*Purpose: The coronavirus disease 2019 (COVID-19) global pandemic has seen the development of effective vaccines in record time. We report a series of five liver transplant (LT) recipients who developed acute cellular rejection (ACR) after receiving COVID-19 vaccinations.

*Methods: We performed a single-center, retrospective review of LT recipients who presented with biopsy-proven ACR after receiving a COVID-19 vaccination.

*Results: 603 LT recipients were fully vaccinated against COVID-19 at our center on 10/4/2021. Five (0.77%) patients developed elevated liver enzymes after COVID-19 vaccination without an identifiable cause and had a subsequent liver biopsy consistent with ACR: four (80%) patients were male and the median age was 54 years old. The indication for LT was cirrhosis secondary to non-alcoholic steatohepatitis in three (60%) and alcohol in two (40%) patients. The median time from LT to the first dose of COVID-19 vaccination was 19 months (range 7-26 months). Three (60%) patients had moderate (RAI= 5/9) ACR. All patients were treated with high-dose intravenous methylprednisolone for 3 days and had normalization of liver enzymes. No patients required rescue therapy with anti-thymocyte globulin or developed graft failure. All patients eventually completed their vaccination series.

*Conclusions: LT recipients may be at risk for developing ACR after the COVID-19 vaccination. Further study is required to better understand this relationship while closer monitoring following vaccination may be warranted in this patient population. Figure 1: Liver Enzymes of Five Patients Relative to Vaccine Doses

Figure 2: Liver Histopathology in Five Patients Showing Acute Cellular Rejection and C4d Staining in One Patient

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