Chronic Liver Rejection
Histologic Features of Early and Late Chronic Liver Allograft Rejection
and Suggested Fibrosis Scoring

Early CR

Late CR

Small bile ducts

(<60 um)

Senescence-related changes involving a majority of ducts (eosinophilic transformation of the cytoplasm; increased N:C ratio; nuclear hyperchromasia; uneven nuclear spacing; ducts only partially lined by biliary epithelial cells)

Bile duct loss <50% of portal tracts

Degenerative changes in remaining bile ducts

Loss in >=50% of portal tracts

Terminal hepatic venules and zone 3 hepatocytes

Perivenular mononuclear inflammation

Lytic zone 3 necrosis and inflammation 

Mild perivenular fibrosis (See below)

Focal obliteration

Variable inflammation

Moderate to severe (bridging) fibrosis (See below)

Portal tract hepatic arterioles 

Occasional loss involving <25% of portal tracts

Loss involving >25% of portal tracts


So-called "transition" hepatitis with spotty necrosis of hepatocytes

Sinusoidal foam cell accumulation; marked cholestasis

Large perihilar hepatic artery branches 

Intimal inflammation, focal foam cell deposition without luminal compromise

Lumenal narrowing by subintimal foam cells

Fibrointimal hyperplasia

Large perihilar bile ducts 

Inflammation damage and focal foam cell deposition

Mural fibrosis

Suggested Fibrosis Scoring 

Score as 0 to 3 for the following:
Portal/periportal: 0 (none) to 3 (portal-portal or portal-central bridging)
Subsinusoidal: 0 (none) to 3 (marked and diffuse)
Perivenular: 0 (none) to 3 (central-central or central-portal bridging)

Final score is the sum of the scores, ranging from 0-9
Recording the individual scores is also desirable.

  • 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
  • Venturi C et al. Novel histologic scoring system for long-term allograft fibrosis after liver transplantation in children. Am J Transplant 2012; 12:2986-2996
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Last Modified: Fri Jun 15 15:26:51 EDT 2018


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