Immunology demystified: A guide for transplant hepatologists

Table 2 Types of chronic rejection after liver transplantation

	T cell-mediated chronic rejection	Antibody-mediated chronic rejection
Time of occurrence	Months to years after LT[95]
Incidence	2%-5%[96]	Unknown[65]
Clinical manifestations	Cholestatic-pattern in liver function tests – the most typical presentation; Range from mild alterations in blood tests to liver failure and death[65]	Normal liver tests despite histologic evidence of allograft injury; Abnormal liver tests during immunosuppression weaning; Graft injury and/or advanced fibrosis; Development of portal hypertension after transplantation[97]
Definition (liver histology required)	(1) Presence of bile duct atrophy/pyknosis affecting most bile ducts; OR; (2) Bile duct loss in more than 50% of the portal tracts; OR; and (3) Foam cell obliterative arteriopathy[49]	(1) Histopathological pattern of injury - both required: Otherwise unexplained and at least mild mononuclear portal and/or perivenular inflammation with interface and/or perivenular necro-inflammatory activity; At least moderate portal/periportal, sinusoidal and/or perivenular fibrosis; (2) Positive DSA within 3 months of biopsy; (3) Focal C4d positivity (> 10%) portal tracts; and (4) Exclusion of other liver insults[49]

AMR: Antibody-mediated rejection; C4d: Complement component 4d; DSA: Donor-specific antibodies; LT: Liver transplantation.