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D cholesterol medication ezetrol buy discount lipitor 5 mg online, Our presently conceived mirror image of C with reversal of the dimensions proportions of the reciprocally modulating donor and recipient populations of immune cells after profitable bone marrow transplantation cholesterol levels chicken vs beef buy cheap lipitor on line. Immunological therapy failures have been outlined by the lack of therapeutic immunosuppression to control one or the opposite arm or generally both cholesterol ratio is 2.5 order lipitor in india. Therapeutic failure with both type of transplantation implies the inability to management one foods break down cholesterol purchase lipitor discount, the opposite, or both of the responses. Donor cell chimerism permitted by immunosuppressive medication: a new view of organ transplantation. The ability of small numbers of donor cells to carry out this role has been formally proved. Consequently, neither the presence nor quantity of microchimerism can be used to precisely guide management. The double immune reaction is the distinctive function that defines transplantation immunology as a subsection of basic immunology. In independent studies in Zurich of experimental an infection models, Rolf Zinkernagel reported that tolerance (or alternatively immunity) to viruses and other spreading intracellular microparasites is produced and maintained with a staged migration indistinguishable from that of allogeneic leukocytes. Top, Experimental and medical tolerance fashions associated with donor leukocyte macrochimerism. Middle, Tolerance permutations defined as balances between persisting donor leukocytes with access to host lymphoid organs and the variety of antidonor T cells induced at these lymphoid websites. Bottom, Organ and composite tissue transplants whose alloengraftment is contingent on persistent donor leukocyte microchimerism. The overarching conclusion within the 1998 PittsburghZurich review92 was that "the migration and localization of antigen govern the immunological responsiveness or unresponsiveness towards infections, tumors, or self-and in opposition to xenografts and allografts. The weak plank in the basis of transplantation immunology, and of immunology general, was the unchallenged dogma that donor leukocyte chimerism was neither a direct nor oblique think about organ alloengraftment. Blind acceptance of this dogma for more than 30 years precluded the orderly development of transplantation immunology, distorted the maturation of basic immunology, and spawned multiple spinoff dogmas Table 88-4). Return of the donor cells from their protected niches again to host lymphoid organs is indicated by inward-directed arrows. The cell migration and localization govern host immune responsiveness or nonresponsiveness. Persistence of some donor cells is a prerequisite for maintenance of the variable deletional tolerance induced by the initial surge of donor cells. The saga of liver replacement, with explicit reference to the reciprocal affect of liver and kidney transplantation (1955-1967). It is, after all, their skilled enterprise to remedy issues, not merely to grapple with them. Unknown chimerism-independent mobile humoral or "network" factors permit immunosuppression-assisted organ alloengraftment. Tolerogenesis is more protracted and tougher to accomplish in people than in the rodents and other lower species used for transplantation research. In a supreme irony, resolution of the problem to which Medawar referred (the mystique of tolerance) was close at hand. However, the missing half of the BillinghamBrent-Medawar discoveries, particularly the microchimerism that lay on the tipping point between immunity and tolerance, awaited detection with extra discriminating and sensitive immune-cytochemical and molecular probes. Immunosuppression will not be required for liver engraftment in three of the five species, indicated by flippantly shaded parts of the transverse bars. Instead, the quantity of immunosuppression required to keep donor leukocyte dominance after both organ or bone marrow transplantation is the final word determinant of the completeness of tolerance. In the methods of bone marrow transplantation, situations that tip the stability to the mobile donor cells either preexist naturally (immune deficiency diseases) or are created by pretransplant irradiation or medication that enfeeble international immune reactivity and thereby make exhaustion-deletion easier in the impending donor-specific response. In the contrasting extensively used organ transplant protocols, donor leukocyte dominance is established after arrival of the donor passenger leukocytes. The chance of favorably tilting the stability to donor cells by the adjunct infusion of donor leukocytes is foreclosed if the additional load is delivered under heavy immunosuppression. The dose ceilings of these drugs have been imposed by their toxicity: the bone marrow melancholy of azathioprine and the more complex unwanted effects of cyclosporine and tacrolimus. These rejections occurred routinely with azathioprine (1962-1963),34,38 much less frequently with cyclosporine (1979-1980),39,40 and uncommonly with tacrolimus (1989-1990).
The persistent type is seen in older sufferers and produces mild to moderate hemolysis serum cholesterol ratio uk order cheapest lipitor. Previously related to syphilis, paroxysmal cold hemoglobinuria is now seen more usually as an acute transient condition secondary to viral infections, significantly in younger children cholesterol good foods purchase lipitor 40 mg mastercard. This IgG autoantibody, a biphasic hemolysin, could be demonstrated by performing the traditional Donath-Landsteiner check how many cholesterol in an eggs lipitor 40mg without prescription. The autoantibody has anti-p specificity and reacts with all except the rare p or pk phenotypes cholesterol test youtube order lipitor 10 mg line. The reactivity has been described as being brought on by 4 fundamental mechanisms: (1) drug adsorption; (2) immune complexing; (3) membrane modification; and (4) autoantibody formation. The antibody is specific for this advanced and no reactions will happen until the drug is adsorbed on erythrocytes. There seems to be no connection between this type of antibody manufacturing and allergic penicillin sensitivity attributable to IgE manufacturing. Immune complexing is related to quite a lot of drugs, together with phenacetin, quinine, rifampin, and stibophen. Once connected, this complex initiates the complement cascade, which culminates in intravascular hemolysis. When the offending drug is discontinued, the hemolytic process disappears shortly. Children are most often affected with the acute sort, whereas adults predominantly expertise the persistent sort. Thrombocytopenia, a condition of absent or severely decreased platelets (<10-20 � 109/L), could result from a wide variety of situations, corresponding to after extracorporeal circulation in cardiac bypass surgical procedure or from alcoholic liver disease. However, most thrombocytopenic circumstances can be categorised into the next three major categories: � Decreased production of platelets � Disorders of platelet distribution � Increased destruction or use of platelets Decreased platelet manufacturing may end result from invasion of the bone marrow by neoplastic cells and is often not related to an immunologic trigger. Disorders of platelet distribution are related to a sequestering of platelets within the spleen for numerous nonimmunologic reasons. Increased destruction or use of platelets, however, is associated with immunologic mechanisms. These mechanisms of destruction are attributable to antigens, antibodies, or complement. Drugs or overseas substances that may trigger platelet destruction embrace quinidine, sulfonamide derivatives, heroin, morphine, and snake venom. Sulfonamide by-product reactions involve the interaction of platelet antigens with drug antibodies. Bacterial sepsis causes elevated destruction of platelets ensuing from the attachment of platelets to bacterial antigenantibody immune complexes. Certain microbial antigens might initially connect to platelets, followed by particular antibodies to the microorganism. This mechanism has been reported to cause the thrombocytopenia that frequently complicates Plasmodium falciparum malaria. Antibodies of autoimmune or isoimmune origin could cause increased destruction of platelets. Examples of thrombocytopenias of isoimmune origin include posttransfusion purpura and isoimmune neonatal thrombocytopenia. Neonatal autoimmune thrombocytopenia is a condition caused by immunization of a pregnant female by a fetal platelet antigen and by transplacental passage of maternal IgG platelet antibodies. The antigen is inherited by the fetus from the father and is absent on maternal platelets. Pernicious Anemia Pernicious anemia is a megaloblastic anemia characterised by quite a lot of hematologic and chemical manifestations (Table 28-9). Antiparietal cell assays measure antibodies to parietal cells (large cells on the margins of the peptic glands of the stomach). The immune system could play an essential role within the pathogenesis and cause of myasthenia gravis and multiple sclerosis.
Disseminated illness is characterised by fever, anemia, leukopenia, weight loss,andlassitude known cholesterol lowering foods buy 5mg lipitor amex. IfonlyanMband is present, it indicates early infection, chronic infection, or a recentreactiveskintest cholesterol oils chart purchase lipitor 10mg overnight delivery. Asinglepositivetestresult ought to be confirmed by testing a separate serum specimen cholesterol test when not fasting cheap lipitor 20 mg amex. The disease might assume several types, includingprimarypulmonary,primarycutaneous,anddisseminated cholesterol ratio and risk lipitor 20mg with amex. Titershigherthan 1:sixteen happen in 90% to 95% of sufferers with disseminated coccidioidomycosis. Sporotrichosis this chronic, progressive, subcutaneous lymphatic mycosis is causedbySporothrix schenckii. Thediseasetakesthreeforms- lymphatic (which is the most common), disseminated, and respiratory. Itmay initially be asymptomatic or may develop as a symptomatic pulmonaryinfection. New viruses could cause old ailments, and old viruses can causenewdiseases(seeChapters21to25forrepresentative examples of immunologically important viral diseases). Thesurvival of influenza A and B viruses as new viruses is determined by a continualevolutionofmutants. An estimated 50 million infections occur every year in about a hundred countries with the potential to unfold to further. According to the World Health Organization and the Centers for Disease Control and Prevention, Florida and the coastal areas ofTexas are included within the geographic areas that have excessive suitability for Dengue transmission. Recurrencewithcell-to-cell unfold of virus happens within the presence of serum-neutralizing antibodies. Inaddition,detectionofthevirusin body fluids (using monoclonal antibodies) may be performed with immunoassays or immunoblot techniques. This precedes the eruption of the attribute purple macular rash, which progresses to papules, vesicles, and pustules that crust over and shed without scarring. The name of the virus reflects two related diseases- varicella(chickenpox)andzoster(shingles). Rapid preliminary analysis can be made by direct immunofluorescence to detect viral antigens in vesicular lesions. Genomic analysis shows the virus to be molecularly unrelated to different human herpesviruses. Antibody Significance In many ailments, contaminated people show a spectrum of responses. Incomparison,somepatients could reply to an antigenic stimulus by producing antibodies thatcancross-reactwithotherantigens. Theprevalenceofcongenital toxoplasmosisis1/10,000livebirthsintheUnitedStates,in which 85% of women of childbearing age are susceptible to acuteinfectionwithT. If prozoning is suspected, repeat the testwithboth1:10and1:100dilutionsofthespecimen. A vaccine is a organic suspension of weakened or killed pathogensortheircomponents. Widespread vaccination packages in opposition to contagious infectious illnesses now have a constructive influenceworldwide. In 1721, Cotton Mather, a Boston minister, encouraged smallpox variolation as a preventive step subsequent to the Boston smallpox epidemic. Once again, in 2009 and 2010, the H1N1 influenza pandemic evoked robust public fear of vaccination. IntheUnitedStates,therecommended childhood immunization schedule now consists of vaccines to guard in opposition to 15 illnesses, together with seasonal influenza. Especially serious illnesses for adults age sixty five years and older includediphtheria,herpeszoster(shingles),influenza,pneumococcus,andtetanus(lockjaw). Vaccineshavereduced some preventable infectious diseases to an all-time low; few individuals now expertise the devastating results of measles, pertussis,andotherinfectiousdiseases. Thiswasafundamental precept of immunization, which developed over 200 years ago and has resulted in the eradication of smallpox globally.
In a prospective research of 52 kids, of whom 43 had had spleen operate measured with scintigraphy both at baseline and on remedy, 6 patients (14 percent) utterly recovered splenic operate, and a pair of (5 percent) had preserved splenic operate after a median of 2 qrisk cholesterol ratio safe lipitor 5 mg. The research by Santos and coworkers was the one one to describe transfusion use in children, reporting that the transfusion rate decreased from 3 cholesterol healthy range buy generic lipitor line. However, the long-term mortality, when analyzed in accordance with the preliminary treatment assignment within the 2-year randomized trial, was related for the hydroxyurea (3 cholesterol medication fatigue generic 10mg lipitor otc. The rates of stroke, sepsis, and renal and hepatic failure have been additionally related between the 2 groups cholesterol medication and coq10 order 10mg lipitor with amex. Annualized whole costs had been $16,810 for the hydroxyurea group and $22,270 for the placebo group (p=0. This improvement was accompanied by an increase in weight and reduce in the resting coronary heart price within the hydroxyurea group (3. The smallest enhance in Hb F% was seen within the research from Brazil, which reported outcomes by haplotype. This was a study of twenty-two sufferers; the greatest increase was amongst patients who had a homozygous Bantu haplotype (n=9 patients), from four percent to 9 % (p=0. The retrospective research by Loukopoulos reported hematological outcomes very comparable to these seen in the potential research. In a study of Sicilians with Hb S+ thalassemia and Hb S0 thalassemia, the frequency of crises decreased from a mean of seven (median of 9) per yr to a mean of 1. In a non-randomized research evaluating sufferers receiving hydroxyurea to those receiving cognitive behavioral therapy, these receiving the drug had fewer ache crises (1. In the research of Sicilians, the number of hospitalized days in a year declined from 22. In the examine comparing hydroxyurea to cognitive behavioral therapy, the patients receiving the drug and those receiving behavioral remedy had similar hospitalization charges (1. Many studies have explored predictors of benefit from hydroxyurea (Table 3); one was designed specifically to handle this question. Hospital admissions had been significantly decreased in adults with no much less than 2 years of hydroxyurea remedy with no interruptions exceeding 2 weeks, when compared to these with a shorter length of remedy or interruptions. As described above, studies have been typically stratified by age (adult or pediatric); however, other subgroups have been much less thoroughly investigated. While the majority of patients studied had been homozygous for Hb S, many of the studies had some patients with other genotypes. We identified eight studies that in contrast potential surrogate markers of disease severity or response in sufferers treated with or without hydroxyurea. The research enrolled sufferers from North America (5), Europe (2), or Central and Latin America (1). The description of the eligibility criteria was typically fairly restricted, and the majority of studies have been of moderate to poor high quality. There was only limited information relating to affected person traits and the beginning dose, monitoring, and titration of hydroxyurea. Four studies included a report of hemoglobin and Hb F levels amongst groups and reported increases in total and fetal hemoglobin that had been corresponding to these of the opposite observational studies in sickle cell disease after treatment with hydroxyurea. Other potential biomarkers of vasoocclusion had been the significant decreases in rigidity and charges of elastic shear in patients with sickle cell disease who had been treated with hydroxyurea, when in comparability with these in untreated sickle cell disease sufferers. A last pediatric study demonstrated significant decreases in total bilirubin (most likely secondary to decreased hemolysis and release of heme) after treatment with hydroxyurea. There was average evidence to assist the claim that hydroxyurea reduces the frequency of ache crises, and a excessive grade of proof to support the contention that treatment reduces the frequency and/or length of hospitalization in children. There was solely a low grade of evidence to help the claim that hydroxyurea reduces neurological events in youngsters and insufficient proof to permit any conclusions regarding transfusion frequency. There was also high-grade evidence that the drug reduces the frequency of pain crises and that it reduces the frequency and/or duration of hospitalization in adults. The evidence base was insufficient to allow us to touch upon neurological events in adults (Table 5).
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Passive Latex Rubella Agglutination Test Principle Latex particles are sensitized with solubilized rubella virus antigens cholesterol test variance order 5 mg lipitor visa. Demonstration of any detectable antibody is indicative of immunity and safety against subsequent viral an infection reduce cholesterol yoga order lipitor 20 mg on-line. Inamature,freeextracellularvirion,thecoreappearsasa gp120 bar-shaped nucleoid structure in cross part cholesterol levels hdl ldl generic lipitor 5mg fast delivery. The pol gene encodes for reverse transcriptase, endonuclease,andproteaseactivities colesterol ideal en mujeres cheap lipitor online. Retroviruses are so named as a end result of they reverse the conventional move of genetic data. This part is followed by a prolonged period of clinical latency (range, 7 to eleven years; median, 10 years). Serologic Markers Detection of Core Antigen After preliminary an infection, the physique mounts a vigorous immune responseagainsttheviremia(seeColorPlate10). Antibodies to p24 antigen are a better predictive marker of progression thanp24antigen. Ingeneral, thepresenceofabandatp24,p31,orp55,althoughstillclassified as indeterminate, is more indicative of true an infection as comparedwithotherbandpatterns. Follow-up serology testing at three months is recommended to verify the earlier outcomes. Infected cells are treated with polyclonal or monoclonal antibody in opposition to p17 or p24. Health care personnel ought to assume that the blood and different body fluids from all sufferers are probably infectious (StandardPrecautions;seeChapter6). This test analyzes sequences that embody the whole protease geneandcodons1-335ofthereversetranscriptasegene. Tropism or coreceptor testing, like resistance testing, can be accomplished by genotype and phenotype testing. Theadditionof conjugate 1 and sample is validated through a colour change fromyellow-greentoblue. Colordevelopment is stopped by the addition of acid, which adjustments the blue-green shade to yellow. This binding is detected with an enzymelinked secondary antibody that causes a colour change on additionofsubstrate. When this criterion is used, the phrases immediate hypersensitivity and delayed hypersensitivity are appropriate. Metals (particularly nickel) and chemical compounds can even cause sort I hypersensitivity reactions. The influenza virus can cause hypersensitivity that leads to damage to epithelial cells in the respiratory tract. Incomparison,streptococci could cause a hypersensitivity response termed immune advanced illness. Self Antigens Very small immune responses to self antigens is normal and happen in most individuals. Food allergy may cause extreme allergic reactions and even deathfromfood-inducedanaphylaxis. Common allergens include animal dander, pollens, foods, molds,dust,metals,drugs,andinsectstings. However, a single-blind or open-food problem may be thought-about diagnostic beneath certain circumstances. Thisantigenreceptor alsooccursonantigen-presentingcells,whereitcanfacilitate the IgE-dependent trapping and presentation of allergen to Tcells. Inapersonwithatopy,exposureofthe skin, nostril, or airway to a single dose of allergen produces symptoms(skinredness,sneezing,wheezing)withinminutes. Ageneralized(anaphylactic)reaction is produced by mediators corresponding to cytokines and vasoactive amines. Inhumanbeings,antihistaminesareeffective antagonists of edema and pruritus, most likely related to their blockage of a histamine-induced enhance in capillary permeability however are comparatively much less effective in preventing bronchoconstriction. TheformationofIgEantibodies begins early in life, and sensitization can be detected beforeclinicalsymptoms. To evaluate take a look at results, the responses for patient samples are in contrast directly to the responses for calibrators.
Predicting severity and clinical course of acute rejection after liver transplantation using blood eosinophil depend cholesterol nutrition facts trusted lipitor 40mg. Acute rejection in heart transplant sufferers is associated with the presence of committed donor-specific cytotoxic lymphocytes within the graft however not in the blood cholesterol fighting foods purchase lipitor 5mg otc. Alterations in immunologic measurements in sufferers experiencing early hepatic allograft rejection cholesterol medication makes me sick buy lipitor 10 mg without a prescription. Use of monoclonal antibodies to T-cell subsets for immunologic monitoring and therapy in recipients of renal allografts total cholesterol levels nz cheap lipitor 40mg fast delivery. Circulating lymphocyte subsets in different clinical situations after renal transplantation. The sample and phenotype of T-cell infiltration associated with human liver allograft rejection. Intrahepatic proliferation of "naive" and "reminiscence" T cells during liver allograft rejection: primary immune response within the allograft. Cell surface molecules and early events involved in human T lymphocyte activation. Immune response in liver transplantation: is there a preferential pattern in acute rejection? Acute rejection after liver transplantation: Is there a selected immunological pattern? Functional characterization of infiltrating T lymphocytes in human hepatic allografts. The immunopathology and clinical relevance of lymphocyte cultures in liver transplantation. Characterization of in vivo-activated allospecific T lymphocytes propagated from human renal allograft biopsies undergoing rejection. In vitro characterization of a donor-specific cytolytic T cell line established from human lymphocytes homing in a rejected kidney allograft. Cyclosporin A mediates immunosuppression of main cytotoxic T cell responses by impairing the release of interleukin 1 and interleukin 2. Cytokines induce the event of functionally heterogeneous T helper cell subsets. Effect of 1,25-dihydroxyvitamin D3 on preventing allograft from acute rejection following rat orthotopic liver transplantation. Immunobiology of tissue transplantation: a return to the passenger leukocyte idea. Apoptosis in liver transplantation: a mechanism contributing to immune modulation, preservation harm, neoplasia, and viral illness. Identification of a novel biomarker gene set with sensitivity and specificity for distinguishing between allograft rejection and tolerance. Analysis of sequential modifications in major histocompatibility complicated expression in human liver grafts after transplantation. Sensitized Lyt-2+ T cells trigger rejection of grafts expressing class I main histocompatibility complicated alloantigens. Influence of human leukocyte antigen matching on liver allograft survival and rejection: "the dualistic impact. Impact of human leukocyte antigen mismatching on outcomes of liver transplantation: a meta-analysis. Consensus opinion from the antibody working group on the analysis, reporting, and danger evaluation for antibody-mediated rejection and desensitization protocols. Antibody-mediated rejection of the kidney after simultaneous pancreas-kidney transplantation. Responder T-cell subsets and antigenic stimulus in mixed lymphocyte-hepatocyte culture. Purified hepatocytes can stimulate allospecific cytolytic T lymphocytes in a blended lymphocytehepatocyte culture. Cell subsets responding to purified hepatocytes and evidence of indirect recognition of hepatocyte major histocompatibility complex class I antigen. The function of L3T4+ T cells within the growth of allospecific cytotoxicity in hepatocyte-sponge matrix allografts. Clinical, immunological, and pathological features of operational tolerance after pediatric living-donor liver transplantation.
Similar to kidney and coronary heart allografts cholesterol medication pancreatitis purchase line lipitor, liver C4d deposits have additionally been related to microvasculitis cholesterol numbers chart explained lipitor 20 mg amex,115 cholesterol lowering diet plan new zealand purchase lipitor,134 and macrophage and plasma cell infiltrates cholesterol levels change with age discount 10mg lipitor. When it does occur, however, it might be troublesome to distinguish from hemorrhagic liver necrosis attributable to hypotension and poor perfusion, sepsis, or vascular thrombosis. Excluding different potential causes of fibrosis is very necessary in reduced-size grafts contemplating their relatively high fee of technical problems. The prognosis is strengthened if greater than 50% of the ducts or terminal hepatic veins are damaged or if unequivocal endotheliitis of portal or terminal hepatic vein branches can be recognized. Histopathological evidence of severe harm, which is used for histopathological grading, contains perivenular inflammation, centrilobular necrosis, arteritis, and inflammatory, normally central-to-central, bridging inflammation/ necrosis. This characteristic function of acute rejection can also be seen with different causes of allograft dysfunction. Lymphocytes are discovered inside the ductal basement membrane in affiliation with proof of biliary epithelial cell harm and response to injury. Included are paranuclear vacuolization, apoptotic our bodies, and increased nuclear-cytoplasmic ratio, mitoses, and nucleoli. Two of 4 portal tracts in this photomicrograph are expanded with reasonably intense predominantly mononuclear inflammation. On close examination (top left inset), the affected portal tract shows attribute rejection-type infiltrate consisting of blastoid lymphocytes and eosinophils, lymphocytic damage to the ductal epithelium, and reactive changes of the biliary epithelium. In addition, recognition of arteritis in peripheral needle biopsies is poorly reproducible. The top left inset exhibits rejection-type portal infiltrate, as properly as moderate bile duct harm. The high proper inset exhibits subendothelial localization of lymphocytes and slight extension of the infiltrate into the perivenular hepatic parenchyma with mild hemorrhage. Treatment earlier than biopsy can also contribute to centrilobular hepatocyte swelling and hepatocanalicular cholestasis, inflicting additional confusion. In general, 7 to 10 days, or extra are normally required for rejection-related modifications to fully resolve after therapy. Note the marked portal tract irritation involving most of portal tracts, as well as related infiltrate across the central veins. The top left inset exhibits subendothelial infiltration of the hepatic venule with perivenular hepatocyte necrosis/dropout and hemorrhage. Late acute rejection can even present as predominantly or solely perivenular lymphohistiocytic inflammation and hepatocyte dropout with minimal or no portal tract modifications (isolated "central perivenulitis"). Perivenular fibrosis and a BuddChiari or a venoocclusive-like clinical syndrome can develop as a consequence of the severe perivenular harm. Perivenular inflammation involving a minority of terminal hepatic veins with patchy perivenular hepatocyte loss with out confluent perivenular necrosis. As above, with a minimal of focal confluent perivenular hepatocyte dropout and mild-to-moderate inflammation, however with out bridging necrosis. As above, with confluent perivenular hepatocyte dropout and irritation involving a majority of hepatic venules with central-to-central bridging necrosis. Differential Diagnosis the differential analysis for acute mobile, or T cell mediated, rejection depends on the time since transplantation. Both hepatitis and acute cellular or T cellmediated rejection current with predominantly mononuclear portal irritation, bile duct harm, and acidophilic necrosis of hepatocytes. Large- and medium-sized arteries show extreme obliterative arteriopathy (top left inset). Foam cell obliterative arteriopathy is characteristic of persistent liver allograft rejection. Here foam cells are seen obliterating the medium-sized hepatic artery and in the media of the big hepatic artery (arrowheads). This biopsy specimen additionally confirmed severe bile duct injury of the interlobular bile ducts, which is characterized by eosinophilic transformation and uneven nuclear spacing (arrows). This biopsy shows nearly full bile duct loss, which is demonstrated by an immunohistochemical stain for cytokeratin 7 (bottom).
