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.