Acute rejection on immune-mediated chronic rejection after liver transplantation

Rejection is frequent after liver transplantation (LT). Pathogenesis of acute cellular rejection (ACR) is attributable to recipient Tcells; chronic rejection (CR) has a multifactorial pathogenesis. There is a striking increase in LTamong women of reproductive age. Thus, it is very important to understand how pregnancy can influence immune system and graft function. An 8-year-old female was liver transplanted in 1990 due to congenital atresia of biliary tract. Patient started immunosuppressive therapy with cyclosporine and corticosteroids. Afew weeks after transplantation, she had an acute rejection, treated with fourfold therapy. At 18 years old, a hepatic biopsy showed an immune-mediated chronic hepatitis. Immunosuppressive therapy was increased with azathioprine. In 2014 she had a baby and in 2015 she suspended immunosuppressive therapies. After thirty days, she attended Hospital for jaundice. Histologic examination revealed both chronic hepatitis in cirrhotic evolution and acute rejection. Patient was treated with steroids at high doses. Cyclosporine was replaced with tacrolimus and everolimus, azathioprine was stopped. Due to the clinical conditions, evaluation for a re-LTwas started. In the following years, a progressive improvement in patient's general conditions and liver function was observed and, therefore, re-LTwas not necessary. Patient developed a sub-clinical CRand then ACRfollowing suspension of immunosuppressive drugs. Probably, pregnancy played a contribution in the development of liver damage mediated by the immune system. Furthermore, patient completed pregnancy with compensated cirrhosis. Anti-rejection therapy needs to be modulated constantly, obtaining a good clinical response