Donor-specific antibodies and their impact on antibody-mediated rejection post-liver transplantation: A comprehensive review

Abstract

Antibody-mediated rejection (AMR) following liver transplantation is a significant clinical challenge, with donor-specific antibodies (DSAs) playing a pivotal role. Understanding the mechanisms and impact of DSAs is crucial for improving transplant outcomes and patient care. This review provides an in-depth analysis of the pathogenesis, diagnosis, and management of AMR in liver transplantation, focusing on the role of DSAs. AMR in liver transplants, though less common than in other organ transplants, presents unique diagnostic and therapeutic challenges. The review explores the latest diagnostic criteria, including serum DSAs, C4d staining, and liver biopsy findings. It delves into the pathogenesis of AMR, emphasizing the role of both preformed and de novo DSAs in causing graft injury and rejection. The review also discusses current therapeutic strategies, such as the use of immunosuppressants, plasmapheresis, intravenous immunoglobulin, and proteasome inhibitors, highlighting their efficacy and limitations. Furthermore, it examines the unique aspects of liver immunology that contribute to the organ's relative resistance to DSA-mediated injury. Emerging research, particularly on gene expression changes in renal allografts during simultaneous liver-kidney transplantation, is also discussed, offering insights into future directions. This review is instrumental for clinicians and researchers in understanding the complexities of AMR in liver transplantation and in developing more effective management strategies.