FAQs About Liver Rejection
If you have received a transplanted liver—or if you are a candidate for transplantation—you may have learned about the possibility of liver transplant rejection. On this page, we provide answers to some of patients’ most frequently asked questions about liver transplant rejection, along with some helpful resources to help you learn more about this important topic.
As with any medical procedure, it is crucial that you follow the instructions of your doctor after your transplant. Your liver transplant clinical team will work closely with you to develop a plan to maintain the health of your transplanted organ. If you believe you may be experiencing any symptoms of liver transplant rejection, contact your doctor immediately.
The main job of your immune system is to protect you from proteins, germs, and other entities that are dangerous to your health. Liver transplant rejection occurs when the recipient’s immune system identifies the donor’s liver as “foreign” and starts to attack it. If left untreated, transplant rejection can lead to the failure of the new liver.
There are two main types of rejection. Acute rejection typically occurs within the first few weeks to months after the liver transplant. It often presents with sudden and severe signs and symptoms, like jaundice (yellowing of the skin and eyes), pain, fever, and elevated liver enzymes.
Chronic rejection develops gradually, often months or years after transplantation. The symptoms are usually more subtle and include fatigue and gradual changes in liver function tests.
Liver rejection after transplantation can happen for several reasons. The most common risk factors for liver rejection include:
- Not taking immunosuppressive medications as prescribed
- Infections
- Donor-recipient mismatch
- History of previous rejection
- Medication side effects
- presence of other medical conditions
- Age
- Genetic factors
It’s important to work closely with the transplant team to minimize these risks. Steps you can take include undergoing a thorough evaluation process before transplantation and taking all of your medication exactly as prescribed after transplantation.
Research shows that the rejection process begins well before symptoms develop, with what we call “silent” rejection, or subclinical acute rejection (subAR). In subAR, you will likely feel normal.
When liver rejection symptoms occur, they can vary from patient to patient. Some of these symptoms may include:
- Unexplained and persistent fatigue or weakness
- Jaundice
- Dark colored urine
- Light colored or pale stools
- Pain or discomfort in the abdominal area, particularly in the right upper quadrant
- Swelling of the abdomen or legs
- Persistent nausea and vomiting
- A sudden loss of appetite or weight loss
- Fever, especially if accompanied by other symptoms
- Changes in liver function tests
- Confusion or other changes in mental status
Contact your doctor immediately if you have any of these symptoms.
The current standard of care to diagnose liver rejection is a liver biopsy, where a sample of the transplanted liver is removed and tested for signs of rejection. Other tests that aid in the diagnosis of liver rejection include liver function tests, imaging studies, immunologic tests, and a clinical evaluation.
Novel molecular diagnostic tests assess gene expression patterns in blood to help in the diagnosis of rejection, especially in cases of subclinical or “silent” rejection. Transplant Genomics has developed a new noninvasive blood test to rule out subclinical acute rejection through genetic testing, confirming that a patient’s immunosuppressive medication is correctly balanced and helping avoid unnecessary biopsies. This test is called OmniGraf Liver.
OmniGraf analyzes genes in the blood of liver transplant recipients who have had their new liver for more than 90 days. OmniGraf compares a patient’s blood gene profile with that of a group of people who had a biopsy to confirm that they had stable graft function.
In this test, you will receive a simple blood test at a phlebotomy lab. The sample will be sent to Transplant Genomics for testing, and your doctor will receive the results. There are two possible results:
Negative: This means the new liver is stable, with no rejection. This result allows doctors to rule out the need for a biopsy.
Positive: This indicates that there may be subclinical rejection. This result lets doctors know that a patient may benefit from additional tests, like biopsies.
If you are diagnosed with liver transplant rejection, your transplant team will tailor your treatment approach based on the type and severity of rejection and your individual circumstances.
Acute rejection is usually treated with high doses of immunosuppressive medicine to suppress the immune response and prevent further damage to the graft.
Chronic rejection is more challenging to treat, and management may involve adjustments to immunosuppressive medications, bile duct interventions, or even re-transplantation in severe cases.
After a liver transplant, it’s important to follow some guidelines to ensure a successful recovery and maintain your new liver’s health.
DON’T skip your medications. Take your prescribed medications exactly as your transplant team instructs—these medicines help prevent rejection.
DON’T skip your medical visits. Attend all your follow-up appointments and tests as scheduled, as they allow your medical team to monitor your progress and check for early signs of rejection.
DON’T drink alcohol, smoke, or take recreational drugs. Maintain a healthy lifestyle by eating a balanced diet, staying physically active as recommended by your doctor, and avoiding substances that are harmful for your liver.
DO avoid infections. Wash your hands frequently and follow your medical team’s advice on social distancing and vaccinations.
DO communicate with your healthcare team. Reach out to your transplant team if you notice any unusual symptoms or have concerns—early detection and communication are key to your long-term well-being.
The immunosuppressive drugs given after a liver transplant are the most important preventative step against organ rejection. These drugs act as a shield to protect your new liver from your immune system.
Your transplant team will discuss the risks of immunosuppressive medications, including an increased risk of infection and common side effects including bone thinning, diarrhea, diabetes, high blood pressure, and others. Your healthcare team will work with you to develop a medication plan that addresses these side effects.
Regular monitoring of liver function—including liver enzyme levels and other tests—is crucial for early detection and management of rejection.
Following a healthy lifestyle is another key component of keeping your new liver healthy. You should avoid all substances that harm the liver—like alcohol and tobacco—and follow a healthy diet and exercise plan.
One of the greatest challenges after a liver transplant is balancing the anti-rejection benefits of immunosuppressive therapy with the risks of long-term use of these medications. Noninvasive rejection monitoring with OmniGraf Liver can help your healthcare team confirm that your drug regimen is properly balanced.
There are a variety of excellent resources to learn more about liver transplantation and rejection. Here are just a few:
National Institute of Diabetes and Digestive and Kidney Diseases
Wondering what “silent” rejection is, and why it’s important to catch it early? Visit our patient education website and Get Ahead of Rejection!
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We invite you to join ETG’s Patient Ambassador Program!