Reperfusion injury can cause liver dysfunction after cold storage and warm ischemia. Recently it has been suggested that more than 50% of hepatocytes and sinusoidal endothelial cells (SEC) are undergoing apoptosis during the first 24 hours of reperfusion. The aim of our study was to quantify apoptotic and necrotic hepatocytes and apoptotic SEC after 60 or 120 minutes of warm, partial no-flow ischemia and 0 to 24 hours reperfusion in male SD rats. Apoptotic cells were identified by TUNEL assay in combination with morphological criteria. After 60 minutes of ischemia and 1 hour of reperfusion there was a significant increase of apoptotic hepatocytes (0.7 ؎ 0.1% vs. 0.3 ؎ 0.1% in controls) and SEC (1.5 ؎ 0.6% vs. 0.3 ؎ 0.1% in controls). The number of apoptotic SEC and hepatocytes was not different from controls at 6 hours or 24 hours of reperfusion. In contrast, the number of necrotic hepatocytes was quantified as 12 ؎ 2% at 1 hour, 34 ؎ 6% at 6 hours, and 57 ؎ 11% at 24 hours. These results correlated with the increase in plasma ALT levels at these time points. Longer (120 min) ischemia times did not affect the number of apoptotic cells but increased hepatocellular necrosis to 58 ؎ 4% at 6 hours reperfusion. No significant increase in caspase-3 activity and processing was detectable in any of these livers. Moreover, the caspase inhibitor Z-Asp-cmk (2 mg/kg IV) had no significant effect on reperfusion injury. Our results suggest that only a small minority of SEC and hepatocytes undergo apoptosis after 60 to 120 minutes of warm ischemia followed by 0 to 24 hours of reperfusion. Oncotic necrosis appears to be the principal mechanism of cell death for both cell types. (HEPATOLOGY 2001;33:397-405.)Ischemia-reperfusion injury is responsible for primary liver dysfunction and failure after transplantation, 1-5 after liver resection (Pringle maneuver), 6 or after hemorrhagic shock. 7 Cold storage appears to cause injury mainly to sinusoidal endothelial cells (SEC), 8,9 whereas warm ischemia affects hepatocytes and endothelial cells. 10 In addition, Kupffer cells are activated and primed, 11-13 which causes a substantial aggravation of the injury during the early reperfusion period. At the same time, activation of complement 14 and the formation of cytokines 15 and chemokines 16,17 lead to hepatic neutrophil sequestration and a neutrophil-dependent injury 18 several hours later. Injury by Kupffer cells and neutrophils is largely dependent on reactive oxygen species 19-21 and proteases. [22][23][24] Although the postischemic oxidant stress is not sufficient to kill hepatocytes by lipid peroxidation, 25 there is evidence that reactive oxygen species and proteases cause hepatocellular necrosis. 22,26,27 In recent years, several laboratories reported evidence for apoptotic cell death during hepatic ischemia and reperfusion. [28][29][30][31] According to these studies, 50% to 70% of endothelial cells and 40% to 60% of hepatocytes undergo apoptosis during reperfusion. 30,31 A high percentage of apoptotic hepatocytes were also ide...