Detrimental impact of early biopsy‐proven rejection in liver transplantation

Abstract

Existing literature offers conflicting conclusions about whether early acute cellular rejection influences long‐term outcomes in liver transplantation. We retrospectively collected donor and recipient data on all adult, first‐time liver transplants performed at a single center between 2008 and 2020. We divided this population into two cohorts based on the presence of early biopsy‐proven acute cellular rejection (EBPR) within the first 90 days post‐transplant and compared outcomes between the groups. There were 896 liver transplants that met inclusion criteria with 112 cases (12.5%) of EBPR. Recipients who developed EBPR had higher biochemical Model for End‐Stage Liver Disease scores (28 vs. 24, p < .01), but other donor and recipient characteristics were similar. Recipients with EBPR had similar overall survival compared to patients without EBPR (p = .09) but had decreased graft survival (p < .05). EBPR was also associated with decreased time to first episode of late (> 90 days post‐transplant) rejection (p < .0001) and increased vulnerability to bacterial and viral infection (p < .05). In subgroup analysis of recipients with autoimmune indications for liver transplantation, EBPR had a more pronounced association with patient death (hazard ratio [HR] 3.9, p < .05) and graft loss (HR 4.0, p < .01). EBPR after liver transplant is associated with inferior graft survival, increased susceptibility to late rejections, and increased vulnerability to infection.