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Acute Cellular Rejection in Liver Transplant Recipients Following Vaccination Against Covid-19

R. Sarwar1, O. Adeyi2, N. Lim1

1Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, 2Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN

Meeting: 2022 American Transplant Congress

Abstract number: 525

Keywords: COVID-19, Liver transplantation, Rejection, Vaccination

Topic: Clinical Science » Liver » 54 - Liver: Immunosuppression and Rejection

Session Information

Session Name: Retransplantation and Other Complications

Session Type: Rapid Fire Oral Abstract

Date: Tuesday, June 7, 2022

Session Time: 5:30pm-7:00pm

 Presentation Time: 6:50pm-7:00pm

Location: Hynes Room 313

*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

Table 1. Clinical Characteristics of Patients with COVID-19 Vaccination and Acute Cellular Rejection
Pt. Age, Gender and Etiology of liver disease IS Regimen Time since LT (days) Last Pre-Vaccine TB/AST/ALT/ALP Peak Post-Vaccine TB/AST/ALT/ALP Liver Biopsy (RAI=n/9) Treatment and Outcomes
1 52, M Alcohol MMF 750mg BID + PRED 5mg daily 827 0.8/19/42/67 2.8/22/25/82 ACR (5/9) METHYLPRED 1g IV x3 days, Oral PRED taper, Added EVE. Improved
2 71, M Alcohol TAC (goal 7-10) + MPA 720mg BID 1029 1.4/50/72/136 2.4/61/128/128 ACR (3/9) METHYLPRED 500mg IV x3 days, Oral PRED taper.Improved, Repeat biopsy on day 890 since LT showed mild portal and lobular inflammation with pseudo ground-glass inclusions
3 50, M 

NASH
TAC (goal 7-10) + MPA 720mg BID 438 0.2/20/25/182 0.7/184/318/349 Immune-med (2-3/9) Improved, Repeat biopsy on day 890 since LT showed mild portal and lobular inflammation with pseudo ground-glass inclusions.Improved
4 61, F NASH/A1AT/Iron Overload CSA (goal 80-120) 778 1.7/68/65/172 2.0/75/72/180 ACR (5/9), focal C4d + METHYLPRED 1g IVx3 days, Oral PRED taper, Increased CSA goal, Added MMF.Improved
5 54, M NASH MMF 750mg BID + PRED 5mg daily 906 2.8/22/25/82 2.2/235/354/119 ACR (5/9) METHYLPRED 500mg IV x3 days, Oral PRED taper, Added TAC.Improved
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To cite this abstract in AMA style:

Sarwar R, Adeyi O, Lim N. Acute Cellular Rejection in Liver Transplant Recipients Following Vaccination Against Covid-19 [abstract]. Am J Transplant. 2022; 22 (suppl 3). https://atcmeetingabstracts.com/abstract/acute-cellular-rejection-in-liver-transplant-recipients-following-vaccination-against-covid-19/. Accessed May 8, 2025.

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