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PBC transplant listings decrease, PSC now leading autoimmune indication
In both the United States and the United Kingdom, primary sclerosing cholangitis rose to the leading indication for liver transplantation among patients with autoimmune diseases while the number of patients listed with primary biliary cholangitis decreased by 50%, according to results of a 20-year comparative analysis.
“Our examination of the numbers of patients listed for transplantation over time showed that PSC has become the dominant autoimmune indication for liver transplantation in both countries,” Gwilym James Webb, MD, from the University of Birmingham, United Kingdom, and colleagues wrote. “These findings highlight the need for better PSC therapies and the need to focus on the minority of PBC patients who deteriorate despite standard therapy.”
Webb and colleagues gathered data on point-of-listing indication for liver transplantation from the National Health Service Blood and Transplant UK Transplant Registry and the United Network for Organ Sharing. Between Jan. 1, 1995, and Dec. 31, 2014, the United Kingdom had significantly more listings for PBC (9.7% vs 3.6%; P < .001), PSC (7.4% vs. 4.4%; P < .001) and AIH (3.6% vs. 3.2%; P = .005).
After adjusting for population change, the researchers observed a significant decrease in PBC per million per year (0.039; 95% CI, 0.025-0.052; r2 = 0.67) and significant increases in PSC (0.027; 95% CI, 0.017-0.038; r2 = 0.59) and AIH (0.014; 95% CI, 0.007-0.02; r2 = 0.52) per million per year in the UK.
In contrast, the U.S. had significant decreases for PBC (0.035; 95% CI, 0.027-0.043; r2 = 0.83), PSC (0.017; 95% CI, 0.009-0.025; r2 = 0.53) and AIH (0.012; 95% CI, 0.003-0.02; r2 = 0.034) per million per year after adjusting for population change and health insurance coverage.
While the UK had no significant change in MELD listing scores for any autoimmune liver disease, the U.S. had increased MELD listing scores for PBC (0.29 per year; 95% CI, 0.23-0.37; r2 = 0.022), PSC (0.19 per year; 95% CI, 0.14-0.26; r2 = 0.0096) and AIH (0.28 per year; 95% CI, 0.19-0.28; r2 = 0.014).
Patients in the UK with AIH were significantly younger than those in the U.S. (45 vs. 49 years; P < .001), and age at listing in the U.S. increased significantly over the study period for PBC (0.16 years per year; 95% CI, 0.12-0.2; r2 = 0.0096) and AIH (0.21 years per year; 95% CI, 0.14-0.29; r2 = 0.0061).
Patients in the UK with PSC (69.7% vs. 66.1%; P = .01) and those with AIH (32.9% vs. 24.8%; P < .0001) were more likely to be men than those in the U.S. Men with PBC were significantly older than women in both the UK (59 vs. 56 years; P = .006) and the U.S. (58 vs. 56 years; P = .001), whereas men with AIH were significantly younger than women in the U.S. (46 vs. 50; P < .001).
Men with PSC were listed with higher severity scores than women in both the UK (17 vs. 16; P = .048) and the U.S. (15 vs. 14; P = .0033), and men with AIH were listed with higher MELD scores than women in both the UK (17 vs. 15; P = .001) and the U.S. (15 vs. 14; P = .003).
In the UK, most patients with PBC (95.5%), PSC (88.2%) and AIH (85.1%) were white, whereas the U.S. had a greater diversity between the three disease groups. In the U.S., 64.8% of the patients with AIH were white, 15.8% were Hispanic and 15.5% were black.
During the study period, the researchers observed a significant increase in the proportion of non-white patients listed per year in the U.S. for PBC (0.76%; 95% CI, 0.53-0.98; r2 = 0.73), PSC (0.31%; 95% CI, 0.17-0.45; r2 = 0.54) and AIH (0.76%; 95% CI, 0.58-0.95; r2 = 0.8), and in the UK for PSC (0.58%; 95% CI, 0.25-0.91; r2 = 0.44) and AIH (0.96%; 95% CI, 0.39-1.52; r2 = 0.41).
“Across the spectrum of liver disease, the family of rare autoimmune liver diseases continues to cause high morbidity and mortality,” the researchers wrote. “Advances such as obeticholic acid have shown that these orphan diseases can be the subject of positive phase II and III randomized trials, as well as gain regulatory approval. Epidemiologic data are invaluable in targeting and monitoring the effects of such new agents.” – by Talitha Bennett
Disclosure: The authors report no relevant financial disclosures.