LAUSR

1. Longterm, morbidity-minimized survival of liver allograft recipients requires an immunosuppression management approach that balances the health of the allograft with that of the entire recipient. 2. Monitoring allograft health can use a variety of approaches including serum markers of liver injury and/or fibrosis, radiographic techniques, and histopathological analysis of biopsy specimens. 3. Because subtle allograft injury is often clinically silent and not easily detected with radiographic procedures, obtaining protocol liver biopsies, perhaps guided by surrogate serum markers, should be strongly considered. If liver biopsies are obtained, they should be adequate as determined by current American Association for the Study of Liver Diseases guidelines. 4. Major causes of late liver allograft dysfunction include late-onset T cell–mediated rejection and/ or chronic antibody-mediated rejection (cAMR); original primary liver disease recurrence; “plumbing problems”; de novo disease; and the myriad of other causes of liver dysfunction not restricted to allografts. 5. Donor and recipient human leukocyte antigen typing is needed to determine the relative contribution of donor-specific antibody (DSA) and cAMR to graft injury and the use of DSA as a biomarker of immunosuppression. 6. Newer analytical techniques applied to biopsies, such as messenger RNA expression profiles from formalin-fixed, paraffin-embedded tissues; multiplex protein labeling; and automated image analysis can enhance data extraction from biopsies that provide pathophysiological insights into the underlying causes of the damage and immunosuppression management equation.