The Kupffer' s cells and macrophages within the lobules and portal tracts continue to show moderately abundant green-brown pigment, which likely represents a mixture of iron and ceroid pigment. This series of biopsies shows mild to moderate preservation injury within the first biopsy, which shows significant improvement by the second and third biopsy. The abundant pigment in the Kupffer' s cells and macrophages likely represents a mixture of both a ceroid pigment and iron. By verbal report, an Iron stain showed abundant positivity. In our experience, causes of increased iron deposits in Kupffer' s cells include hemolysis in ABO non-identical allografts, or hemolysis from other causes, aggressive exogenous iron therapy for anemia, transfusion and other sources of exogenous iron.
Clinical correlation is recommended.
Overall, the histopathologic changes suggest that more than one insult is contributing to the liver allograft injury. The most significant insult in the current sample appears to be attributable to recurrent hepatitis C viral hepatitis, as evidence by the marked acidophilic necrosis of hepatocytes, which is commonly the first histopathologic manifestation. The last biopsy also shows some cholestasis, which can be related to the hepatitis, or an additional insult, such as an adverse drug reaction. The former interpretation is favored. Lastly, the presence of cholestasis, minimal inflammation and mild ductular reaction in a patient with recurrent hepatitis C raises the possibility of a developing cholestatic hepatitis variant.