An Approach to Antibody-Mediated Rejection in Pediatric Liver Transplantation

Antibody-mediated rejection (AMR) is an important but infrequent cause of pediatric liver allograft injury. There is a lack of standardized guidance, and treatment approaches vary across institutions. A writing group from the Society of Pediatric Liver Transplantation conducted a comprehensive review of the published literature and collected institutional guidance documents from pediatric transplant centers across the United States to synthesize current diagnostic and management approaches to AMR in pediatric liver transplant recipients. AMR is diagnosed by the presence of characteristic histologic injury, C4d deposition, circulating donor-specific antibody (DSA), and exclusion of alternative causes of graft dysfunction, including T cell-mediated rejection. Management strategies focus on reducing circulating DSA through therapeutic plasma exchange and suppressing ongoing immune activation with corticosteroids and intravenous immunoglobulin. In severe or refractory cases, targeted therapies such as rituximab, bortezomib, and eculizumab may be considered. A stepwise diagnostic and management algorithm is presented. This resource outlines a practical approach to the diagnosis and management of AMR in pediatric liver transplantation, serving as a reference for busy clinicians who may encounter this serious but underrecognized cause of graft dysfunction and loss.