Extra Neural Metastasis Of Glioblastoma Multiforme: A Literature Review.

Extra-neural metastases of glioblastoma multiforme are uncommon with unidentified metastatic mechanism. There is no consensus over optimum treatment regimen. The current narrative review was planned to illuminate the presence criteria, sites of metastatic spread, incidence, mechanism, risk factors and management.

Gastroenteropancreatic neuroendocrine tumours: Clinicopathological evaluation at Shifa International Hospital, Islamabad.

OBJECTIVE: Clinicopathological features of gastroenteropancreatic neuroendocrine tumours (GEP-NETs) have rarely been studied in Pakistani population. We investigated clinical characteristics of these tumours according to updated World Health Organization (WHO) 2010 classification. METHODS: The data of Shifa International Hospital, Islamabad was retrospectively analysed for pathologically confirmed GEP-NETs from January 2013 to March 2018. RESULTS: One hundred and eighteen patients (mean age, 52.2± 16.4 years; Of these 65(55.1%) were males. Majority, 98(83.1%) of the patients were symptomatic including 6(5.1%) with functional tumours. Pancreas was the most frequent primary site noted in 33(28%) patients. The most common histologic type was well differentiated neuroendocrine tumour (WDNET) in 96(81.4%) patients followed by neuroendocrine carcinoma (NEC) in 11(16.1%) patients. Almost half the cases or 54(45.8%) of WDNET were grade 1, 32 (27.1%) were grade 2, and 10 (8.5%) were grade 3. Distant metastasis at the time of diagnosis was found in 18(15.3%) cases with 14,(77.7%) in liver as the most common metastatic site. Synaptophysin positivity was seen in 60 (96.8%) cases of grade 1, 32(27.2%) of grade 2 WDNET, 8(100%) cases of grade 3 WDNET and 12(92.3%) of NEC and chromogranin was positive in 49(94.2%) of grade 1 and grade 2 WDNET, 5 (83.3%) cases of grade 3 WDNET and 5 (45.4%) cases of NEC. CONCLUSIONS: GEP-NETs showed a wide clinicopathological spectrum. Pancreas is the most common site of involvement by the GEP-NET, however, grade 3 WDNET had a predilection for colon. Small cell carcinoma was commonly observed in the oesophagus.

Spectrum of histopathological diagnosis in paediatric patients with liver disorders in Pakistan.

OBJECTIVE: To document spectrum of paediatric liver disorders confirmed on liver biopsy. METHODS: The retrospective review of patients was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of all children who underwent ultrasound-guided percutaneous liver biopsy between December 2008 and June 2015. Frequency of individual diagnosis was assessed and compared on gender basis. SPSS 16 was used for statistical analysis. RESULTS: There were medical records of 74 patients in the study with an overall median age of 6.9 years (interquartile range: 0.2-17.7 years). Metabolic 27(36.5%) and inflammatory 19(25.6%) disorders were the most common aetiologies. At presentation 29(39.1%) patients had cirrhosis; and 25(34%) children were <5 years of age. Metabolic disorders were the most common aetiology in children upto 10 years of age with 19(25.6%) patients. Above the age of 10 years, inflammatory disorders were more frequent and were seen in 10(13.5%). Based on gender, a trend towards significance was observed for metabolic disorders (p=0.08) and children who presented with cirrhosis (p= 0.07), but it was not statistically significant. CONCLUSIONS: Metabolic disorders were the most common cause of liver disorders. A number of children at presentation had underlying cirrhosis.

Interobserver variability in HER-2/neu reporting on immunohistochemistry in breast carcinomas.

OBJECTIVE: To evaluate human epidermal growth factor receptor 2 (HER2/neu) interobserver variability between specially trained and untrained general histopathologists. METHODS: The retrospective study cases of invasive breast carcinoma received at Shifa International Hospital, Islamabad, from June 2010 to December 2011, for assessment of HER2/neu status by immunohistochemistry which were retrieved from the files and, 30 consecutive cases each of score 0, 1+, 2+ and 3+ were selected for a total of 120 cases. Two groups of two histopathologists each examined the cases blindly. One group had attended a short course in Germany, while the other group comprised two qualified histopathologists who had not had any special training. Each histopathologist reported the cases independently according to standard guidelines. Kappa statistics were applied. RESULTS: The trained group of histopathologists showed agreement in 113 (94%) cases. Kappa value was calculated to be 0.96 which means 'perfect agreement. In contrast the untrained group showed agreement in 83 (69%) cases with a kappa value of 0.59 which means 'moderate agreement. CONCLUSION: Interobserver variability in immunohistochemical scoring of HER-2/neu in breast carcinoma is high among untrained general histopathologists. This may adversely affect the selection of patients with cancers who could benefit from Herceptin therapy.

To evaluate the utility of Oxford classification in predicting renal outcome in IgA nephropathy patients.

BACKGROUND: Immunoglobulin A Nephropathy (IgAN) is a heterogeneous disorder. Multiple ethnicities conducted studies to assess the effectiveness of the Oxford classification of IgAN in prognostication. However, there is no study on the Pakistani population. We aim to identify its prognostic effectivity in our patients. METHODS: We retrospectively reviewed the medical records of 93 biopsy-proven cases of primary IgAN. We collected the clinical and pathological data at baseline and on follow-ups. The median follow-up period was 12 months. We defined the renal outcome as a ≥ 50% decline in eGFR or end-stage renal disease (ESRD). RESULTS: Of 93 cases, 67.7% were males with a median age of 29. Glomerulosclerosis was the most prevalent lesion (71%). The median MEST-C was 3. On follow-up, median serum creatinine worsened from 1.92 to 2.2 mg/dL, and median proteinuria reduced from 2.3 g/g to 1.072 g/g. The reported renal outcome was 29%. T and C scores and MEST-C scores above 2 were significantly associated with pre-biopsy eGFR. On Kaplan-Meier analysis, the T and C scores' association was significant with the renal outcome (p-value 0.000 and 0.002). In univariate and multivariate analyses, the association of T-score (p-value 0.000, HR 4.691), total MEST-C score (p-value 0.019), and baseline serum creatinine (p-value 0.036, HR 1.188) were significant with the outcome. CONCLUSION: We validate the prognostic significance of the Oxford classification. T and C scores, baseline serum creatinine, and total MEST-C score significantly affect the renal outcome. Furthermore, we recommend the inclusion of the total MEST-C score in determining the IgAN prognosis.

Lipoprotein Glomerulopathy With Complete Resolution With Fenofibrate: Report of First Case From Pakistan.

Background: Lipoprotein glomerulopathy is an infrequent glomerular disorder that culminates in nephrotic syndrome and often progresses to kidney failure. Whereas most patients have been reported in Japan and China, limited reports have been documented outside these regions. This patient represents the first report of lipoprotein glomerulopathy in Pakistan. Case Presentation: A 25-year-old male patient, hypertensive for 2 years, presented with progressive body edema, frothy urine, and fatigue. Examination revealed elevated blood pressure, bilateral pedal edema, and positive shifting dullness. Laboratory results showed significant proteinuria and elevated cholesterol and triglyceride levels. Renal biopsy revealed enlarged glomeruli with a dilated capillary lumen filled with pale-staining mesh-like material "lipoprotein thrombi." Mild tubular atrophy and interstitial inflammation were observed. No interstitial fibrosis was evident. Electron microscopy detailed the lipoprotein thrombi with lipid granules and vacuoles of various sizes. A diagnosis of lipoprotein glomerulopathy was rendered. Treatment with fenofibrate, rosuvastatin, and captopril led to notable improvements in symptoms, blood pressure, and lipid levels during a 6-month follow-up. Subsequent biopsy showed complete resolution of the lipoprotein thrombi and a significant reduction in subendothelial granular densities. However, the flocculent subendothelial material persisted to some extent despite the complete resolution of lipoprotein thrombi. Conclusion: This report underscores the rarity of lipoprotein glomerulopathy in Pakistan and contributes valuable insights into its histopathologic features and global epidemiology. This unique instance aims to raise awareness among healthcare professionals, aiding in improved recognition of this rare entity. The favorable response to fenofibrate treatment underscores its effectiveness in managing lipoprotein glomerulopathy.

Role of immunoflourescence in the diagnosis of glomerulonephritis.

OBJECTIVE: To correlate the findings of immunoflorescence (IF) with morphology in renal biopsies of patients with glomerulonephritis (GN) of both primary and secondary nature. METHODS: The cross-sectional analytical study was conducted at the Shifa International Hospital's Department of Pathology form March 2007 to August 2008, during which a total of 207 renal biopsies were done. Of them, the study included 92 cases which were diagnosed as primary or secondary glomerulonephritis under light microscope. Those cases were selected in which both light microscopy (LM) and immunoflorescence were done. RESULTS: Of the 92 patients, 79 (85.8%) were adults (> or = 19 years) and 13 (14%) were children (< 19 years). The mean age of adults was 36.44 +/- 11.55 (range 19-69 years) and that of the children was 10.54 +/- 3.85 years (range 4-18 years). immunoflorescence changed the morphologic diagnosis in 20 (21.73%) cases. The pattern of disease was: membranous glomerulonephritis in 24%, focal segmental glomerulosclerosis (FSGS) in 18.4%, mesangiocapillary glomerulonephritis in 2%, and minimal change disease (MCD) in 16% of the cases. CONCLUSION: Light microscopy alone can misdiagnose renal disease. This is especially important in cases of early stage membranous, IgA nephropathy (IgAN), Lupus nephritis and IgM nephropathy (IgMN), as these entities can only be diagnosed by correlating the microscopic, immunoflorescence findings and clinical details.

Renal Amyloidosis: A Clinicopathological Study From a Tertiary Care Hospital in Pakistan.

Introduction Systemic amyloidosis can affect any organ in the body, but the kidney is the most commonly involved site. It is characterized by the extracellular deposition of insoluble fibrillar proteins. Amyloid deposits can be identified histologically by Congo red stain, which gives apple-green birefringence under polarized light. Typing of renal amyloidosis is done by direct immunofluorescence on frozen tissue. The most common types of amyloidosis seen in renal tissue are amyloid light chain (AL) primary amyloidosis and amyloid A (AA) secondary amyloidosis. Although primary amyloidosis is considered the most common type in western countries, however, in the subcontinent region, secondary amyloidosis is more common. The spectrum of signs and symptoms in renal amyloidosis is variable including isolated proteinuria, nephrotic syndrome, hypertension, hypotension, and renal insufficiency. The present study aims to evaluate the incidence and aetiology of various types of renal amyloidosis, determine their distribution within the kidney, and study various clinicopathological features. Objective The present study aims to evaluate the aetiology and clinicopathological profile of renal amyloidosis, determine its various types, and their distribution within the kidney. Materials and methods This retrospective cross-sectional study was conducted from 1st January 2013 to 31st December 2020 at the Department of Histopathology, Shifa International Hospital (SIH), Islamabad. All renal biopsies diagnosed as renal amyloidosis were included in the study. Data were analysed using SPSS version 23 (IBM Corp., Armonk, NY). Frequency and percentages were calculated for qualitative variables, and mean and standard deviation were calculated for quantitative variables. Results A total of 131 cases were diagnosed with renal amyloidosis during the study period of eight years (from 1st January 2013 to 31st December 2020) at SIH. The age range varied from 17 to 82 years. The mean age of the patients was 45 ± 16.33 years. Out of 131 patients, 82 (62.6%) were males and 49 (37.4%) were females. Amongst them, 72 (54%) cases were diagnosed with secondary AA amyloidosis and 16 (12%) cases were diagnosed with primary AL amyloidosis. The rest of the cases 43 (34%) were of indeterminate type. The associated conditions in secondary amyloidosis were tuberculosis in 41 (57%), rheumatoid arthritis in 16 (22%), ankylosing spondylitis in five (7%), lymphoma in three (4%), diabetes in two (3%), and chronic osteomyelitis, chronic heart disease, hepatitis, and vasculitis in one case each (1.7%). Out of 16 cases reported with AL amyloidosis, 10 cases (62.5%) had a history of multiple myeloma. The most common clinical presentation was nephrotic syndrome followed by subnephrotic proteinuria, renal failure, and hypertension. Conclusion The findings of the present study show underlying etiological factors and clinicopathological characteristics of renal amyloidosis. AA amyloidosis is the most common type of renal amyloidosis in our study and tuberculosis is the most common aetiological factor. AL amyloidosis is less frequent in our population.

Yolk sac tumour arising in mature teratoma in the parapharyngeal space.

Yolk sac tumour is germ cell tumour commonly found in children and infants under three years of age in its pure form with a good prognosis. The commonest location for the yolk sac tumour is gonads i.e. testis and gonads. Yolk sac tumour is rarely reported in extra- gonadal locations. Parapharyngeal space is an uncommon site for mature teratoma and very few cases have been reported in adults and children. Malignant transformation in a mature teratoma in the extragonadal sites has been reported but development of yolk sac tumour has not been reported so far in the world literature. We report to our knowledge, the only and first case of yolk sac tumour arising in a mature teratoma presenting as a parapharyngeal mass in a four year old male child.

Association of Adult-Onset Bartter Syndrome With Undifferentiated Connective Tissue Disorder.

Bartter syndrome is a rare autosomal recessive, salt-losing disorder characterized by hypokalemic hypochloremic metabolic alkalosis. We are reporting a case of 21 years old patient, who presented with lower limb weakness, marked hypokalemia, proteinuria, and renal impairment detected on laboratory evaluation. The diagnosis of Bartter syndrome was suspected by marked hypokalemia and was supported by renal biopsy which showed evidence of Juxtaglomerular (JG) hyperplasia. This is the first case report about clinicopathological features of the patient with acquired Bartter syndrome and associated undifferentiated connective tissue disorder manifesting as hypokalemia with paralysis.

Analysis of Clinical, Pathological and Prognostic Features of Coexistent Membranous and IgA Nephropathy in a Series of 13 Patients at a Tertiary Care Hospital.

Background Membranous nephropathy (MN) and immunoglobulin A nephropathy (IgAN) are although two different entities, yet can rarely coexist. There is not much data available on this coexistent disorder, specifically with regard to the treatment modality and outcome. Here, we analyse in detail, retrospectively, 13 cases of coexistent IgA and membranous nephropathy (IgA-MN). Methods Renal biopsy data of 1084 diagnosed cases of either membranous or IgA nephropathy was obtained from March 2015 till March 2021. Out of 1084 patients, 19 diagnosed cases of the coexistent disorder were identified. Six out of 19 patients were excluded because of their unwillingness. From remaining 13 patients, data regarding clinical presentation, investigations, management and treatment response was collected from hospital database, files and via telephonic interview. Results The overall prevalence noted was 1.75%. Among them, 53.8% were females and 46.2% were males. Their median age was 40 years (range: 14-71 years). On workup, mean serum albumin was 2.64 g/dl (range: 1.6-3.8 g/dl), mean proteinuria was 5.5 g/24 hours (range: 1.55-11.48 g/24 hours) and mean creatinine was 0.98 mg/dl (range: 0.5-2.8 mg/dl). Anti-phospholipase A2 receptor antibody positivity was only 14.2%. The renal biopsy of all patients showed thickening of the glomerular basement membrane with granular IgG deposits and mesangial expansion with granular IgA deposits. A total of 80% patients showed complete remission with steroids, calcineurin inhibitors (CNIs) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs). Conclusion IgA-MN is probably a separate disorder that can only be confirmed on immunofluorescence microscopy. The response to the combination of steroids, CNIs and ACEi/ARBs is found to be the most effective; hence, this combination must often be used for the management of this coexistent disorder.

Esophageal haemangioma: a case report and review of literature.

A 28-year-old female presented with the history of dysphagia to liquids. Initial evaluation through endoscopy was unremarkable and biopsy was reported negative for malignancy. Re-biopsy revealed a stricture like esophageal growth at 23 cm from upper incisors, causing narrowing of esophagus that raised suspicion of malignancy. Microscopic examination revealed dilated blood vessels lined by flattened endothelial cells. Diagnosis of esophageal cavernous haemangioma was made. Immunohistochemistry (CD34) confirmed the diagnosis. Endoscopic resection of tumor is being planned for the patient.

C1Q Nephropathy: A Multifaceted Disease With Infrequent Diagnosis.

BACKGROUND: C1q nephropathy (C1qN) is a rare glomerulopathy, with a very low prevalence world wide varying from 0.2 to 2.5%. Even though more than three decades have passed since this entity was first explained, still, it remains a dilemma for many due to the rarity of this lesion. This study was carried out principally to determine the clinical presentation, morphologic features and distribution of C1qN in our region based on renal biopsies studied by light microscopy (LM), and immunofluorescence (IF) so that this entity is better understood both by nephrologists and pathologists as no such study has ever been conducted in Pakistan to our knowledge. METHODS: It was a cross-sectional study carried out from 1st January 2012 to 30th December 2016 in Histopathology department, Shifa International Hospital. All cases diagnosed as C1q nephropathy were retrieved from the hospital's computerized database. Their clinical profiles, morphology and immunohistochemical profiles were studied.. RESULTS: Over this period a total of 31 cases were diagnosed with C1qN. Mean age of the patients was 32.09±18.66 years. The most common clinical presentation was nephrotic syndrome seen in 22 (71%) patients. The most frequent morphological pattern seen was minimal change disease (MCD) in 13 (41.9%) cases. All cases showed dominant 22 (71%) or codominant 9 (42.9%) mesangial±membranous C1q deposition. No correlation was found (p-value >0.05) between morphological pattern and clinical presentation of the disease or immunofluorescence findings. CONCLUSIONS: C1qN is a rare entity which is primarily diagnosed on the basis of immunofluorescence findings with a dominant or codominant fluorescent intensity for C1q. It is recommended that C1qN is sought for preferably with immunofluorescence staining of biopsies for immune reactants, especially for C1q. Studies from this part of the world are strongly recommended to predict clinical outcome and treatment options.

Is TLE1 Expression Limited to Synovial Sarcoma? Our Experience at Shifa International Hospital, Pakistan.

INTRODUCTION: Synovial sarcoma (SS) accounts for 10-15 percent of adult soft tissue sarcomas. Transducin-like enhancer of split 1 (TLE1), a transcriptional repressor, is essential in hematopoiesis, neuronal differentiation, and terminal epithelial differentiation. TLE1 proteins inhibit Wnt signaling and other cell fate determination signals, and so have an established role in repressing differentiation. TLE1 has recently been shown to be a highly sensitive and relatively specific marker of SS. MATERIALS AND METHODS: Study design is retrospective, descriptive. A total of 25 cases of SS and 28 of soft tissue lesions were retrieved from the record. TLE1 (clone 1F5) expression was evaluated and scored as negative (<5% of cells positive), 1+ (5-25% of cells positive), 2+ (26-50% of cells positive), or 3+ (>50 % of cells positive). RESULT: Twenty-four out of twenty-five (96%) cases of SS showed 3+ TLE1 expression. One (4%) case of poorly differentiated SS showed 2+ positivity. 3+ TLE1 positivity was seen in one (100%) case each of infantile fibrosarcoma and low-grade fibromyxoid sarcoma, while two cases (100%) of schwannoma also showed 3+ positivity. All cases of solitary fibrous tumor) (n=2), clear cell sarcoma of tendons and aponeurosis (n=2), embryonal rhabdomyosarcoma (n=1), and de-differentiated liposarcoma (n=2) showed 2+ positivity. 1+ positivity was seen in alveolar soft part sarcoma (n=2), Ewing's sarcoma (n=4), undifferentiated pleomorphic sarcoma (n=1), myxoid liposarcoma (n=1) and malignant peripheral nerve sheath tumor (n=1). TLE1 was negative in all cases of chordomas (n=2), lipomas (n=2), nodular fasciitis (n=2), malignant perivascular epithelioid cell tumor (n=1) and dermatofibrosarcoma protuberans (n=1). CONCLUSION: TLE1 may be a reliable immunostain for diagnosing SS, but its expression is not limited to SS. Its expression should be interpreted in the light of morphological features and a panel of antibodies.

Lymphoepithelioma-Like Carcinoma of the Esophagus: A Rare Tumor.

Lymphoepithelioma-like carcinoma of esophagus is a rare tumor with about 20 cases reported worldwide. It can involve the salivary gland, esophagus, stomach, thymus, thyroid, breast, lung, uterus, cervix, urinary bladder, and the skin. Its association with Epstein Barr virus has been postulated. We report the case of a 45-year female who had been treated for hepatitis C and esophageal tuberculosis and recovered fully from these conditions. She presented with dysphagia of 2-3 month duration. Endoscopic examination revealed narrowing of the esophageal lumen with a fungating mass at the lower end of esophagus with no extension into the stomach. ACTscan confirmed a mass at the lower end of esophagus with multiple enlarged mediastinal lymph nodes. Histological and immunohistochemistry of esophageal biopsy sample showed lymphoepithelioma-like carcinoma. She was managed with chemotherapy comprising of capecitabine, epirubicin and cisplatin followed by esophagectomy and made full recovery.

Recurrent verrucous carcinoma of the urinary bladder after transurethral resection followed by intravesical mitomycin, and a review of the literature.

Verrucous carcinoma (VC) is a locally invasive, non-metastasising well differentiated variant of squamous cell carcinoma. It is very rare in the urinary bladder and mostly associated with schistosomiasis. It has a characteristic multilobular appearance with small surface projections on contrast cystogram. Owing to its bland cytology, it is a challenging diagnosis. We report a case of VC of the bladder-unrelated to schistosomiasis and involving the prostate-that recurred after transurethral resection of the tumour and prostate followed by six doses of intravesical mitomycin. To the best of our knowledge, no such case has been reported from Pakistan.

Frequency of IgA Nephropathy Presenting at a Tertiary Care Hospital in Pakistan.

OBJECTIVE: To determine the frequency of IgAnephropathy presenting at a tertiary care hospital. STUDY DESIGN: Across sectional, observational study. PLACE AND DURATION OF STUDY: Pakistan Institute of Medical Sciences, Islamabad and Shifa International Hospital, Islamabad, Pakistan, from November 2008 to November 2014. METHODOLOGY: This was a retrospective analysis of renal biopsies for the diagnosis of nephropathy during the study period. Biopsies were stained with fluorescence isothyocyanate (FITC) labelled antibodies against IgG, IgA, IgM, C3, C4 and C1q for fluorescent microscopy. For histopathological examination, the specimens were stained with hematoxylin and eosin, Periodic acid Schiff and methanamine silver stains for light microscopy. RESULTS: Out of total 1,658 renal biopsy cases, 142 (8.6%) were diagnosed as IgA nephropathy on light and immunofluorescence microscopy. Majority of IgAnephropathy patients were young (mean age = 33.2) and presented with proteinuria. The frequency rose from 2% in 2008 to 9.4% in 2014. CONCLUSION: IgAnephropathy was present in younger population and has a rising trend in our population.

Intrameningioma Metastasis: Clinical Manifestation of Occult Primary Lung Carcinoma.

We report a case of lung carcinoma metastasizing into a meningioma in a 68-year-old female, who presented with progressively worsening right-sided hemiparesis and multiple episodes of adult onset epilepsy. Magnetic resonance imaging revealed an oval-shaped extra-axial hypointense lesion with a central hyperintense nodule in the left frontal region favoring a most probable diagnosis of a meningioma. Left frontoparietal craniotomy and excision of the tumor were carried out and histopathology with hematoxylin and eosin stain revealed a meningioma with metastatic adenocarcinoma and was confirmed by immunohistochemistry. The origin of metastasis was presumed to be from the lungs. A computed tomography (CT) scan of the chest with contrast showed a 3.1 x 2.9 cm mass with spiculated margins in the left lower lobe. Fine needle aspiration cytology (FNAC) proved it to be adenocarcinoma.

Spectrum of Histopathological Findings in Live Donor Liver Graft Biopsies.

OBJECTIVE: To study the spectrum of histopathological findings in live donor liver graft biopsies. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Histopathology Department, Shifa International Hospital, Islamabad, from January 2011 to March 2014. METHODOLOGY: The biopsies were received in formalin and routinely processed. The changes encountered were divided into three categories: (i) new-onset post liver transplantation (LT) complications (early and late), (ii) acute rejection and (iii) recurrence of original disease. Banff schema 1997 of rejection activity index (RAI), modified histological activity index (mHAI) and recent literature were utilized for evaluation. The results were finalized in the light of clinical details along with relevant laboratory investigations and radiological findings. RESULTS: Seventy eight percutaneous hepatic graft biopsies of 59 patients were evaluated. Among them, findings noticed in descending order of frequencies were Acute Cellular Rejection (ACR) in 37% (n=30), recurrent hepatitis C (HCV) in 22% (n=18), cholestasis/ductular proliferation in 27% (n=22), ischemic/reperfusion injury in 9.8% (n=8) and drug-induced liver injury in 3.7% (n=3). In the first six months post LT, ACR was the commonest cause of graft dysfunction, while recurrent HCV was noticed to be predominant reason after 6 months. CONCLUSION: In this study, ACR was the most frequent finding in graft biopsies, followed by recurrent HCV. However, in first six months, ACR is the commonest histopathological finding while recurrent HCV was more frequently documented after 6 months.