*Purpose: Existing literature offers conflicting conclusions about whether early acute cellular rejection influences long-term outcomes in liver transplantation.

*Methods: We retrospectively collected donor and recipient data on 813 adult, first-time liver transplants performed at a single center between 2009 and 2019. We divided this population into two cohorts based on the presence of early biopsy-proven acute cellular rejection (EBPR) within the first 12 weeks post-transplant and compared outcomes (overall survival, death censored graft survival (DCGS), infection and long-term rejection rates) between the groups. Kaplan-Meier estimates were used to assess time to first event with p value < 0.05 for significance.

*Results: Of the 813 liver transplants, 97 (12%) met inclusion criteria of EBPR. Donor and recipient characteristics did not differ between patients with and without EBPR (Tables 1).

Recipients with EBPR had similar overall survival compared to patients without EBPR (p=0.29), but had inferior one year death-censored graft survival (95.8% for EBPR vs. 98.7% for no EBPR, p<0.05). EBPR was also associated with decreased time to first episode of late (>12 weeks post-transplant) rejection (p<0.0001, Fig 1).

Recipients with EBPR had increased rates of bacterial and viral infection (p<0.05, Fig 2).

*Conclusions: EBPR after liver transplant is associated with inferior death-censored graft survival, increased susceptibility to late rejections, and increased vulnerability to infection. Identifying strategies to mitigate EBPR may lead to improved long-term outcomes after liver transplantation.

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