Compromised blood flow to liver at body temperature before and during harvesting
Resumption of blood flow after implantation
Clinical Issues
• Elevation of serum transaminases and poor bile production within first 24-48 hours after revascularization
• Enzyme levels typically decrease progressively within several days if graft survives injury
• Complete resolution in most cases
• Graft failure in rare cases (primary nonfunction)
Microscopic
• Hepatocyte ballooning and microvesicular/small droplet steatosis, imparting distinctive pale appearance on low-power view
• Hepatocyte detachment from each other, scattered acidophil bodies, and spotty necrosis
• Confluent necrosis in severe cases, can also involve periportal areas
• Cytoplasmic and canalicular cholestasis, more pronounced at zone 3
• Varying degree of neutrophilic infiltrates in lobules
• No significant portal inflammation in general
Top Differential Diagnoses
• Antibody-mediated rejection
• Hepatic artery thrombosis
• Hepatic vein stenosis and thrombosis
• Biliary obstruction
Zone 3 Hepatocyte Ballooning Mild preservation injury features hepatocyte ballooning around the terminal hepatic venule , imparting a distinctive pale appearance at zone 3 on low power. Note the presence of a small unremarkable portal tract .
Zone 3 Necrosis This case shows typical features of preservation injury demonstrated in a postreperfusion allograft biopsy. There is zone 3 necrosis and microvesicular steatosis, along with scattered neutrophils in the lobules.
Coagulative Necrosis This posttransplant day 1 biopsy shows severe preservation injury, featuring extensive coagulative necrosis with dyscohesive hepatocytes. Clinically, the allograft showed primary nonfunction that required retransplantation.
Lipopeliosis This allograft biopsy performed 6 days after transplantation shows large fat droplets in extracellular spaces , which are released from damaged steatotic hepatocytes secondary to preservation injury (lipopeliosis). Note the presence of inflammatory cells around the fat droplets.
TERMINOLOGY
Synonyms
• Preservation/reperfusion injury
• Harvesting injury
• Ischemia and reperfusion injury
Definitions
• Tissue damage sustained during graft harvesting, preservation, transportation, and reperfusion
• 1 of major causes of initial graft dysfunction
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, imparting a distinctive pale appearance at zone 3 on low power. Note the presence of a small unremarkable portal tract 
.
and microvesicular steatosis, along with scattered neutrophils 
in the lobules.
, which are released from damaged steatotic hepatocytes secondary to preservation injury (lipopeliosis). Note the presence of inflammatory cells around the fat droplets.
