Chronic Liver Allograft Rejection: Histopathological Insights and Future Directions

Chronic liver allograft rejection (CR) remains a significant cause of late graft dysfunction and failure despite advances in surgical techniques and immunosuppression. This chapter reviews the current understanding of CR, integrating diagnostic histopathological findings, atypical histological patterns of late rejection that are frequently associated with CR, and emerging diagnostic tools. CR is driven by overlapping T cell-mediated and antibody-mediated mechanisms, leading to progressive bile duct loss, vascular injury, and structural alterations. Diagnostic histopathological criteria include interlobular bile duct atrophy or loss, foam cell obliterative arteriopathy, and portal/periportal, perisinusoidal, and perivenular fibrosis. Chronic antibody-mediated rejection (cAMR) and mixed phenotypes exhibit additional vascular and sinusoidal injury, often with subtle biochemical changes. Structural sequelae such as nodular regenerative hyperplasia and variable parenchymal fibrosis underscore the heterogeneity of late graft injury. This chapter also examines late-onset rejection phenotypes, i.e., plasma cell-rich rejection, idiopathic post-transplant hepatitis, and isolated central perivenulitis and their potential to progress to chronic rejection. Future directions emphasize the integration of molecular diagnostics, digital pathology, and noninvasive biomarkers, such as donor-specific antibodies, liver stiffness measurement, and donor-derived cell-free DNA (dd-cfDNA), to complement or replace protocol biopsies, to guide personalized immunosuppression, and to enable earlier intervention. Advances in regenerative medicine and antifibrotic therapies have the potential to alter the natural history of CR, shifting toward precision medicine approaches that may extend long-term graft survival after liver transplantation.