Finding Nivo: A Case Report of 2 Forms of Nivolumab-Induced Liver Injury in an Allograft Liver in the Immediate Post-Transplant Period

Recent reports have emerged regarding the utilization of checkpoint inhibitors for downstaging hepatocellular carcinoma before liver transplantation. Early post-transplant acute cellular rejection has rarely led to graft loss. We report the first case of 2 forms of nivolumab-associated liver injury on biopsy of the allograft organ in a single patient who received nivolumab for cancer downstaging before liver transplantation: 1. mild acute cellular rejection according to Risk Analysis Index scoring and 2. zone 3 inflammation and apoptosis consistent with a more classic drug-induced liver injury pattern. This case not only adds further evidence about the risk for rejection post-transplant, but sheds light on other injuries checkpoint inhibitors can cause to the allograft.