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Fibrosing cholestatic hepatitis C virus is a rare, cholestatic hepatitis that can occur in the setting of immunosuppression or after transplantation in individuals with active hepatitis C infection. Its onset is heralded by hyperbilirubinemia and rapidly progresses to graft failure without treatment. It is characterized histologically by ballooning hepatocyte degeneration, bile duct proliferation, cholestasis, and perisinusoidal fibrosis. It is important to distinguish fibrosing cholestatic hepatitis from other common causes of hyperbilirubinemia in the posttransplant setting, including biliary obstruction and acute cellular rejection.