Female 30 years

First liver transplant in January 2012 for PSC.

Second transplant in March 2015 for presumed recurrent PSC.

Third transplant in March 2017, again for presumed recurrent PSC.

Biopsy 1 (slide 381798): 7 days post-transplant. Deranged LFTs with rising bilirubin and abnormal liver enzymes ? rejection. Shortly after the biopsy was taken was found to have rising antibodies to HLA Class II (DQ9), MFI 17,000. Treated initially with pulsed steroids and then underwent plasmapheresis (x7).

Biopsy 2 (slide 381799): 4 months post-transplant. LFTs normalised following treatment.
Subsequent problems with episodes of cholangitis. Latest MRI showed evidence of cholangiopathy. Cholestatic LFTs. Suspected AMR with secondary ischaemic cholangiopathy. Latest LFTs (7 days prior to the second biopsy): ALT 99, Alk Phos 145, GGT 184, bilirubin 8.

Male 52 years

Liver transplant Nov 2016 for PSC.

Biopsy 1 (slide 381800): 19 days post-transplant. Low tacrolimus levels associated with increase in AST from day 12. Bilirubin and Alk phos also increased. Developed jaundice. No improvement in LFTs despite increasing Tacrolimus dose. AST 131 Bili 200 Alk Phos 991.

Biopsy 2 (slide 381818): 24 days post-transplant. Treated with pulse of steroids after last biopsy with initial improvement in LFTs then deteriorated post-steroids. AST 137 Bili 274 Alk Phos 938.

Biopsy 3 (slide 381802): 33 days post-transplant. Changed from Azathioprine to MMF. MRCP no duct dilation. High level (MFI >14,000) class II DSA (HLA-DQ7) identified on blood sent 2 days after last biopsy. No real improvement in LFTs. AST 86, Bili 226, Alk Phos 715.

Male 54 years

Patient had liver transplantation for primary sclerosing cholangitis in June 2016. His post operative course was complicated by renal dysfunction with difficulty in maintaining adequate immunosuppression. He developed severe cellular rejection day 14, with little response biochemically or histologically at day 21. This biopsy is day 31 post transplant.

Female 48 years

DBD transplant for ALD/HCV cirrhosis in May 2017. Deranged LFTs with recent MRCP ruling out an obsturctive cause with patent vessels. This biopsy day 18 post transplant when LFTs were: ALT 63, bili 55, alk phos 876.

Female 41 years

Liver transplant in Feb 2017 for PBC. Stable at clinical follow-ups until July 2017 when a liver biopsy was performed for worsening graft function (ALT 210, AST 161, bilitubin 41). ? rejection.

Female 36 years

Patient underwent transplant on 28.03.17 for PSC, receiving a split graft. She developed graft dysfuntion due to hepatic artery thrombosis and required supraurgent re-transplantation on 06.04.17. The time zero liver biopsy at the 1st tranpslantation was negative for D4d. The slides submitted are from the second transplantation (split graft) and post transplant liver biopsy performed on day 5 after the second transplant.

Time zero - slides 381810 and 381811.

Day 5 - slides 381812 and 381813.

Male 57 years

Liver transplant Nov 2014 for cirrhosis due to ASH/NASH/haemochromatosis.

Biopsy 1 (Slides 382050, 382051 and 382052) 18 months post transplant. Deranged LFTs post transplant. Probably steatosis but need to exclude rejection.

Biopsy 2 (Slide 382053) 2 years, 9 months. Biopsy taken following 6 days of abdominal cramps and diarrhoea. Bil 312, ALP 378, ALT 153 at time of biopsy. Viral serology screen negative.

Biopsy 3 (Slides 382054, 382055, 382056 and 382057) 9 days after Biopsy 2. Worsening LFTs despite treatment with pulsed methylprednisolone. Bil 506, ALP 917, ALT 800. Patent vasculature on US liver doppler and triple phase CT. MRCP suggest cholangiopathy.

Female 31 years

Transplanted for AIH in 1997. Retransplanted in 2011, clinically graft failure likely multifactorial. After this second transplant she had an episode of T-cell mediated rejection of moderate degree at +6 days, treated with intensification of the baseline immunosuppression, with improvement. Progressive graft dysfunction, cholestatric LFTs. The slide is from the last biopsy, +5 years.

Female 39 years

Liver transplant PBC Jan 2017.

Biopsy 1 (slide 382373): 37/03/17: LFT increasing, ALT 600 ? rejection.

Biopsy 2 (slide 382374): 06/04/17: recent ACR moderate to severe rejection. Treated with pulsed methyl prted. LFTs remain increased. Biopsy to rule out ongoing rejection.

Biopsy 3 (slide 382375): 01/06/17: Previous moderate acute cellular rejection. Jow rising LFTs (bili 92, ALP 504, ALT 285). ? Rejection.

Biopsy 4: 15/06/17 (slides 382376 - 382389): Previous moderate acute cellular rejection. Last biopsy ? immune mediated. Has had ATG. LFTs continuing to rise.