A liver transplant replaces a diseased liver with a healthy one from a donor. After the surgery, the recipient’s immune system may recognize the new organ as foreign and attack it in a response known as rejection. With modern medical management, rejection is often a treatable and manageable event.
Statistical Overview of Rejection Rates
The term “rejection rate” can refer to a treatable acute rejection episode or the complete failure of the transplanted organ, known as graft loss. Acute rejection episodes are most common in the first six months, with up to 30 in 100 patients experiencing one. Data shows that acute rejection within the first year can occur in over 19% of younger adult recipients (18-34 years old) and around 8% of those aged 65 or older.
An episode of acute rejection does not mean the transplant has failed, as the majority of these episodes are successfully treated. The statistics related to long-term graft survival are a different measure. For deceased donor transplants performed between 2011 and 2021, graft failure occurred in about 8% of recipients at one year, 13.7% at five years, and 20.3% at ten years.
Living donor liver transplants have shown slightly different outcomes, with graft failure occurring in 6.5% at one year, 15.9% at five years, and 32.5% at ten years for transplants performed during a similar period. While short-term rejection is a possibility, long-term success rates have improved with medical advancements. The overall 5-year survival rate for recipients is around 80%.
Types of Liver Transplant Rejection
Rejection is classified into types based on timing and the immune response, which helps guide treatment.
Hyperacute rejection is an immediate response that occurs within minutes to hours after surgery. It is caused by pre-existing antibodies in the recipient’s blood that attack the donor organ. Due to pre-transplant cross-matching tests that check for antibody compatibility, this type is now extremely rare.
Acute cellular rejection is the most common form, occurring within the first few weeks to months after the transplant in about 15-25% of recipients. This type involves the recipient’s T-cells, a type of white blood cell, identifying the new liver as foreign and mounting an attack. This response develops over days or weeks and can be reversed with treatment.
Chronic rejection is a slower process that can develop months or years after surgery, occurring in about 2 in 100 patients. It is characterized by a gradual immune attack on the new liver. This process can lead to the loss of bile ducts and scarring within the liver, impairing its function. Chronic rejection is more difficult to treat and can lead to graft failure.
Recognizing the Warning Signs
Identifying rejection early is a part of post-transplant care. Rejection may not cause noticeable symptoms and is often first detected through routine blood tests showing elevated liver enzymes. These checks are a standard part of follow-up care to monitor the new organ’s health.
When symptoms do appear, they can be general or specific to liver function. Common warning signs include:
- Fever
- Fatigue or a general feeling of being unwell
- Abdominal pain or tenderness over the liver area
- Jaundice, which is a yellowing of the skin and the whites of the eyes
- Dark-colored urine
- Pale, clay-colored stools
- Fluid retention causing swelling in the abdomen or legs
Medical Response to Rejection
When rejection is suspected, the standard procedure for confirmation is a liver biopsy. During this procedure, a small sample of liver tissue is removed with a needle and examined under a microscope. This examination can confirm rejection, determine its type, and assess its severity to guide the treatment plan.
The primary treatment for an episode of acute rejection involves adjusting the patient’s immunosuppressive medications to calm the immune system’s attack. This often means administering high doses of corticosteroid medications, usually intravenously for a few days. For the majority of patients, this approach is effective at reversing the rejection episode.
If the rejection is severe or does not respond to steroids, a condition known as steroid-resistant rejection, stronger immunosuppressive agents may be used. These can include antibody-based therapies like anti-thymocyte globulin (ATG), which target the immune cells responsible for the rejection.
Key Factors in Preventing Rejection
Preventing rejection begins before surgery with the careful matching of the donor and recipient. Matching blood types and considering the size of the donor organ relative to the recipient are important early steps.
Lifelong adherence to a regimen of immunosuppressant medications is the primary method of rejection prevention after the transplant. These drugs work by dampening the body’s immune system to prevent it from attacking the new liver. Doses are highest immediately after surgery and are gradually reduced over time to a maintenance level.
Beyond medication, maintaining overall health and attending all scheduled follow-up appointments is necessary. Regular blood tests allow the transplant team to monitor liver function and drug levels, making adjustments as needed. Avoiding substances known to harm the liver, such as alcohol, also supports the long-term health of the transplanted organ.