1. Chapter 12
Liver Transplantation 1
Orthotopic liver transplant, recurrent chronic HCV and acute (cellular) rejection
Case 12.6

2. Clinical Presentation12
Liver Transplantation 2
Clinical Presentation
A 51-year-old man with cirrhosis secondary to chronic HCV underwent a liver transplant.
Fluctuating liver enzymes developed post-transplant, with a previous biopsy showing features indeterminate for acute rejection.

3. Laboratory Values Course in Hospital Total Protein: 7.112
Liver Transplantation 3
Laboratory Values
Total Protein: 7.1
Albumin: 4.2
AST: 69 rising to 157
ALT: 73 rising to 163
Alk Phos: 183
Total Bilirubin: 0.5
Course in Hospital
Because of the rising transaminases a liver biopsy was performed 3½ months post-transplant.

4. 12
Liver Transplantation 4
Pathology
Many of the portal tracts showed a prominent lymphocytic infiltrate with occasional benign lymphoid aggregate formation and normal interlobular bile ducts (a).
Figure 12.6(a)

5. 12
Liver Transplantation 5
Pathology
Other portal tracts showed numerous eosinophils with variable bile duct atypia (b).
The parenchyma showed little necroinflammatory change.
Figure 12.6(b)

6. 12
Liver Transplantation 6
Diagnosis
Orthotopic liver transplant (OLT), recurrent HCV and changes consistent with a coexisting acute (cellular) rejection (3½ months post-transplant)

7. 12
Liver Transplantation 7
Comment
The marked increase in eosinophils in some of the portal tracts is most consistent with an accompanying acute cellular rejection which is not uncommon and is problematic in adjusting the medications.
In addition, grading the degree of rejection using the rejection activity index (RAI) can also be difficult in that some of the portal inflammation and even duct damage may be due to the recurrent HCV as well; hence a numerical RAI should sometimes be avoided and a comment used instead (such as coexisting “mild” or “moderate” acute rejection).
The possibility of a drug-induced hypersensitivity reaction must also be considered in this setting with numerous portal eosinophils as well, although the coexisting focal duct damage favors the eosinophils as rejection related.