Late Acute Rejection after OLT

Dr. Welvaert presented a case of an elderly gentleman who was 10 years s/p OLT for hepatitis C cirrhosis who presented with subacute nausea, vomiting, generalized abdominal pain and weight gain, found to have evidence of decompensated cirrhosis and pancytopenia, ultimately diagnosed with late acute rejection with progressive cirrhosis.

 This figure shows the causes of liver allograft dysfunction published in the UpToDate article entitled, "Liver Transplantation: Diagnosis of acute cellular rejection."

This figure shows the causes of liver allograft dysfunction published in the UpToDate article entitled, "Liver Transplantation: Diagnosis of acute cellular rejection."

Learning Points:

  • We reviewed potential long-term complications of liver transplantation including acute or chronic rejection, complications of immunosuppression (renal insufficiency, infection, malignancy, hypertension, metabolic diseases), biliary complications such as leaks or strictures, and recurrence of the primary liver disease.

  • Dr. Welvaert focused his discussion on late acute rejection (LAR) after liver transplantation which typically refers to rejection greater than 180 days following transplant. He reviewed two articles including, "Late acute rejection after liver transplantation: the Western Canada experience" which retrospectively evaluated incidence, predictive factors, and outcomes of late acute rejection and "Late Acute Rejection in Liver Transplant: A systematic review." Not surpriseingly, risk factors for developing LAR included steroid taper and subtherapeutic immunosuppressant levels. Interestingly, those patients whose etiology of their cirrhosis was viral had lower risk of LAR.