell enlargement (portal veins, capillaries, inlet venules) involving majority of portal tracts
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Sparse microvasculitis (3-4 marginated and/or intraluminal monocytes, neutrophils or eosinophils in maximally involved capillary |
Generally mild |
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2 |
Prominent portal and/or sinusoidal microvascular endothelial cell enlargement involving majority of portal tracts or sinusoids |
Microvasculitis/capillaritis (at least 5-10 marginated and/or intraluminal monocytes, neutrophils or eosinophils in the maximally involved capillary) |
Variable but noticeable portal capillary and inlet venule dilatation |
Variable |
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3 |
Prominent portal and/or sinusoidal microvascular endothelial cell enlargement involving majority of portal tracts or sinusoids |
Marked microvasculitis/capillaritis (10 or more marginated and/or intraluminal monocytes, neutrophils or capillaries in the maximally involved capillary) |
Marked capillary dilatation |
Variable |
At least focal microvascular disription with fibrin deposition and extravasation of red blood cells into portal stroma and/or Space of Disse |
C4d (Immune) Score for Acute/Active AMR Components
Score
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Appearance in Formalin-fixed, Paraffin-embedded Tissue |
0
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No C4d deposition in portal microvasculature
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1
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Minimal (<10% of portal tracts) C4d deposition in >50% of the circumference of portal microvascular endothelia (portal veins and capillaries)
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2 |
Focal (10-50% of portal tracts) C4d deposition in >50% of the circumference of portal microvascular endothelia (portal veins and capillaries), usually without extension into periportal sinusoids |
3 |
Diffuse (>50% of portal tracts) C4d deposition in >50% of the circumference of portal microvascular endothelia (portal vaines and capillaries), often with extension into inlet venules or periportal sinusoids |
Reference
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Demetris AJ et al. 2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of antibody-mediated rejection. Am J Transplant 2016;16:2816-28335
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Last Modified: Thu Jun 18 10:14:08 EDT 2009
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