Mixed Cellular and Antibody-Mediated Rejection—A Rare yet Morbid Occurrence

Liver transplantation remains the definitive treatment for end-stage liver disease, yet rejection of the transplanted organ poses a significant challenge to long-term graft survival. We present a case of a 47-year-old woman who underwent liver transplantation for primary sclerosing cholangitis. Following the procedure, the patient experienced a rare phenomenon of dual rejection, characterized by both acute cellular rejection and antibody-mediated rejection. Despite initial immunosuppressive therapy, the patient's condition deteriorated. Histopathological examination revealed concurrent signs of acute cellular rejection and antibody-mediated rejection, highlighting the complexity of immune response in allograft rejection. Management involved intensified immunosuppression targeting both T-cell-mediated and antibody-mediated pathways, along with plasmapheresis to remove circulating antibodies. This case highlights an atypical presentation of rejection after transplantation. Further research is warranted to elucidate the underlying mechanisms and optimal management approaches for dual rejection in liver transplantation.