Chronic allograft dysfunction—liver

In the United States, more than six thousand patients undergo liver transplantation (LT) annually with generally excellent outcomes reflected in patient survival of 88% at one year and 80% at three years and graft survival of 83% and 74%.1 Advances in immunosuppression have made acute cellular rejection a negligible threat to hepatic graft survival in compliant patients and generally long-term threats to graft survival reflect recurrent disease rather than rejection. Chronic rejection although relatively infrequent in LT recipients remains an important cause of graft loss and may reflect noncompliance. However, other threats to graft viability have been recognized as the practice of liver transplant has evolved. Use of nonheart beating donors results in frequent non-anastomotic stricturing and higher graft failure (relative risk 1.85) with the need for retransplantation.2 Older donor grafts are a factor in more severe recurrence of HCV. Interferon therapy to treat HCV recurrence has been implicated in profound graft dysfunction reminiscent of chronic rejection. With longer term follow-up recurrence of nonviral disease has become more obvious. Recurrent cholestatic liver disease, most notably primary sclerosing cholangitis, can lead to graft loss. As the significance of non-alcoholic fatty liver disease as a cause of decompensated cirrhosis and hepatocellular carcinoma has become more fully appreciated, recurrent hepatic steatosis has now entered into the differential of graft dysfunction as has denovo hepatic steatosis.