Preservation Injury

 Prolonged storage in preservation solutions

• Warm ischemia
image Compromised blood flow to liver at body temperature before and during harvesting

image 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)


• 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 image, imparting a distinctive pale appearance at zone 3 on low power. Note the presence of a small unremarkable portal tract image .

Zone 3 Necrosis
This case shows typical features of preservation injury demonstrated in a postreperfusion allograft biopsy. There is zone 3 necrosis image and microvesicular steatosis, along with scattered neutrophils image 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.

This allograft biopsy performed 6 days after transplantation shows large fat droplets in extracellular spaces image, which are released from damaged steatotic hepatocytes secondary to preservation injury (lipopeliosis). Note the presence of inflammatory cells around the fat droplets.



• Preservation/reperfusion injury

• Harvesting injury

• Ischemia and reperfusion injury


• Tissue damage sustained during graft harvesting, preservation, transportation, and reperfusion

• 1 of major causes of initial graft dysfunction

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Apr 20, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Preservation Injury

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