A 22-year-old woman with end-stage liver disease secondary to primary sclerosing cholangitis received a liver transplant four months ago. She presents with a rise in her liver enzymes. A biopsy shows acute cellular rejection.
What biopsy findings would you expect with this diagnosis? How would you treat her?
Acute rejection can be either cellular (T-cell mediated) or humoral (antibody-mediated). The characteristic findings of acute cellular rejection vary by organ. This reflects the obvious differences in the organs themselves, as well as differences in histologic findings that are significant in each organ. In liver transplants, typical findings include an infiltrate of mixed cellularity (lymphocytes, plasma cells, monocytes, eosinophils and often even neutrophils). It is also important to note that the correlation between a patient’s clinical symptoms or tests results and the histologic picture is not perfect. For example, a patient may have significant rejection on biopsy with no obvious organ dysfunction.
Treatment of acute cellular rejection depends on the severity (grading) of the rejection episode, whether acute humoral rejection or chronic changes are present and the patient’s clinical status. In general, milder acute rejections are generally treated with pulses steroids. More sever rejections may require thymoglobulin. In all cases, an episode of rejection requires re-evaluation of the patient’s baseline immunosuppression.