Female 20 years

Transplanted for acute hepatitis with submassive necrosis. First OLTx failed on day 9, after initial reasonable function, going off on day 5. Failed allograft showed massive haemorrhagic necrosis with extensive hepatic venous and intrasinusoidal platelet rich thrombi and the possibility of a donor specific antibody mediated process was raised, however the C4d was negative and no serum was sent to look for a DSA. Second transplant had initial dysfunction and showed severe cholestasis with no features of rejection, at approximately 3 weeks she developed rejection with features of antibody mediated rejection and a donor specific antibody was found. The changes persisted and became more complex with biliary features, vascular features, the development of dissecting zone 3 fibrosis associated with/secondary to persistent sinusoidal inflammation. During this period the DSA titre decreased significantly, but she went on to develop increasing fibrosis. MRCP at 11 months showed a stricture at the biliary anastomosis.
Retransplanted about 14 months after the second transplant. At this stage LFTs: AST 200, alkaline phosphatase 130 and bilirubin 630.

Macroscopic description:
Green liver weighing 1164 g. No focal lesions seen. Hilar and hepatic vessels are patent.

Female 20 years

Routine follow-up biopsy, 22 months following second re-transplant operation. Currently well with good graft function. Persistent mild elevation of Alk Phos (now 115). ALT and bilirubin normal.

Female 44 years

Transplant 8 weeks earlier for acute liver failure as a result of paracetamol overdose. She had a previous post transplant biopsy at day 21 for raised LFTs, which showed mild portal inflammation only, no cellular rejection.

Sex unknown age unknown

5 months post transplant for NASH and A1AT: CMV treated previously. Now raised ALT.

Sex unknown age unknown

8mm incidental nodule in explant for HCV cirrhosis.

Male 10 years

Transplant for biliary cirrhosis, ? underlying cause. This biopsy is 2y 4 m post transplant. Recent cryptosporidium diarrhoea treated. Abnormal liver function ? rejection.

Female 37 years

Orthotopic liver transplant for ALD in November 2013. Transplant biopsies taken on days 4, 10, 15 and 17. Submitted biopsy from day 15, liver function tests at that time: Bilirubin 127, Alk Phos 472, ALT 192, CRP 70.

Female 46 years

Three months post transplant for HCV and HCC. Now deranged LFTs.

Female 53 years

Transplant for ALD/HCV (genotype 3a) cirrhosis. DCD transplant. One year pre-transplant, treatment for HCV 1 year but stopped due to decompensation.

First biopsy (237516), 2 months 20 days post transplant: Running ALT of 193 ? cause, ? rejection ? hepatitis C. Additional information - MNF stopped 3 days before this biopsy due to neutropenia.

Second biopsy (237517), 3 months 5 days post transplant: increased ALT and ALP, readmitted with pruritis, bilirubin 50 therefore repeat biopsy, ? FCH.

Third biopsy (237518), 4 months post transplant: On-going deterioration in LFTs - ? hep C, ? rejection.