Immunostaining Patterns of Posttransplant Liver Biopsies Using 2 Anti-C4d Antibodies

Appl Immunohistochem Mol Morphol. 2020 Feb;28(2):146-153. doi: 10.1097/PAI.0000000000000723.


Histopathologic diagnosis of antibody-mediated rejection in posttransplant liver biopsies is challenging. The recently proposed diagnostic criteria by the Banff Working Group on Liver Allograft Pathology require positive C4d immunohistochemical staining to establish the diagnosis. However, the reported C4d staining patterns vary widely in different studies. One potential explanation may be due to different antibody preparations used by different investigators. In this study, posttransplant liver biopsies from 69 patients histopathologically diagnosed with acute cellular rejection, chronic rejection, or recurrent hepatitis C were immunohistochemically stained using 2 polyclonal anti-C4d antibodies. On the basis of the distribution of C4d immunoreactivity, 5 different staining patterns were observed: portal vein and capillary, hepatic artery, portal stroma, central vein, and sinusoids. The frequency, extent, and intensity of positive C4d staining with the 2 antibody preparations differed significantly for portal veins/capillaries and central veins, but not for hepatic arteries and portal stroma. Positive sinusoidal staining was seen in only 1 case. There were no significant differences in the frequency, extent, and intensity of positive C4d staining among the acute cellular rejection, chronic rejection, and recurrent hepatitis C groups with the 2 anti-C4d antibodies. These data show that different anti-C4d antibodies can show different staining patterns, which may lead to different interpretation. Caution is thus needed when selecting C4d antibodies for clinical use to aid in the diagnosis of antibody-mediated rejection.

Publication types

  • Clinical Trial

MeSH terms

  • Adult
  • Aged
  • Antibodies / chemistry*
  • Biopsy
  • Complement C4 / metabolism*
  • Female
  • Graft Rejection* / metabolism
  • Graft Rejection* / pathology
  • Hepatitis C, Chronic* / metabolism
  • Hepatitis C, Chronic* / pathology
  • Hepatitis C, Chronic* / surgery
  • Humans
  • Immunohistochemistry
  • Liver Transplantation*
  • Liver* / metabolism
  • Liver* / pathology
  • Male
  • Middle Aged


  • Antibodies
  • Complement C4