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Biliary strictures, recurrent PSC impact survival after liver transplant

Researchers found that multiple biliary strictures and recurrent primary sclerosing cholangitis may influence long-term graft and patient survival after liver transplantation for primary sclerosing cholangitis.

In a retrospective study, researchers evaluated charts of 335 patients from 10 German transplant centers who received a first liver transplant due to primary sclerosing cholangitis (PSC) from January 1990 and December 2006.

“The analysis of our multicenter cohort … clearly demonstrates that after exclusion of patients who lost their grafts during the first 6 months, the recipient and graft survival is significantly lower in patients with [biliary strictures (BS)] or [recurrent] PSC,” the researchers wrote.

The investigators included 305 patients who were comparable with the overall study population for the final analysis to estimate the incidence of BS and recurrent PSC.

Over a mean follow-up of 98.8 months, BS were found in 36.1% of patients. Of these patients, 21.8% had anastomotic stricture, 34.5% had nonanastomotic stricture, and 43.6% had a combination. The mean time to diagnosis of BS was 3.9 years.

Recurrent PSC was diagnosed in 20.3% of patients after a mean duration to recurrence of 4.6 years. The diagnosis of recurrent PSC was based on histology and cholangiography in 45% of patients, on cholangiography in 32%, on histology in 19% and on the explant pathology after second liver transplantation in two, according to the research.

The rate of survival was not significantly different between patients with or without BS or recurrent PSC. However, during the first 6 months, 14 patients died for nonhepatic reasons, and 48 patients lost their graft, primarily due to nonfunction (n = 14) and hepatic artery thrombosis (n = 12). After excluding these patients and six additional patients with less than 6 months of follow-up, graft and recipient overall survival at the end of follow-up was worse in patients with BS (recipient survival: 93.9% vs. 81%; P = .004; graft survival: 93.9% vs. 60%; P < .001) or recurrent PSC (recipient survival: 91.4% vs. 79%; P = .02; graft survival: 85.1% vs. 61.3%; P < .001).

Cox proportional hazards analysis showed donor age was a strong risk factor for BS (P = .003). In the univariate Cox proportional hazards model, MELD score was a significant risk factor for recurrent PSC, with international normalized ratio (INR) at LT being the main MELD parameter (P = .02). Inflammatory bowel disease was found in more patients with BS compared with patients without IBD after transplant, indicating this was a risk factor for BS as well. 

“Donor age, IBD, and the INR at liver transplantation were identified as independent risk factors for [recurrent] PSC and BS,” the researchers concluded. “Especially in patients with IBD and an INR greater than 1.2, organs from older donors should be avoided in PSC. Thus, these three parameters could help the transplant team to estimate the risk of BS or [recurrent] PSC depending on the recipient-donor constellation.” – by Melinda Stevens

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