Banff Liver Allograft Pathology Group: late rejection activity is insufficiently represented in the current diagnostic framework – rationale and goals for revision
Year: 2026
Type: review
Abstract: Late liver allograft rejection is under-recognized because it is often clinically silent, liver tests are insensitive, protocol biopsies are uncommon, and the histology differs from classic early acute T cell-mediated rejection (TCMR) manifesting in the initial weeks after transplantation. Differences in tempo and pathogenesis lead to distinct clinical and histologic manifestations. Late- compared with acute-TCMR is characterized by more prevalent interface and perivenular inflammatory activity, a lymphocyte-predominant infiltrate and fibrosis, with less conspicuous portal duct-centered and subendothelial venular inflammation. The traditional Banff RAI scheme that works consistently well to diagnose acute-TCMR is less well calibrated to account for these later shifts of inflammatory target and density, risking under-diagnosis of clinically significant late-TCMR. This document lays out the histopathologic characteristics of acute- vs. late-TCMR and the rationale for updating the Banff scoring system for liver allograft rejection to better incorporate currently unrepresented histology features correlating with a molecular rejection signature into the Banff rejection scheme.
Authors: Christopher Bellamy, Claudia Mescoli, Khashayar Asadi, Oyedele A. Adeyi, Rachel M. Brown, Lindsey Clarke, Zeynep Demir, Sadhna Dhingra, Michail Doukas, Mohamad El Hag, Bastian Engel, Sandy Feng, Maria I. Fiel, Alessandro Gambella, Krzyztof Grzyb, Horonori Haga, Laura Heij, Elmar Jaekel, Anthea Lafreniere, Jan P. Lerut, Andrew Lesniak, Geoffrey W. McCaughan, Catriona McKenzie, Rosa Miquel, Charlotte Mussini, Deslie Neil, Anna L. Paterson, Avandi A. Pendse, Henrik M. Reims, Olorunda Rotimi, Alberto Sanchez Fueyo, Thomas D. Schiano, Mylene Sebagh, Maxwell Smith, Heather L. Stevenson, Timucin Taner, Ryan Y. Tanigawa, Richard Taubert, Elena Y. Uebayashi, Funda Yilmaz, Jacqueline G. O’Leary, Anthony J. Demetris
Institutions: Edinburgh Royal Infirmary, Centre for Inflammation Research, University of Edinburgh, University of Padua, Azienda Ospedale - Università Padova, Austin Hospital, University of Alabama at Birmingham, University Hospitals Birmingham NHS Foundation Trust, St. Vincent's University Hospital, Inserm, Houston Methodist, Erasmus MC, Cleveland Clinic, Medizinische Hochschule Hannover, University of California, San Francisco, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, University of Genoa, Oslo University Hospital, Kyoto University, University of Toronto, Hospital for Sick Children, UCLouvain, University of Pittsburgh Medical Center, Royal Prince Alfred Hospital, Centenary Institute, The University of Sydney, NSW Health Pathology, King's College Hospital, Assistance Publique – Hôpitaux de Paris, Bicêtre Hospital, Queen Elizabeth Hospital Birmingham, Duke University Health System, Leeds Teaching Hospitals NHS Trust, King's College London, Mount Sinai Health System, Hôpital Paul-Brousse, Mayo Clinic in Arizona, Mayo Clinic Hospital, The University of Texas Medical Branch at Galveston, Mayo Clinic, Hospital Alemão Oswaldo Cruz, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ege University, The University of Texas Southwestern Medical Center
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,300
OpenAlex ID: W7203538707