A new composite scoring system developed by researchers in Brussels could spare roughly one in three liver transplant recipients from unnecessary steroid treatments for early tissue rejection, according to research published on April 30, 2026, in Hepatobiliary & Pancreatic Diseases International.
For decades, clinicians have relied heavily on standard biopsy findings to catch and treat early post-transplant complications. Yet a fundamental tension has long persisted in transplant medicine: the fear of graft loss has driven aggressive immunosuppression protocols, even though many early tissue rejection episodes may resolve entirely on their own. Managing these patients with high-dose steroids carries documented risks, exposing recipients to avoidable harms such as infections, cardiovascular events, kidney dysfunction, and metabolic disorders.
How the Seven-Up Score Changes Early Post-Transplant Biopsy Evaluation
To address the high interobserver variability and the poor correlation between clinical suspicion and traditional biopsy results under the Banff histology system, a research team at Université catholique de Louvain in Brussels, Belgium, led by Prof. Jan P. Lerut, developed a combined bio-histological approach known as the Seven-Up score. The research evaluated 421 consecutive adult liver transplant recipients with complete follow-through December 2024.
The new framework integrates two distinct components measured during the first week following a transplant. First, the histological score utilizes the standard Banff scale ranging from zero to nine from a protocol biopsy performed on post-operative day seven. Second, the biological component—called the Bio-score, which ranges from zero to four—captures dynamic changes in three routine blood markers between post-operative day five and day seven. These markers track a rising total bilirubin level, a rising eosinophil count, and a declining platelet count. An absolute eosinophils count of 600 per microliter or higher serves as an additional marker within this biological trend.
Evaluating Treatment Rates and Patient Outcomes After Liver Transplantation
Under a conventional biopsy-only strategy, all 157 patients—representing 37.3% of the cohort—who showed Banff scores between six and nine would have received immediate steroid treatment. However, when researchers applied the Seven Up score, which requires both a Banff score of six or higher and a Bio-score of two or greater to define clinically relevant rejection, only 19 patients qualified for therapy during the first 15 days. This refined threshold successfully spared 138 patients from receiving early steroid boluses.
Long-term data from the study showed that overall graft and patient survival rates remained comparable between the treated and untreated groups. Furthermore, the Bio-score demonstrated strong diagnostic accuracy for very early clinically relevant T cell-mediated rejection, registering an area under the curve of 0.78 with a 95% confidence interval spanning from 0.68 to 0.89 and a P-value of less than 0.001.
“The key message is simple: not every rejection seen under the microscope needs to be treated. For decades, we’ve been treating the biopsy rather than the patient. Our data show that the liver allograft is remarkably resilient—most early histological rejection resolves without intervention.”
Authors, Université catholique de Louvain
Understanding Standard Diagnostic Procedures for Liver Damage and Rejection
To accurately monitor graft health or investigate unexplained dysfunction, medical providers utilize different diagnostic methods depending on a patient’s risk profile. A liver biopsy involves a doctor obtaining a small tissue sample so a pathologist can examine it under a microscope for signs of damage, disease, or rejection. While percutaneous biopsy—where a needle is inserted through the skin of the upper abdomen—remains the most common approach, it carries procedural risks for patients with bleeding disorders or fluid accumulation known as ascites.
For individuals facing a higher risk of complications during percutaneous sampling, providers often perform a transjugular liver biopsy. In this alternative procedure, a doctor passes a needle through the jugular vein in the neck down to the liver. This technique allows clinical teams to safely secure tissue while simultaneously measuring pressure inside the liver veins, proving especially useful for patients with abnormal blood clotting profiles or those requiring platelet or clotting factor transfusions beforehand.
By pairing non-invasive biological blood markers with standard histological findings, the newly validated scoring method offers clinicians an immediate framework to minimize heavy immunosuppression and protect recipients from avoidable steroid-related complications without compromising long-term survival.
