ICI Before Liver Transplant in HCC: irAEs Signal Rejection Risk: Gut | June 2026
Immune checkpoint inhibitors are increasingly used in patients with hepatocellular carcinoma before liver transplantation, but post-transplant allograft rejection remains a major concern.
This multicenter Chinese retrospective study evaluated 209 patients with HCC who received immune checkpoint inhibitors before liver transplantation.
Allograft rejection occurred in 17.2% of patients, highlighting that rejection is a clinically meaningful risk after pretransplant immunotherapy.
Rejection was much more frequent in patients who developed immune-related adverse events before transplant.
Patients with irAEs had a rejection rate of 58.3%, compared with 13.3% in those without irAEs.
Any-grade irAE was the strongest independent predictor of allograft rejection, suggesting that irAEs may reflect a heightened immune activation state.
Other independent risk factors included younger age below 40 years and a short ICI washout interval of less than 30 days.
A predictive model combining irAEs, age, and ICI washout interval performed better than any individual factor alone.
Importantly, rejection was not just a laboratory or histological event; it was associated with worse survival.
One-year survival was significantly lower in patients who developed allograft rejection.
The study suggests that irAEs should be considered a practical pretransplant biomarker of immune risk.
Patients with irAEs may require longer washout intervals, closer perioperative immune monitoring, and individualized immunosuppression strategies.
The findings support a more cautious transplant selection pathway for HCC patients previously exposed to ICIs.
This does not mean that ICIs should be avoided in all transplant candidates, but they should be used with careful planning and multidisciplinary coordination.
Prospective validation is needed before universal cutoffs for washout period or immunosuppression protocols can be standardized.
Bottom line: In HCC patients receiving immune checkpoint inhibitors before liver transplantation, the development of immune-related adverse events strongly predicts post-transplant allograft rejection and may help guide washout timing, monitoring intensity, and immunosuppressive strategy.
