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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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2
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Jones O, Claasen MPAW, Ivanics T, Choi WJ, Gavaria F, Rajendran L, Ghanekar A, Hirschfield G, Gulamhusein A, Shwaartz C, Reichman T, Sayed BA, Selzner M, Bhat M, Tsien C, Jaeckel E, Lilly L, McGilvray ID, Cattral MS, Selzner N, Sapisochin G. Pursuing living donor liver transplantation improves outcomes of patients with autoimmune liver diseases: An intention-to-treat analysis. Liver Transpl 2024; 30:785-795. [PMID: 38619393 DOI: 10.1097/lvt.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/01/2024] [Indexed: 04/16/2024]
Abstract
Living donor liver transplantation (LDLT) offers the opportunity to decrease waitlist time and mortality for patients with autoimmune liver disease (AILD), autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. We compared the survival of patients with a potential living donor (pLDLT) on the waitlist versus no potential living donor (pDDLT) on an intention-to-treat basis. Our retrospective cohort study investigated adults with AILD listed for a liver transplant in our program between 2000 and 2021. The pLDLT group comprised recipients with a potential living donor. Otherwise, they were included in the pDDLT group. Intention-to-treat survival was assessed from the time of listing. Of the 533 patients included, 244 (43.8%) had a potential living donor. Waitlist dropout was higher for the pDDLT groups among all AILDs (pDDLT 85 [29.4%] vs. pLDLT 9 [3.7%], p < 0.001). The 1-, 3-, and 5-year intention-to-treat survival rates were higher for pLDLT versus pDDLT among all AILDs (95.7% vs. 78.1%, 89.0% vs. 70.1%, and 87.1% vs. 65.5%, p < 0.001). After adjusting for covariates, pLDLT was associated with a 38% reduction in the risk of death among the AILD cohort (HR: 0.62, 95% CI: 0.42-0.93 [ p <0.05]), and 60% among the primary sclerosing cholangitis cohort (HR: 0.40, 95% CI: 0.22-0.74 [ p <0.05]). There were no differences in the 1-, 3-, and 5-year post-transplant survival between LDLT and DDLT (AILD: 95.6% vs. 92.1%, 89.9% vs. 89.4%, and 89.1% vs. 87.1%, p =0.41). This was consistent after adjusting for covariates (HR: 0.97, 95% CI: 0.56-1.68 [ p >0.9]). Our study suggests that having a potential living donor could decrease the risk of death in patients with primary sclerosing cholangitis on the waitlist. Importantly, the post-transplant outcomes in this population are similar between the LDLT and DDLT groups.
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Affiliation(s)
- Owen Jones
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Marco P A W Claasen
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tommy Ivanics
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
- Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Woo Jin Choi
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Felipe Gavaria
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Luckshi Rajendran
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Chaya Shwaartz
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Trevor Reichman
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Blayne Amir Sayed
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Cynthia Tsien
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Les Lilly
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Ian D McGilvray
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Mark S Cattral
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- HBP & Multi Organ Transplant Program, Ajmera Transplant Center, University Health Network Toronto, Toronto, Ontario, Canada
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3
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Montano-Loza AJ, Corpechot C, Burra P, Schramm C, Selzner N, Ronca V, Oo YH. Recurrence of autoimmune liver diseases after liver transplantation: Review and expert opinion statement. Liver Transpl 2024:01445473-990000000-00399. [PMID: 38857316 DOI: 10.1097/lvt.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Abstract
Autoimmune liver diseases (AILDs) constitute the fourth most common indication for liver transplantation (LT) across the world. In general, the outcomes after LT are acceptable; however, disease recurrence after LT is common for all AILD, which can negatively affect graft and overall survival. Several questions persist, including the risk factors associated with recurrent disease, optimal antirejection medications, strategies to reduce the risk of recurrence, and how to best incorporate these strategies into clinical practice. For that reason, we assembled an international group of experts to review evidence to address these outstanding questions regarding LT for AILD. Survival rates after LT are ~90% and 70% at 1 and 5 years, and recurrent disease occurs in 10%-50% of patients with AILD. In patients with disease recurrence, graft survival decreased by 18% and 28% and overall survival by 8% and 12% at 5 and 10 years after LT, respectively. Recurrent autoimmune hepatitis is associated with high aminotransferases and immunoglobulin G (IgG) before LT, lymphoplasmacytic infiltrates in the explants, and may be associated with the absence of steroids after LT. However, the efficiency and safety of triple immunosuppressive maintenance therapy is still debatable. Younger age at diagnosis with primary biliary cholangitis or LT is associated with primary biliary cholangitis recurrence. Preventive use of ursodeoxycholic acid reduces the risk of recurrence and has a benefit in graft and patient survival. Episodes of systemic inflammation, including T-cell-mediated rejection, active ulcerative colitis, and episodes of cholangitis, are associated with recurrent PSC. Recurrent disease for AILD is associated with worse graft and patient survival. Patients with autoimmune hepatitis could be considered for long-term low-dose predniso(lo)ne, whereas patients with primary biliary cholangitis should be placed on preventive ursodeoxycholic acid after LT. There are no specific treatments for PSC recurrence; however, adequate control of inflammatory bowel disease and optimal immunosuppression to avoid T-cell-mediated rejection should be encouraged.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, European Reference Network for Hepatological Diseases (ERN RARE-LIVER), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Patrizia Burra
- Department of Surgery, Oncology and Gastroenterology, European Reference Network for Hepatological Diseases (ERN RARE-LIVER), University of Padova, Padova, Italy
| | - Christoph Schramm
- Martin Zeitz Center for Rare Diseases, and 1st Department of Medicine, European Reference Network for Hepatological Diseases (ERN RARE-LIVER), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nazia Selzner
- Ajmera Transplant Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vincenzo Ronca
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ye H Oo
- Center for Liver and Gastro Research & National Institute of Health Research Birmingham Biomedical Research Centre, University of Birmingham; Centre for Rare Disease and ERN Rare Liver Centre, Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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4
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Medina-Morales E, Ismail M, Barba Bernal R, Abboud Y, Sierra L, Marenco-Flores A, Goyes D, Saberi B, Patwardhan V, Bonder A. Two Decades of Liver Transplants for Primary Biliary Cholangitis: A Comparative Study of Living Donors vs. Deceased Donor Liver Transplantations. J Clin Med 2023; 12:6536. [PMID: 37892674 PMCID: PMC10607081 DOI: 10.3390/jcm12206536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Primary biliary cholangitis (PBC) prompts liver transplantation (LT) due to cholestasis, cirrhosis, and liver failure. Despite lower MELD scores, recent studies highlight higher PBC waitlist mortality, intensifying the need for alternative transplantation strategies. Living donor liver transplant (LDLT) has emerged as a solution to the organ shortage. This study compares LDLT and deceased donor liver transplant (DDLT) outcomes in PBC patients via retrospective analysis of the UNOS database (2002-2021). Patient survival, graft failure, and predictors were evaluated through Kaplan-Meier and Cox-proportional analyses. Among 3482 DDLTs and 468 LDLTs, LDLT showed superior patient survival (92.3%, 89.1%, 87.6%, 85.0%, 77.2% vs. 91.5%, 88.3%, 86.3%, 82.2%, 71.0%; respectively; p = 0.02) with no significant graft survival difference at 1-, 2-, 3-, 5-, and 10-years post-LT (91.0%, 88.0%, 85.7%, 83.0%, 75.4% vs. 90.5%, 87.4%, 85.3%, 81.3%, 70.0%; respectively; p = 0.06). Compared to DCD, LDLT showed superior patient and graft survival (p < 0.05). Younger male PBC recipients with a high BMI, diabetes, and dialysis history were associated with mortality and graft failure (p < 0.05). Our study showed that LDLT had superior patient survival to DDLT. Predictors of poor post-LT outcomes require further validation studies.
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Affiliation(s)
- Esli Medina-Morales
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA; (E.M.-M.); (M.I.); (Y.A.)
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
| | - Mohamed Ismail
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA; (E.M.-M.); (M.I.); (Y.A.)
| | - Romelia Barba Bernal
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Yazan Abboud
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA; (E.M.-M.); (M.I.); (Y.A.)
| | - Leandro Sierra
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
| | - Ana Marenco-Flores
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
| | - Daniela Goyes
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
| | - Vilas Patwardhan
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
| | - Alan Bonder
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.B.); (L.S.); (A.M.-F.); (B.S.)
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5
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Sierra L, Barba R, Ferrigno B, Goyes D, Diaz W, Patwardhan VR, Saberi B, Bonder A. Living-Donor Liver Transplant and Improved Post-Transplant Survival in Patients with Primary Sclerosing Cholangitis. J Clin Med 2023; 12:jcm12082807. [PMID: 37109144 PMCID: PMC10145248 DOI: 10.3390/jcm12082807] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/29/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is the leading indication of liver transplantation (LT) among autoimmune liver disease patients. There is a scarcity of studies comparing survival outcomes between living-donor liver transplants (LDLT)s and deceased-donor liver transplants (DDLTs) in this population. Using the United Network for Organ Sharing database, we compared 4679 DDLTs and 805 LDLTs. Our outcome of interest was post-LT patient survival and post-LT graft survival. A stepwise multivariate analysis was performed, adjusting for recipient age, gender, diabetes mellitus, ascites, hepatic encephalopathy, cholangiocarcinoma, hepatocellular carcinoma, race, and the model for end-stage liver disease (MELD) score; donor' age and sex were also included to the analysis. According to univariate and multivariate analysis, LDLT had a patient and graft survival benefit compared to DDLT (HR, 0.77, 95% CI 0.65-0.92; p < 0.002). LDLT patient survival (95.2%, 92.6%, 90.1%, and 81.9%) and graft survival (94.1%, 91.1%, 88.5%, and 80.5%) at 1, 3, 5, and 10 years were significantly better than DDLT patient survival (93.2%, 87.6%, 83.3%, and 72.7%) and graft survival (92.1%, 86.5%, 82.1%, and 70.9%) (p < 0.001) in the same interval. Variables including donor and recipient age, male recipient gender, MELD score, diabetes mellitus, hepatocellular carcinoma, and cholangiocarcinoma were associated with mortality and graft failure in PSC patients. Interestingly, Asians were more protected than Whites (HR, 0.61; 95% CI, 0.35-0.99; p < 0.047), and cholangiocarcinoma was associated with the highest hazard of mortality (HR, 2.07; 95% CI, 1.71-2.50; p < 0.001) in multivariate analysis. LDLT in PSC patients were associated with greater post-transplant patient and graft survival compared to DDLT patients.
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Affiliation(s)
- Leandro Sierra
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Romelia Barba
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Bryan Ferrigno
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Daniela Goyes
- Department of Medicine, Loyola Medicine-MacNeal Hospital, Berwyn, IL 60402, USA
| | - Wilfor Diaz
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Vilas R Patwardhan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Alan Bonder
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Kelly C, Zen Y, Heneghan MA. Post-Transplant Immunosuppression in Autoimmune Liver Disease. J Clin Exp Hepatol 2023; 13:350-359. [PMID: 36950491 PMCID: PMC10025678 DOI: 10.1016/j.jceh.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/10/2022] [Accepted: 07/04/2022] [Indexed: 02/17/2023] Open
Abstract
Autoimmune liver diseases (AILDs) are a group of conditions where immune-mediated liver damage can lead to the need for transplantation. Collectively, they account for almost a quarter of all liver transplants. Outcomes in terms of graft and patient survival for all liver transplants have improved markedly over decades with improvements in patient selection, surgical techniques and longer-term care and this is also seen in patients with AILDs. The current five- and ten-year survival rates post-transplant in autoimmune disease are excellent, at 88% and 78%, respectively. A key factor in maintaining good outcomes post liver transplant for these autoimmune conditions is the immunosuppression strategy. These patients have increased the rates of rejection, and autoimmune conditions can all recur in the graft ranging from 12 to 60% depending on the population studied. Immunosuppressive regimens are centred on calcineurin inhibitors, often combined with low dose corticosteroids, with or without the addition of antimetabolite therapy. There is no clear evidence-based immunosuppressive regimen for these conditions, and a tailored approach balancing the individuals' immunological profile against the risks of immunosuppression is often used. There are disease-specific considerations to optimised graft function including the role of ursodeoxycholic acid in both primary biliary cholangitis and primary sclerosing cholangitis and the role and timing of colectomy in primary sclerosing cholangitis in inflammatory bowel disease patients. However, unmet needs still exist in the management of AILDs post liver transplantation particularly in building the evidence base for optimal immunosuppression as well as mitigating the risk of recurrent disease.
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Key Words
- AIH, Autoimmune hepatitis
- AILD, Autoimmune liver disease
- CNI, Calcineurin inhibitors
- IBD, Inflammatory bowel disease
- LT, Liver transplantation
- PBC, Primary biliary cholangitis
- PSC, Primary sclerosing cholangitis
- autoimmune liver disease
- immunosuppression
- rAIH, Recurrent autoimmune hepatitis
- rPBC, Recurrent primary biliary cholangitis
- rPSC, Recurrent primary sclerosing cholangitis
- transplantation
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - Yoh Zen
- Institute of Liver Studies, Kings College Hospital, London, UK
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7
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Martin EF. Liver Transplantation for Primary Biliary Cholangitis. Clin Liver Dis 2022; 26:765-781. [PMID: 36270728 DOI: 10.1016/j.cld.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite a significant increase in the total number of liver transplants (LTs) performed over the last 3 decades, primary biliary cholangitis (PBC) has become an uncommon indication for LT, which likely reflects the benefits of earlier diagnosis and available treatment, such as ursodeoxycholic acid (UDCA). Nonetheless, LT remains the only cure for patients with progressive PBC despite medical therapy with survival rates that are among the highest of all indications for LT. Post-LT PBC patients, however, are at increased risk of rejection and disease recurrence.
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Affiliation(s)
- Eric F Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami Transplant Institute, Highland Professional Building, 1801 Northwest 9(th) Avenue, Miami, FL 33136, USA.
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8
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Mijic M, Saric I, Delija B, Lalovac M, Sobocan N, Radetic E, Martincevic D, Filipec Kanizaj T. Pretransplant Evaluation and Liver Transplantation Outcome in PBC Patients. Can J Gastroenterol Hepatol 2022; 2022:7831165. [PMID: 35910038 PMCID: PMC9337972 DOI: 10.1155/2022/7831165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune chronic cholestatic liver disease characterized by progressive cholangiocyte and bile duct destruction leading to fibrosis and finally to liver cirrhosis. The presence of disease-specific serological antimitochondrial antibody (AMA) together with elevated alkaline phosphatase (ALP) as a biomarker of cholestasis is sufficient for diagnosis. Ursodeoxycholic acid (UDCA) is the first treatment option for PBC. Up to 40% of patients have an incomplete response to therapy, and over time disease progresses to liver cirrhosis. Several risk scores are proposed for better evaluation of patients before and during treatment to stratify patients at increased risk of disease progression. GLOBE score and UK PBC risk score are used for the evaluation of UDCA treatment and Mayo risk score for transplant-free survival. Liver transplantation (LT) is the only treatment option for end-stage liver disease. More than 10 years after LT, 40% of patients experience recurrence of the disease. A liver biopsy is required to establish rPBC (recurrent primary biliary cholangitis). The only treatment option for rPBC is UDCA, and data show biochemical and clinical improvement, plus potential beneficial effects for use after transplantation for the prevention of rPBC development. Additional studies are required to assess the full impact of rPBC on graft and recipient survival and for treatment options for rPBC.
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Affiliation(s)
- Maja Mijic
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
| | - Ivona Saric
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
| | - Bozena Delija
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
| | - Milos Lalovac
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
| | - Nikola Sobocan
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
- University of Zagreb, School of Medicine, Salata 3, Zagreb, Croatia
| | - Eva Radetic
- University of Zagreb, School of Medicine, Salata 3, Zagreb, Croatia
| | - Dora Martincevic
- University of Zagreb, School of Medicine, Salata 3, Zagreb, Croatia
| | - Tajana Filipec Kanizaj
- Department of Gastroenterology, University Hospital Merkur, Zajceva 19, Zagreb, Croatia
- University of Zagreb, School of Medicine, Salata 3, Zagreb, Croatia
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9
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CAVALCANTE LN, QUEIROZ RMTD, PAZ CLDSL, LYRA AC. BETTER LIVING DONOR LIVER TRANSPLANTATION PATIENT SURVIVAL COMPARED TO DECEASED DONOR — A SYSTEMATIC REVIEW AND META-ANALYSIS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:129-136. [DOI: 10.1590/s0004-2803.202200001-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background Deceased donor liver transplantation (DDLT) is the first choice, but living donor transplantation (LDLT) is an alternative to be considered in special situations, such as lack of donated organs and emergencies. So far, there is no consensus on which transplantation method provides better survival and fewer complications, which is still an open point for discussion. Methods This meta-analysis compared the 1, 3, and 5-year patient and graft survival rates of LDLT and DDLT. We included studies published from April-2009 to June-2021 and adopted the generic model of the inverse of variance for the random effect of hazard ratios. The adequacy of the studies was determined using the Newcastle-Ottawa Scale — NOS (WELLS). Results For patient survival analysis, we included a total of 32,258 subjects. We found a statistically significant better survival for the LDLT group at 1, 3 and 5 years, respectively: 1.35 HR (95%CI 1.10—1.66, P=0.005), 1.26 HR (95%CI 1.09—1.46, P=0.002) and 1.27 HR (95%CI 1.09—1.48, P=0.002). Our meta-analysis evaluated a total of 21,276 grafts. In the overall analysis, the 1-year survival was improved in favor of the LDLT group (1.36 HR, 95%CI 1.16—1.60, P<0.0001), while the 3-year survival (1.13 HR, 95%CI 0.96—1.33, P<0.13), and 5 (0.99 HR, 95%CI 0.74—1.33, P<0.96), did not differ significantly. Conclusion This metanalysis detected a statistically significant greater 1-, 3- and 5-years patient survival favoring LDLT compared to DDLT as well as a statistically significant difference better 1-year graft survival favoring the LDLT group.
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10
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Heinemann M, Liwinski T, Adam R, Berenguer M, Mirza D, Malek-Hosseini SA, Heneghan MA, Lodge P, Pratschke J, Boudjema K, Paul A, Zieniewicz K, Fronek J, Mehrabi A, Acarli K, Tokat Y, Coker A, Yilmaz S, Karam V, Duvoux C, Lohse AW, Schramm C. Long-term outcome after living donor liver transplantation compared to donation after brain death in autoimmune liver diseases: Experience from the European Liver Transplant Registry. Am J Transplant 2022; 22:626-633. [PMID: 34605157 DOI: 10.1111/ajt.16864] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/22/2021] [Accepted: 09/20/2021] [Indexed: 01/25/2023]
Abstract
Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29 902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90 days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15 years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR] = 1.95, 95% confidence interval [CI] = 1.36-2.80, p < .001). Pediatric PSC patients showed also increased mortality >90 days after LDLT compared to DBD (HR = 3.00, 95% CI 1.04-8.70, p = .043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR = 2.49, p = .025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR] = 5.36, p = .001) and biliary complications (subHR = 4.40, p = .006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death.
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Affiliation(s)
- Melina Heinemann
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timur Liwinski
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany
| | - Rene Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Valencia, Valencia, Spain
| | - Darius Mirza
- Department of HPB Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Seyed Ali Malek-Hosseini
- Avicenna Center for Medicine and Organ Transplant, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Michael A Heneghan
- King's Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Peter Lodge
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, Rennes, France
| | - Andreas Paul
- Department of Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Koray Acarli
- Organ Transplantation Center, Memorial Hospital, Istanbul, Turkey
| | - Yaman Tokat
- Liver Transplantation Center, Florence Nightingale Hospital, Istanbul, Turkey
| | - Ahmet Coker
- Department of General Surgery, Ege University Medical School, Izmir, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Vincent Karam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Christophe Duvoux
- Department of Hepatology and Gastroenterology, University Hospital of Henri-Mondor, Creteil, France
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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11
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Nakamura T, Shirouzu T. Antibody-Mediated Rejection and Recurrent Primary Disease: Two Main Obstacles in Abdominal Kidney, Liver, and Pancreas Transplants. J Clin Med 2021; 10:5417. [PMID: 34830699 PMCID: PMC8619797 DOI: 10.3390/jcm10225417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023] Open
Abstract
The advances in acute phase care have firmly established the practice of organ transplantation in the last several decades. Then, the next issues that loom large in the field of transplantation include antibody-mediated rejection (ABMR) and recurrent primary disease. Acute ABMR is a daunting hurdle in the performance of organ transplantation. The recent progress in desensitization and preoperative monitoring of donor-specific antibodies enables us to increase positive outcomes. However, chronic active ABMR is one of the most significant problems we currently face. On the other hand, recurrent primary disease is problematic for many recipients. Notably, some recipients, unfortunately, lost their vital organs due to this recurrence. Although some progress has been achieved in these two areas, many other factors remain largely obscure. In this review, these two topics will be discussed in light of recent discoveries.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takayuki Shirouzu
- Molecular Diagnositcs Division, Wakunaga Pharmaceutical Co., Ltd., 13-4 Arakicho, shinjyuku-ku, Tokyo 160-0007, Japan;
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12
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Long Term Outcomes of Liver Transplantation For Patients With Autoimmune Hepatitis. Transplant Proc 2021; 53:2339-2345. [PMID: 34474912 DOI: 10.1016/j.transproceed.2021.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is a rare indication for liver transplantation (LT). Data on the long-term outcomes of living-related LT for AIH are limited and inconsistent. The present study aimed to assess the long-term outcomes of deceased donor LT (DDLT) and living donor LT (LDLT) for AIH. METHODS All patients who received transplants for AIH-related cirrhosis from 2001 to 2018 were included in this study. RESULTS Seventy-four patients (31 male, 43 female) received LT. The average follow-up was 7.9 ± 6.9 years (median = 7.2 years), average age was 34.3 ± 13.8 years, and average Model for End-Stage Liver Disease (MELD) score was 23.6 ± 8.5. Thirty-six (49.3%) patients received a graft from a living donor, and 83% of patients were maintained on steroids. The 1-, 3-, 5-, and 10-year survival rates of patients were 91%, 89%, 87%, and 82% and of grafts were 89%, 88%, 86%, and 76%, respectively. In univariate analysis, MELD score (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.17; P = .028), donor age (OR per 5 years, 1.45; 95% CI, 1.07-2.02; P = .021), donor type (OR LDLT vs DDLT, 0.19; 95% CI, 0.04-0.67; P = .017), and renal function (OR glomerular filtration rate <60 vs ≥60 mL/min/m2, 7.41; 95% CI, 1.88-31.25; P = .004) were significant predictors of graft survival; however, none of the factors remained significant in multivariate analysis. CONCLUSION We have shown the highest reported long-term survival rates in LT for AIH, including a large number of patients who underwent LDLT. Standardized management and immunosuppressive therapy, including the maintenance of a low-dose steroid protocol, may have contributed to this outcome.
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13
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Akamatsu N, Hasegawa K, Egawa H, Ohdan H, Yoshizawa A, Kokudo N, Tazuma S, Tanaka A, Takikawa H. Donor age (≥45 years) and reduced immunosuppression are associated with the recurrent primary sclerosing cholangitis after liver transplantation - a multicenter retrospective study. Transpl Int 2021; 34:916-929. [PMID: 33629379 DOI: 10.1111/tri.13852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/18/2021] [Accepted: 02/22/2021] [Indexed: 01/25/2023]
Abstract
The present study investigated the possible risk factors, including relationship/HLA matching between donor and recipient, and immunosuppressive therapies on the recurrence of primary sclerosing cholangitis (PSC) after liver transplantation (LT). Subjects were 197 recipients of LT for PSC, among whom 180 surviving more than 1 year after LT were further analyzed for risk factors of recurrence. The 5- and 10-year patient- and graft survival rates were 83% and 68%, and 71% and 62%, respectively. The overall PSC recurrence rate was 25% with a 5- and 10-year graft survival rate of 34% and 18%, which was significantly lower than the survival rate of those without recurrence (P < 0.001). Univariate analysis identified the following as risk factors for recurrence: donor age (P < 0.001), cyclosporine use (P = 0.012), mono or no immunosuppressive agent (P < 0.001), postoperative biliary complication (P < 0.001), and active intestinal bowel disease after LT (P < 0.001). Among these factors, donor age ≥45 years [hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.21-2.69; P = 0.003] and mono or no immunosuppressive agent 1-year after LT (HR, 2.38; 95% CI, 1.23-3.45; P = 0.011) were identified as independent risk factors in the final multivariate Cox regression model. The results were similar in sub-analysis for ABO-identical/compatible adult living donor LT cases.
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Affiliation(s)
- Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Yoshizawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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14
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[Surgical treatment of primary sclerosing cholangitis : Experiences from 30 years in a single center cohort with 173 consecutive patients]. Chirurg 2021; 92:148-157. [PMID: 32488382 PMCID: PMC7875955 DOI: 10.1007/s00104-020-01197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND In recent years substantial progress has been made in the treatment, surveillance and understanding of the pathogenesis of primary sclerosing cholangitis (PSC); however, in most cases liver transplantation (LTX) is still the only curative option for cancer or end-stage liver disease (ELD). In rare cases a partial liver resection is a possible curative treatment of a PSC-associated cholangiocellular carcinoma (CCC). These operations represent a significant additional burden for PSC patients. OBJECTIVE Due to the rarity of PSC detailed studies regarding hepato-pancreato-biliary (HPB) surgery are lacking. The aim of this study was to analyze the surgical indications and prognosis of PSC patients. PATIENTS AND METHODS A single center retrospective cohort study from 1990 to 2020 was carried out. In this study patients with PSC were included and investigated with respect to factors associated with surgery and the prognosis. RESULTS As a consequence of PSC-associated conditions, in 62 patients (36%) a major HPB operation or explorative laparotomy was necessary. The prevalence of chronic inflammatory bowel disease was significantly higher in these patients (P < 0.019). An LTX was carried out in 46 patients (73%) because of ELD. A liver resection (LR) was performed in 8 patients (11%) and 9 patients only underwent an explorative laparotomy. The overall survival in the LTX subgroup was significantly longer than patients who underwent LR and explorative laparotomy (258 months; 95% confidence interval, CI 210-306 months vs. 88 months; 95% CI 16-161 months vs. 13 months; 95% CI 3-23 months; p < 0.05, respectively). CONCLUSION The majority of patients with PSC have to be operated on because of the disease with substantial risks for morbidity and mortality. Curative treatment options are lacking, thus underlining the need for effective early detection and treatment strategies for PSC-CCC.
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15
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Irlès-Depé M, Roullet S, Neau-Cransac M, Dumortier J, Dharancy S, Houssel-Debry P, Boillot O, Chiche L, Laurent C, Laharie D, De Lédinghen V. Impact of Preexisting Inflammatory Bowel Disease on the Outcome of Liver Transplantation for Primary Sclerosing Cholangitis. Liver Transpl 2020; 26:1477-1491. [PMID: 32603007 DOI: 10.1002/lt.25838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/21/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Approximately 80% of patients with primary sclerosing cholangitis (PSC) also have inflammatory bowel disease (IBD), and its effect on the outcomes of liver transplantation (LT) for PSC is unclear. We retrospectively collected data from adults who underwent LT for PSC from 1989 to January 2018 in 4 French LT centers. We compared the rates of patient and graft survivals and of complications after LT. Among 87 patients, 52 (60%) had preexisting IBD. Excluding those who died within the first 3 months, the 10-year patient survival and graft survival rates were 92.6% (95% confidence interval [CI], 84.3%-100%) and 77.1% (53.8%-85.3%), respectively, in the PSC with IBD (PSC-IBD) group and 97.1% (91.4%-100%; P = 0.44) and 83.2% (69.6%-96.9%; P = 0.43) in the isolated PSC group, respectively. Exposure to azathioprine after LT was significantly associated with mortality (odds ratio [OR], 15.55; 1.31-184.0; P = 0.03), whereas exposure to mycophenolate mofetil was associated with improved survival (OR, 0.17; 95% CI, 0.04-0.82; P = 0.03), possibly an era effect. The rate of recurrent PSC was 21% in the PSC-IBD group and 11% in the isolated PSC group (P = 0.24). Severe infections occurred in 125 per 1000 person-years in both groups. Exposure to mycophenolate mofetil was associated with a lower risk of infection (OR, 0.26; 95% CI, 0.08-0.85; P = 0.03). The presence of IBD was associated with cytomegalovirus (CMV) infection (OR, 3.24; 95% CI, 1.05-9.98; P = 0.04). IBD prior to LT for PSC may not affect patient or transplant survival but may increase the risk of CMV infection.
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Affiliation(s)
- Marie Irlès-Depé
- Service d'Hépatologie, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Stéphanie Roullet
- Service de Chirurgie Hépatobiliaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Martine Neau-Cransac
- Service de Chirurgie Hépatobiliaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jérôme Dumortier
- Service de Gastro-Entérologie, Hôpital Haut-Lévêque, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Sébastien Dharancy
- Service d'Anesthésie-Réanimation Uro-Vasculaire et Transplantation Rénale, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Pauline Houssel-Debry
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Olivier Boillot
- Service de Gastro-Entérologie, Hôpital Haut-Lévêque, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Laurence Chiche
- Service d'Hépatologie, Hôpital Claude Huriez, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Christophe Laurent
- Service d'Hépatologie, Hôpital Claude Huriez, Centre Hospitalier Universitaire de Lille, Lille, France
| | - David Laharie
- Service d'Hépatologie, Hôpital Pont-Chaillou, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Victor De Lédinghen
- Service d'Hépatologie, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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16
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Chen L, Shi X, Lv G, Sun X, Sun C, Cai Y, Niu J, Jin J, Liu N, Li W. The long-term outcomes of deceased-donor liver transplantation for primary biliary cirrhosis: a two-center study in China. PeerJ 2020; 8:e9563. [PMID: 32879788 PMCID: PMC7443077 DOI: 10.7717/peerj.9563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background & Aims Factors that influence the outcomes after deceased-donor liver transplantation (DDLT) for primary biliary cirrhosis (PBC) are not well known. We aimed to clarify these effects on the outcomes after DDLT. Methods We retrospectively analyzed patients with PBC who underwent DDLT from March 2006 to July 2018 at the organ transplantation center of the First Hospital of Jilin University and the First Central Hospital of Tianjin. Changes in liver function were assessed posttransplantation. Recurrence, survival rate, and complications were recorded at follow-up. The effect of liver transplantation on survival and recurrence was evaluated using univariate and/or multivariate Cox regression analyses. Results In total, 69 patients with PBC undergoing DDLT were included in this study. At 4 weeks posttransplant, all liver function tests were normal. During a median follow-up time of 32 months, 5-year overall survival and recurrence rates were estimated as 95.1% and 21.8%, respectively. A recipient aspartate aminotransferase-to-platelet ratio index (APRI) greater than 2 was negatively associated with survival (P = 0.0018). Multivariate regression analysis demonstrated that age younger than 48 years was an independent risk factor for recurrent PBC in recipients undergoing liver transplantation (hazard ratio 0.028, 95% confidence interval 0.01-0.71, P = 0.03). Posttransplant infections (62%) and biliary tract complications (26%) were the most common complications. Conclusion Liver transplantation is an effective treatment for patients with PBC. Liver function normalizes by 4 weeks posttransplant. Although posttransplant survival rate is high, recurrence is possible. To some extent, survival rate and recurrence rate can be predicted by APRI and age, respectively.
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Affiliation(s)
- Lin Chen
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Xiaodong Shi
- Department of Rheumatology, First Hospital, Jilin University, Changchun, China
| | - Guoyue Lv
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, Jilin University, Changchun, China
| | - Xiaodong Sun
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, Jilin University, Changchun, China
| | - Chao Sun
- Department of Transplant Center, First Central Hospital, Tianjin, Tianjin, China
| | - Yanjun Cai
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Junqi Niu
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Jinglan Jin
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Ning Liu
- Department of Cardiology, First Hospital, Jilin University, Changchun, China
| | - Wanyu Li
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
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17
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Vierling JM, Kerkar N, Czaja AJ, Mack CL, Adams D, Assis DN, Manns MP, Mayo MJ, Nayfeh T, Majzoub AMM, Alzuabi MA, Ding J, Haffar S, Murad MH, Alsawas M. Immunosuppressive Treatment Regimens in Autoimmune Hepatitis: Systematic Reviews and Meta-Analyses Supporting American Association for the Study of Liver Diseases Guidelines. Hepatology 2020; 72:753-769. [PMID: 32500593 DOI: 10.1002/hep.31407] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
Affiliation(s)
- John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nanda Kerkar
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Cara L Mack
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Adams
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - David N Assis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | | | - Muayad A Alzuabi
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Jingyi Ding
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Samir Haffar
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Mouaz Alsawas
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
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18
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Ziogas IA, Alexopoulos SP, Matsuoka LK, Geevarghese SK, Gorden LD, Karp SJ, Perkins JD, Montenovo MI. Living vs deceased donor liver transplantation in cholestatic liver disease: An analysis of the OPTN database. Clin Transplant 2020; 34:e14031. [PMID: 33427333 DOI: 10.1111/ctr.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/11/2020] [Accepted: 06/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) and donation after circulatory death (DCD) can expand the donor pool for cholestatic liver disease (CLD) patients. We sought to compare the outcomes of deceased donor liver transplant (DDLT) vs LDLT in CLD patients. METHODS Retrospective cohort analysis of adult CLD recipients registered in the OPTN database who received primary LT between 2002 and 2018. Cox proportional hazards regression models with mixed effects were used to determine the impact of graft type on patient and graft survival. RESULTS Five thousand, nine hundred ninety-nine DDLT (5730 donation after brain death [DBD], 269 DCD) and 912 LDLT recipients were identified. Ten-year patient/graft survival rates were DBD: 73.8%/67.9%, DCD: 74.7%/60.7%, and LDLT: 82.5%/73.9%. Higher rates of biliary complications as a cause of graft failure were seen in DCD (56.8%) than LDLT (30.5%) or DBD (18.7%) recipients. On multivariable analysis, graft type was not associated with patient mortality, while DCD was independently associated with graft failure (P = .046). CONCLUSION DBD, DCD, and LDLT were associated with comparable overall patient survival. No difference in the risk of graft failure could be observed between LDLT and DBD. DCD can be an acceptable alternative to DBD with equivalent patient survival, but inferior graft survival likely related to the high rate of biliary complications.
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Affiliation(s)
- Ioannis A Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lee D Gorden
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth J Karp
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA, USA
| | - Martin I Montenovo
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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19
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Outcomes of Liver Transplant Candidates with Primary Biliary Cholangitis: The Data from the Scientific Registry of Transplant Recipients. Dig Dis Sci 2020; 65:416-422. [PMID: 31451982 DOI: 10.1007/s10620-019-05786-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary biliary cholangitis (PBC) is progressive and can cause end-stage liver disease necessitating a liver transplant (LT). PBC patients may be disadvantaged on LT waitlist due to MELD-based priority listing or other factors. AIM The aim was to assess waitlist duration, waitlist mortality, and post-LT outcomes of PBC patients. METHODS The Scientific Registry of Transplant Recipients data for 1994-2016 was utilized. Adult patients with PBC without hepatocellular carcinoma (HCC) were selected. Their clinico-demographic parameters and waitlist and post-transplant outcomes were compared to those of patients with hepatitis C (HCV) without HCC. RESULTS Out of 223,391 listings for LT in 1994-2016, 8133 (3.6%) was for PBC without HCC. Mean age was 55.5 years, 76.9% white, 86.2% female, mean MELD score 21, 6.6% retransplants. There were 52,017 patients with hepatitis C included for comparison. The mean waitlist mortality was 17.9% for PBC and 17.6% for HCV (p > 0.05). The average transplantation rate was 57.7% for PBC and 53.3% for HCV (p < 0.0001), while waitlist dropout (death or removal due to deterioration) rate was 25.0% for PBC and 25.4% for HCV (p > 0.05). There was no significant difference in median waiting duration till transplantation between PBC patients and HCV after 2002 (103 vs. 95 days, p > 0.05). Post-LT mortality and graft loss rates were significantly lower in PBC than in HCV patients (all p < 0.02). CONCLUSIONS Despite no evidence of impaired waitlist outcomes and favorable post-transplant survival in patients with PBC, there is still a high waitlist dropout rate suggesting the presence of an unmet need for effective treatment.
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20
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Tanaka A, Kono H, Leung PSC, Gershwin ME. Recurrence of disease following organ transplantation in autoimmune liver disease and systemic lupus erythematosus. Cell Immunol 2019; 347:104021. [PMID: 31767117 DOI: 10.1016/j.cellimm.2019.104021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
Disease recurrence after organ transplantation associated with graft failure is a major clinical challenge in autoimmune diseases. Primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and autoimmune Hepatitis (AIH) are the three most common (autoimmune liver diseases) ALD for which liver transplantation (LT) is the most effective treatment option for patients with end-stage diseases. Although the 5- and 10-year survival rates of post-LT patients are remarkable (80-84% and 71-79% in PBC, 73-87% and 58-83% in PSC, 76-79% and 67-77% respectively in AIH patients), post-LT disease recurrence is not uncommon. Here, we summarize literature findings on disease recurrence of these ALD with emphasis on the incidence, risk factors and impact on long-term outcome. We noted that the incidence of disease recurrence varies between studies, which ranges from 53% to 10.9% in PBC, 8.2% to 44.7% in PSC and 7% to 42% in AIH. The variations are likely due to differences in study design, such as sample size, duration of studies and follow up time. This is further compounded by the lack of precise clinical diagnosis criteria and biomarkers of disease recurrence in these ALD, variation in post-LT treatment protocols to prevent disease recurrence and a multitude of risk factors associated with these ALD. While recurrence of PBC and AIH does not significantly impact long term outcome including overall survival, recurrent PSC patients often require another LT. Renal transplantation, like LT, is the treatment of choice in patients with end-stage lupus nephritis. While calcineurin inhibitor (CNI) and immunosuppressive drugs have improved the survival rate, post-transplant recurrence of lupus nephritis from surveillance-biopsy proven lupus nephritis range from 30% to 44%. On the other hand, recurrence of post-transplant lupus nephritis from registry survey analysis were only 1.1% to 2.4%. In general, risk factors associated with an increased frequency of post-transplant recurrence of autoimmune diseases are not clearly defined. Large scale multi-center studies are needed to further define guidelines for the diagnosis and clinical management to minimize disease recurrence and improve outcomes of post-transplant patients.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hajime Kono
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Patrick S C Leung
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States
| | - M Eric Gershwin
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States.
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21
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Vinnitskaya EV, Abdulkhakov SR, Abdurakhmanov DT, Alikhanov RB, Bakulin IG, Belousova EA, Bueverov AO, Burnevitch EZ, Efanov MG, Eremina EY, Ignatova ТМ, Ilchenko LY, Karmazanovsky GG, Knyazev OV, Kulezneva YV, Lopatkina TN, Nekrasova TP, Nikitin IG, Pavlenko VV, Parfenov AI, Podymova SD, Raichelson KL, Reisis AR, Sayfutdinov RG, Skazyvaeva EV, Syutkin VE, Khomeriki SG, Haimenova TY, Sandler YG. Important problems in the diagnosis and treatment of primary sclerosing cholangitis (based on the Russian consensus on diagnosis and treatment autoimmune hepatitis. Moscow, 2018). TERAPEVT ARKH 2019; 91:9-15. [PMID: 31094167 DOI: 10.26442/00403660.2019.02.000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The article is published based on the results of the Russian Consensus on the diagnosis and treatment of primary sclerosing cholangitis (PSC), discussed at the 44th annual Scientific Session of the CNIIG "Personalized Medicine in the Era of Standards" (March 1, 2018). The aim of the review is to highlight the current issues of classification of diagnosis and treatment of patients with PSC, which causes the greatest interest of specialists. The urgency of the problem is determined by the multivariate nature of the clinical manifestations, by often asymptomatic flow, severe prognosis, complexity of diagnosis and insufficient study of PSC, the natural course of which in some cases can be considered as a function with many variables in terms of the nature and speed of progression with numerous possible clinical outcomes. In addition to progression to portal hypertension, cirrhosis and its complications, PSC can be accompanied by clinical manifestations of obstructive jaundice, bacterial cholangitis, cholangiocarcinoma and colorectal cancer. Magnetic resonance cholangiography is the main method of radial diagnostics of PSC, which allows to obtain an image of bile ducts in an un-invasive way. The use of liver biopsy is best justified when there is a suspicion of small-diameter PSC, autoimmune cross-syndrome PSC-AIG, IgG4-sclerosing cholangitis. Currently, a drug registered to treat primary sclerosing cholangitis which can significantly change the course and prognosis of the disease does not exist. There is no unified view on the effectiveness and usefulness of ursodeoxycholic acid and its dosage in PSC. Early diagnosis and determination of the phenotype of PSC is of clinical importance. It allows to determine the tactics of treatment, detection and prevention of complications.
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Affiliation(s)
- E V Vinnitskaya
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | | | - D T Abdurakhmanov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - R B Alikhanov
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - I G Bakulin
- I.I. Mechnikov North-Western State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - E A Belousova
- M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - A O Bueverov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - E Z Burnevitch
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - M G Efanov
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - E Yu Eremina
- Medical Institut of the N.P. Ogarev Mordovia State University, Saransk, Russia
| | - Т М Ignatova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - L Yu Ilchenko
- N.I. Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - G G Karmazanovsky
- A.V. Vishnevsky Institute of Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - O V Knyazev
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - Yu V Kulezneva
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - T N Lopatkina
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - T P Nekrasova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - I G Nikitin
- N.I. Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - V V Pavlenko
- Stavropol State Medical University of the Ministry of Health of the Russian Federation, Stavropol, Russia
| | - A I Parfenov
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - S D Podymova
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - K L Raichelson
- St Petersburg State University, Saint Petersburg, Russia
| | - A R Reisis
- Central Research Institute of Epidemiology of the Federal Service on Customers, Moscow, Russia
| | - R G Sayfutdinov
- Kazan State Medical Academy - the Branch of Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - E V Skazyvaeva
- I.I. Mechnikov North-Western State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - V E Syutkin
- N.V. Sklifosovsky Research Institute of Emergency Medical Care of the Department of Health of Moscow, Moscow, Russia
| | - S G Khomeriki
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - T Yu Haimenova
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
| | - Yu G Sandler
- A.S. Loginov Moscow Clinical Research and Practical Center of the Department of Health of Moscow, Moscow, Russia
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23
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Levy C. Primary Biliary Cholangitis Guidance Update: Implications for Liver Transplantation. Liver Transpl 2018; 24:1508-1511. [PMID: 30091276 DOI: 10.1002/lt.25321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Cynthia Levy
- Miller School of Medicine, University of Miami, Miami, FL
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24
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Parés A, Albillos A, Andrade RJ, Berenguer M, Crespo J, Romero-Gómez M, Vergara M, Vendrell B, Gil A. Primary biliary cholangitis in Spain. Results of a Delphi study of epidemiology, diagnosis, follow-up and treatment. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:641-649. [PMID: 30032637 DOI: 10.17235/reed.2018.5665/2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION primary biliary cholangitis (PBC) is a rare disease with limited data regarding its epidemiology and standard clinical management in Spain. OBJECTIVE to gain insight into the epidemiology, patient flow, diagnosis, follow-up and treatment of PBC in Spain. METHODS a review of the literature and Delphi study involving 28 specialists in two rounds of consultations and an in-person results validation workshop. RESULTS there are approximately 9,400 patients with PBC in Spain, with an annual incidence of 0.51-3.86 cases/100,000 population. Albeit, a high error margin may be presumed due to the scarcity of relevant studies on this subject. Several months may elapse from suspicion to a confirmed diagnosis, usually by a gastroenterologist or hepatologist. The role of the liver biopsy for diagnosis and follow-up is heterogeneous. Overall, 95% of patients are treated with ursodeoxycholic acid (UDCA) and response is primarily monitored using the Barcelona criteria. Follow-up is performed every six months, with a heterogeneous use of the various available techniques. No recommendations or second-line commercial drugs are available in the case of no response, inadequate response or intolerance to UDCA. CONCLUSIONS while epidemiology may be estimated based on expert opinions, national registries are needed to provide accurate, up-to-date information on epidemiological parameters, disease stage and response to treatment in patients with PBC. Furthermore, novel therapies are required for selected patient groups.
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Affiliation(s)
- Albert Parés
- Unidad de Hepatología. Hospital Clínic, IDIBAPS, CIBERehd, Universidad de Barcelona, Barcelona
| | - Agustín Albillos
- Servicio Gastroenterología y Hepatología. Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Un
| | - Raul Jesús Andrade
- Unidad Aparato Digestivo. Complejo Hospitalario de Especialidades Virgen de la Victoria, Málaga
| | - Marina Berenguer
- Servicio Aparato Digestivo. Hospital Universitari i Politècnic la Fe, Universidad de Valencia, CIBER
| | - Javier Crespo
- Servicio Aparato Digestivo. Hospital Universitario Marqués de Valdecilla, Santander
| | | | - Mercè Vergara
- Unidad de Hepatología. Servicio Aparato Digestivo. Parc Taulí Sabadell. Institut d'Investigació i In
| | | | - Alicia Gil
- CEO Market Access, Omakase Consulting, España
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25
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Adike A, Carey EJ, Lindor KD. Primary sclerosing cholangitis in children versus adults: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2018; 12:1025-1032. [PMID: 30199272 DOI: 10.1080/17474124.2018.1521719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder that presents with multifocal biliary strictures. PSC has a variable course but often leads to progressive liver disease, and most patients will eventually require liver transplantation. PSC has a strong association with inflammatory bowel disease and autoimmune liver disease. Areas covered: The objective of this article is to compare and contrast the clinical features and natural history of PSC in children to adults. We performed a PubMed search of the English literature using keywords 'primary sclerosing cholangitis', 'PSC', 'children', and 'pediatric.' Expert commentary: While certain features of PSC are similar in the pediatric and adult population, there are unique features of pediatric PSC. More longitudinal studies are needed to better understand the natural history of pediatric PSC. It is conceivable that treatment for PSC that will alter the course of disease may become available in the future.
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Affiliation(s)
- Abimbola Adike
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Elizabeth J Carey
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Keith D Lindor
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
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26
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Aguilar MT, Carey EJ. Current Status of Liver Transplantation for Primary Biliary Cholangitis. Clin Liver Dis 2018; 22:613-624. [PMID: 30259857 DOI: 10.1016/j.cld.2018.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune cholestatic liver disease diagnosed with elevated alkaline phosphatase in the presence of antimitochondrial antibody. With the introduction and widespread use of ursodeoxycholic acid the proportion of PBC patients undergoing liver transplant (LT) has decreased. However, up to 40% of patients are ursodeoxycholic acid nonresponders and require second-line treatment or progress to end-stage liver disease requiring LT. Several scoring systems have been developed and validated to assess treatment response and transplant-free survival in patients. Although PBC is a favorable indication for LT, recurrence of PBC may occur and requires biopsy for diagnosis.
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Affiliation(s)
- Maria T Aguilar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
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27
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Harms MH, van Buuren HR, van der Meer AJ. Improving prognosis in primary biliary cholangitis - Therapeutic options and strategy. Best Pract Res Clin Gastroenterol 2018; 34-35:85-94. [PMID: 30343714 DOI: 10.1016/j.bpg.2018.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/08/2018] [Indexed: 01/31/2023]
Abstract
Overall survival in primary biliary cholangitis is diminished. As patients are often asymptomatic, the disease may silently progress towards cirrhosis and liver failure. Timely diagnosis and effective treatment options are of vital importance to improve the prognosis of affected patients. Ursodeoxycholic acid is the standard of care first-line therapy and is associated with a reduced risk of liver transplantation and death. Treatment with UDCA is relevant for all patients, irrespective of disease stage or biochemical response. In case of incomplete biochemical response according to internationally accepted criteria, second-line treatment should be considered to improve long-term prognosis. Ursodeoxycholic acid has been the only accepted treatment for PBC during the last decades. Recent research, however, has identified a number of new therapeutic targets and agents, including obeticholic acid, fibrates and budesonide. While these agents all qualify as potentially beneficial second-line treatment, obeticholic acid is currently the only drug specifically approved for the treatment of PBC. Although long-term follow-up studies for these agents are mostly lacking, improvement of biochemical surrogate markers of clinical outcome induced by these drugs suggests a therapeutic benefit. The authors of this review aim to provide a summary of the results of previous and current studies evaluating medical treatments, and propose a treatment strategy based on the evidence available today.
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Affiliation(s)
- Maren H Harms
- Erasmus University Medical Center, Rotterdam, The Netherlands.
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28
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Gossard AA, Gores GJ. Primary Sclerosing Cholangitis: What the Gastroenterologist and Hepatologist Needs to Know. Clin Liver Dis 2017; 21:725-737. [PMID: 28987259 DOI: 10.1016/j.cld.2017.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, idiopathic biliary tract disease characterized by segmental strictures. The disease is progressive with no proven treatments and may eventually lead to cirrhosis and end-stage liver disease. Abrupt changes in liver biochemistries, pain, and/or cholangitis may suggest a dominant stricture amenable to endoscopic therapy or the development of cholangiocarcinoma. Patients with PSC are at increased risk of cholangiocarcinoma. There is a strong association with inflammatory bowel disease, and an associated increased risk of colorectal cancer. Colonoscopy every 1 to 2 years is appropriate.
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Affiliation(s)
- Andrea A Gossard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55901, USA.
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55901, USA
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29
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Liu K, Strasser SI, Koorey DJ, Leong RW, Solomon M, McCaughan GW. Interactions between primary sclerosing cholangitis and inflammatory bowel disease: implications in the adult liver transplant setting. Expert Rev Gastroenterol Hepatol 2017. [PMID: 28627935 DOI: 10.1080/17474124.2017.1343666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease which is associated with inflammatory bowel disease (IBD) in most cases. As there is currently no medical therapy which alters the natural history of PSC, liver transplantation may be required. Areas covered: We searched for articles in PubMed and critically reviewed current literature on the interrelationship between PSC and IBD with a specific focus on considerations for patients in the liver transplant setting. Expert commentary: PSC is an uncommon disease which limits available studies to be either retrospective or contain relatively small numbers of patients. Based on observations from these studies, the behavior and complications of PSC and IBD impact on each other both before and after a liver transplant. Both these autoimmune conditions and their associated cancer risk also influence patient selection for transplantation and may be impacted by immunosuppression use post-transplant. Hence, a complex interplay exists between PSC, IBD and liver transplantation which requires clarification with ongoing research.
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Affiliation(s)
- Ken Liu
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,b AW Morrow Gastroenterology and Liver Centre , Royal Prince Alfred Hospital , Sydney , NSW , Australia.,c Liver Injury and Cancer Program, Centenary Institute , The University of Sydney , Sydney , NSW , Australia
| | - Simone I Strasser
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,b AW Morrow Gastroenterology and Liver Centre , Royal Prince Alfred Hospital , Sydney , NSW , Australia
| | - David J Koorey
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,b AW Morrow Gastroenterology and Liver Centre , Royal Prince Alfred Hospital , Sydney , NSW , Australia
| | - Rupert W Leong
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,d Gastroenterology and Liver Services , Concord Hospital , Sydney , NSW , Australia
| | - Michael Solomon
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,e Department of Colorectal Surgery , Royal Prince Alfred Hospital , Sydney , NSW , Australia
| | - Geoffrey W McCaughan
- a Sydney Medical School , The University of Sydney , Sydney , NSW , Australia.,b AW Morrow Gastroenterology and Liver Centre , Royal Prince Alfred Hospital , Sydney , NSW , Australia.,c Liver Injury and Cancer Program, Centenary Institute , The University of Sydney , Sydney , NSW , Australia
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30
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Filipec Kanizaj T, Mijic M. Inflammatory bowel disease in liver transplanted patients. World J Gastroenterol 2017; 23:3214-3227. [PMID: 28566881 PMCID: PMC5434427 DOI: 10.3748/wjg.v23.i18.3214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
Most common hepatobiliary manifestation of inflammatory bowel disease (IBD) are primary sclerosing cholangitis (PSC) and autoimmune hepatitis, ranking them as the main cause of liver transplantation (LT) in IBD setting. Course of pre-existing IBD after LT differs depending on many transplant related factors. Potential risk factors related to IBD deterioration after LT are tacrolimus-based immunosuppressive regimens, active IBD and cessation of 5-aminosalicylates at the time of LT. About 30% patients experience improvement of IBD after LT, while approximately the same percentage of patients worsens. Occurrence of de novo IBD may develop in 14%-30% of patients with PSC. Recommended IBD therapy after LT is equivalent to recommendations to overall IBD patients. Anti-tumor necrosis factor alpha appears to be efficient for refractory IBD. Due to potential side effects it needs to be applied with caution. In average 9% of patients require proctocolectomy due to medically refractory IBD or colorectal carcinoma. The most frequent complication in patients who undergo proctocolectomy with ileal-pouch anal anastomosis is pouchitis. It is still undeterminable if LT adds to risk of developing pouchitis in PSC patients. Annual colonoscopies are recommended as surveillance and precaution of colonic malignancies.
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Abstract
Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common cholestatic liver diseases (CLD) in adults. Liver transplant (LT) is desirable for those who progress to end-stage liver disease. CLD have become an uncommon indication for LT. PSC and PBC accounted for 7.1% of all adult LT in 2015. CLD have the best post-LT outcomes compared with other indications for LT. Disease recurrence of PSC and PBC after LT is reported in up to 37% and 43% of LT recipients, respectively. Although recurrent PBC does not affect post-LT outcomes, recurrent PSC is associated with worse post-LT survival.
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Affiliation(s)
- Nathalie A Pena Polanco
- Division of Internal Medicine, Miller School of Medicine, University of Miami, 1611 Northwest 12th Avenue, Suite Central 600-D, Miami, FL 33136, USA
| | - Cynthia Levy
- Division of Hepatology, Miller School of Medicine, University of Miami, 1120 Northwest 14th Street, Suite 1112, Miami, FL 33136, USA
| | - Eric F Martin
- Division of Hepatology, Miller School of Medicine, University of Miami, 1120 Northwest 14th Street, Suite 1112, Miami, FL 33136, USA.
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Larson L, James M, Gossard A. Cholestatic Liver Injury: Care of Patients With Primary Biliary Cholangitis or Primary Sclerosing Cholangitis. AACN Adv Crit Care 2017; 27:441-452. [PMID: 27959300 DOI: 10.4037/aacnacc2016202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The most common causes of chronic cholestatic liver disease are primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). Both disease processes are characterized by a destruction of intrahepatic and/or extrahepatic biliary ducts. The etiology is not entirely clear; however, there is an underlying autoimmune component contributing to both disease processes. Although PBC and PSC are often diagnosed and managed in the outpatient setting, in some instances, a patient may have jaundice, fatigue, and pruritus requiring evaluation and determination of the cholestatic cause. Patients with PSC should be monitored for evidence of cholangiocarcinoma, colon cancer, and gallbladder polyps as they are at an increased risk of malignant neoplasms. Liver transplant has the potential for improving quality of life, although disease recurrence is a risk.
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Affiliation(s)
- Laurie Larson
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michelle James
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrea Gossard
- Laurie Larson is Nurse Practitioner, Hepatology, 406 Harvard St SE, MMC 36, University of Minnesota, Minneapolis, MN 55455 . Michelle James is Clinical Director of Transplant Services, University of Minnesota, Minneapolis, Minnesota. Andrea Gossard is Nurse Practitioner, Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Visseren T, Darwish Murad S. Recurrence of primary sclerosing cholangitis, primary biliary cholangitis and auto-immune hepatitis after liver transplantation. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624107 DOI: 10.1016/j.bpg.2017.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Liver transplantation is a well-accepted treatment for decompensated chronic liver disease due to primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC) and auto-immune hepatitis (AIH). Survival after liver transplantation is generally good with 1 and 5-year survival rates around 90% and 70-85%. After transplantation, however, these diseases recur in 8.6-27% (rPSC), 10.9-42.3% (rPBC) and 7-42% (rAIH), and this poses significant challenges in terms of management and graft outcome in these patients. In this review we discuss the incidence, clinical presentation, challenges in diagnosis, reported risk factors and impact on post-transplant outcomes of recurrence of PSC, PBC and AIH after liver transplantation. We also discuss some of the limitations of current investigations and formulate idea's for future research objectives.
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Affiliation(s)
- T Visseren
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - S Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Schnitzbauer AA, Bechstein WO. Equitable distribution in rare indications for liver transplantation: the dilemma of the too small tablecloth continues! Transpl Int 2017; 30:451-453. [PMID: 28226189 DOI: 10.1111/tri.12942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 02/17/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, Frankfurt University Hospital, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Wolf O Bechstein
- Clinic for General and Visceral Surgery, Frankfurt University Hospital, Goethe-University Frankfurt, Frankfurt/Main, Germany
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Montano-Loza AJ, Bhanji RA, Wasilenko S, Mason AL. Systematic review: recurrent autoimmune liver diseases after liver transplantation. Aliment Pharmacol Ther 2017; 45:485-500. [PMID: 27957759 DOI: 10.1111/apt.13894] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/21/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Autoimmune liver diseases (AILD) constitute the third most common indication for liver transplantation (LT) worldwide. Outcomes post LT are generally good but recurrent disease is frequently observed. AIMS To describe the frequency and risk factors associated with recurrent AILD post-LT and provide recommendations to reduce the incidence of recurrence based on levels of evidence. METHODS A systematic review was performed for full-text papers published in English-language journals, using the keywords 'autoimmune hepatitis (AIH)', 'primary biliary cholangitis and/or cirrhosis (PBC)', 'primary sclerosing cholangitis (PSC)', 'liver transplantation' and 'recurrent disease'. Management strategies to reduce recurrence after LT were classified according to grade and level of evidence. RESULTS Survival rates post-LT are approximately 90% and 70% at 1 and 5 years and recurrent disease occurs in a range of 10-50% of patients with AILD. Recurrent AIH is associated with elevated liver enzymes and IgG before LT, lymphoplasmacytic infiltrates in the explants and lack of steroids after LT (Grade B). Tacrolimus use is associated with increased risk; use of ciclosporin and preventive ursodeoxycholic acid with reduced risk of PBC recurrence (all Grade B). Intact colon, active ulcerative colitis and early cholestasis are associated with recurrent PSC (Grade B). CONCLUSIONS Recommendations based on grade A level of evidence are lacking. The need for further study and management includes active immunosuppression before liver transplantation and steroid use after liver transplantation in autoimmune hepatitis; selective immunosuppression with ciclosporin and preventive ursodeoxycholic acid treatment for primary biliary cholangitis; and improved control of inflammatory bowel disease or even colectomy in primary sclerosing cholangitis.
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Affiliation(s)
- A J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - R A Bhanji
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - S Wasilenko
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - A L Mason
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
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Liberal R, Grant CR. Cirrhosis and autoimmune liver disease: Current understanding. World J Hepatol 2016; 8:1157-1168. [PMID: 27729952 PMCID: PMC5055585 DOI: 10.4254/wjh.v8.i28.1157] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/14/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) constitute the classic autoimmune liver diseases (AILDs). While AIH target the hepatocytes, in PBC and PSC the targets of the autoimmune attack are the biliary epithelial cells. Persistent liver injury, associated with chronic AILD, leads to un-resolving inflammation, cell proliferation and the deposition of extracellular matrix proteins by hepatic stellate cells and portal myofibroblasts. Liver cirrhosis, and the resultant loss of normal liver function, inevitably ensues. Patients with cirrhosis have higher risks or morbidity and mortality, and that in the decompensated phase, complications of portal hypertension and/or liver dysfunction lead to rapid deterioration. Accurate diagnosis and monitoring of cirrhosis is, therefore of upmost importance. Liver biopsy is currently the gold standard technique, but highly promising non-invasive methodology is under development. Liver transplantation (LT) is an effective therapeutic option for the management of end-stage liver disease secondary to AIH, PBC and PSC. LT is indicated for AILD patients who have progressed to end-stage chronic liver disease or developed intractable symptoms or hepatic malignancy; in addition, LT may also be indicated for patients presenting with acute liver disease due to AIH who do not respond to steroids.
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Gordon FD, Goldberg DS, Goodrich NP, Lok AS, Verna EC, Selzner N, Stravitz RT, Merion RM. Recurrent primary sclerosing cholangitis in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study: Comparison of risk factors between living and deceased donor recipients. Liver Transpl 2016; 22:1214-22. [PMID: 27339253 PMCID: PMC4996691 DOI: 10.1002/lt.24496] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/12/2016] [Indexed: 12/24/2022]
Abstract
Primary sclerosing cholangitis (PSC) recurs in 15%-25% of patients transplanted for PSC. In the United States, PSC transplant patients are more likely to receive an organ from a living donor (LD) than patients without PSC. Our aims were to (1) compare risk of PSC recurrence in LD versus deceased donor recipients and (2) identify risk factors for PSC recurrence. There were 241 living donor liver transplantations (LDLTs) and 65 deceased donor liver transplantation (DDLT) patients transplanted between 1998 and 2013 enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study who were evaluated. PSC recurrence risk for LDLT and DDLT recipients was compared using Kaplan-Meier survival curves and log-rank tests. Cox models were used to evaluate PSC risk factors. Overall PSC recurrence probabilities were 8.7% and 22.4% at 5 and 10 years after liver transplantation (LT), respectively. The risk of PSC recurrence was not significantly different for DDLT versus LDLT recipients (P = 0.36). For DDLT versus LDLT recipients, unadjusted 5- and 10-year PSC recurrence was 9.4% versus 9.5% and 36.9% versus 21.1%. Higher laboratory Model for End-Stage Liver Disease (MELD) score at LT, onset of a biliary complication, cholangiocarcinoma, and higher donor age were associated with increased risks of PSC recurrence: for MELD (hazard ratio [HR] = 1.06; 95% confidence interval [CI] 1.02-1.10 per MELD point, P = 0.002); for biliary complication (HR, 2.82; 95% CI, 1.28-6.25; P = 0.01); for cholangiocarcinoma (HR, 3.98; 95% CI, 1.43-11.09; P = 0.008); for donor age (per 5-years donor age; HR, 1.17; 95% CI, 1.02-1.35; P = 0.02). Factors not significantly associated with PSC recurrence included the following: first-degree relative donor (P = 0.11), post-LT cytomegalovirus infection (P = 0.38), and acute rejection (P = 0.22). Risk of recurrent PSC was not significantly different for DDLT and LDLT recipients. Biliary complications, cholangiocarcinoma, MELD, and donor age were significantly associated with risk of PSC recurrence. Liver Transplantation 22 1214-1222 2016 AASLD.
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Affiliation(s)
| | | | | | | | | | | | | | - Robert M. Merion
- Arbor Research Collaborative for Health, Ann Arbor, MI,University of Michigan, Ann Arbor, MI
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Krishnamoorthy TL, Miezynska-Kurtycz J, Hodson J, Gunson BK, Neuberger J, Milkiewicz P, Oo YH. Longterm corticosteroid use after liver transplantation for autoimmune hepatitis is safe and associated with a lower incidence of recurrent disease. Liver Transpl 2016; 22:34-41. [PMID: 26335026 DOI: 10.1002/lt.24323] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 07/18/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023]
Abstract
Patients transplanted for autoimmune hepatitis (AIH) are at risk of recurrent disease. Our current practice is to maintain long-term low-dose corticosteroids with additional immunosuppressive agents. This study describes the implications on patients' outcomes, sepsis, and osteoporosis. We collected data on patients transplanted between January 1999 and October 2014 in a single center who survived for more than 6 months. AIH recurrence was diagnosed by a combination of histology, raised immunoglobulin G levels, and exclusion of other etiologies. Sepsis was defined as any infection that resulted in significant morbidity or mortality. Osteoporosis was defined as a bone densitometry T score of less than -2.0 or evidence of osteoporosis-related fractures. Outcomes were assessed using Kaplan-Meier survival analysis methods. Seventy-three AIH patients underwent liver transplantation with a median follow-up of 94 months (interquartile range, 55-144). The cohort was mainly Caucasian (78%), female (79%), with type 1 AIH (90%), and a mean age of 43 ± 15 years. Overall survival was 92%, 90%, 86%, and 73%, and regraft-free survival was 86%, 81%, 78%, and 64% at 1, 3, 5, and 10 years, respectively. Five patients developed AIH recurrence, giving recurrence rates of 0%, 4%, 6%, and 11% at 1, 3, 5, and 10 years, respectively. Pneumonia was the most common infection, but gastroenteritis and cholangitis were the most recurrent. Freedom from sepsis was 91%, 82%, 80%, and 63%, and freedom from osteoporosis was 100%, 94%, 82%, and 58% at 1, 3, 5, and 10 years, respectively. Longterm low-dose corticosteroid in combination with other immunosuppressive agents seems to reduce AIH recurrence without jeopardizing patient and graft survival. Sepsis and osteoporosis did not occur more often compared to the published literature on liver transplant recipients.
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Affiliation(s)
- Thinesh L Krishnamoorthy
- Liver and Hepatobiliary Unit, University of Birmingham, Birmingham, UK.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - James Hodson
- Wolfson Computer Laboratory, University Hospitals Birmingham, UK
| | - Bridget K Gunson
- Liver and Hepatobiliary Unit, University of Birmingham, Birmingham, UK
| | - James Neuberger
- Liver and Hepatobiliary Unit, University of Birmingham, Birmingham, UK
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.,Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - Ye H Oo
- Liver and Hepatobiliary Unit, University of Birmingham, Birmingham, UK.,Centre for Liver Research, National Institute for Health Research Birmingham Liver Biomedical Research Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, UK
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Defining long-term outcomes with living donor liver transplantation in North America. Ann Surg 2015; 262:465-75; discussion 473-5. [PMID: 26258315 DOI: 10.1097/sla.0000000000001383] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To compare long-term survival of living donor liver transplant (LDLT) at experienced transplant centers with outcomes of deceased donor liver transplant and identify key variables impacting patient and graft survival. BACKGROUND The Adult-to-Adult Living Donor Liver Transplantation Cohort Study is a prospective multicenter National Institutes of Health study comparing outcomes of LDLT and deceased donor liver transplant and associated risks. METHODS Mortality and graft failure for 1427 liver recipients (963 LDLT) enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study who received transplant between January 1, 1998, and January 31, 2014, at 12 North American centers with median follow-up 6.7 years were analyzed using Kaplan-Meier and multivariable Cox models. RESULTS Survival probability at 10 years was 70% for LDLT and 64% for deceased donor liver transplant. Unadjusted survival was higher with LDLT (hazard ratio = 0.76, P = 0.02) but attenuated after adjustment (hazard ratio = 0.98, P = 0.90) as LDLT recipients had lower mean model for end-stage liver disease (15.5 vs 20.4) and fewer received transplant from intensive care unit, were inpatient, on dialysis, were ventilated, or with ascites. Posttransplant intensive care unit days were less for LDLT recipients. For all recipients, female sex and primary sclerosing cholangitis were associated with improved survival, whereas dialysis and older recipient/donor age were associated with worse survival. Higher model for end-stage liver disease score was associated with increased graft failure. Era of transplantation and type of donated lobe did not impact survival in LDLT. CONCLUSIONS LDLT provides significant long-term transplant benefit, resulting in transplantation at a lower model for end-stage liver disease score, decreased death on waitlist, and excellent posttransplant outcomes. Recipient diagnosis, disease severity, renal failure, and ages of recipient and donor should be considered in decision making regarding timing of transplant and donor options.Clinical Trials ID: NCT00096733.
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40
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Lindor KD, Kowdley KV, Harrison ME. ACG Clinical Guideline: Primary Sclerosing Cholangitis. Am J Gastroenterol 2015; 110:646-59; quiz 660. [PMID: 25869391 DOI: 10.1038/ajg.2015.112] [Citation(s) in RCA: 303] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/02/2015] [Indexed: 12/11/2022]
Abstract
Primary sclerosing cholangitis is a chronic cholestatic liver disease that can shorten life and may require liver transplantation. The cause is unknown, although it is commonly associated with colitis. There is no approved or proven therapy, although ursodeoxycholic acid is used by many on an empiric basis. Complications including portal hypertension, fat-soluble vitamin deficiency, metabolic bone diseases, and development of cancers of the bile duct or colon can occur.
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Affiliation(s)
- Keith D Lindor
- 1] College of Health Solutions, Arizona State University, Phoenix, Arizona, USA [2] Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
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Retrograde detection of the intrahepatic portal vein in primary biliary cirrhosis: is sinusoidal blockage the underlying pathophysiology? Eur J Gastroenterol Hepatol 2015; 27:321-7. [PMID: 25563140 DOI: 10.1097/meg.0000000000000268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to explore the underlying pathophysiological mechanism for portal hypertension in primary biliary cirrhosis (PBC) using radiological findings. PATIENTS AND METHODS The study included 10 patients with PBC (Scheuer stage I, one patient; stage II, two patients; and cirrhosis, seven patients) and 29 patients with viral cirrhosis. Both groups underwent Doppler ultrasound and hepatic venous catheterization. The Doppler data, pressure data, and vascular enhancement findings were compared between the groups. RESULTS Hemodynamics in the portal trunk and hepatic vein upon Doppler sonography did not differ between patients with viral cirrhosis, cirrhotic PBC, and noncirrhotic PBC. The hepatic venous pressure gradient (mean±SD) was 225.5±77.1 mmH2O (range 125-445 mmH2O) in viral cirrhosis, 224.6±39.5 mmH2O (range 170-262 mmH2O) in cirrhotic PBC, and 41.3±7.4 mmH2O (range 33-47 mmH2O) in noncirrhotic PBC, being significantly higher in viral cirrhosis and cirrhotic PBC than noncirrhotic PBC (P=0.0005). The intrahepatic portal vein was detected in a retrograde manner on the hepatic venogram in 29/29 (100%) patients with viral cirrhosis (all with gastroesophageal varices), 7/7 (100%) patients with cirrhotic PBC (5/7 with gastroesophageal varices), and 3/3 (100%) patients with noncirrhotic PBC (none with gastroesophageal varices). The presence of veno-venous communication was found in 15/29 (51.7%) patients with viral cirrhosis, 6/7 (85.7%) patients with cirrhotic PBC, and 3/3 (100%) patients with noncirrhotic PBC. CONCLUSION The study suggested that sinusoidal blockage is the underlying pathophysiology even in the early-stage PBC, proved by the visible intrahepatic portal vein in three noncirrhotic PBC patients, and veno-venous communication in the liver is responsible for alleviated hepatic venous pressure gradient.
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Yanai H, Matalon S, Rosenblatt A, Awadie H, Berdichevski T, Snir Y, Kopylov U, Katz L, Stein A, Mlynarsky L, Tulchinsky H, Konikoff FM, Horin SB, Braun M, Ben-Ari Z, Chowers Y, Baruch Y, Shibolet O, Dotan I. Prognosis of primary sclerosing cholangitis in israel is independent of coexisting inflammatory bowel Disease. J Crohns Colitis 2015; 9:177-84. [PMID: 25518055 DOI: 10.1093/ecco-jcc/jju013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Primary sclerosing cholangitis (PSC) is a rare chronic progressive cholestatic disorder. We assessed its characteristics and natural history in Israel and compared its outcome with respect to coexisting inflammatory bowel disease (IBD). METHODS Data on characteristics, course and outcome were retrospectively retrieved on patients diagnosed with PSC from five large Israeli medical centers between 1988 and 2012. Patients with isolated PSC were compared with those with coexisting IBD to identify predictors of outcome. RESULTS Of 141 patients (56% males) with confirmed PSC, 98 (69.5%) had coexisting IBD. The average age at presentation was 38.8 ± 15.4 years and duration of follow-up was 7.93 ± 6.26 years. The crude estimated point prevalence was 4 cases per 105 persons. Demographics and clinical characteristics were similar among all patients except for symptoms at diagnosis (which were more prevalent among PSC–IBD patients) and utilization of multiple diagnostic modalities (which was more prevalent among isolated-PSC patients). More than one-third of the entire cohort had cirrhosis. A total of 15 patients (10.6%) died and 19 patients (13.5%) developed malignancy during follow-up. Nine patients (6.3%) underwent liver transplantation. Mean survival for the entire cohort was 26.3 ± 1.4 years and mean transplant-free survival was 23.5 ± 1.6 years. Cox proportional hazard regression for transplantation or death revealed two independent risk factors: cirrhosis and malignancy [hazard ratio 4.25 (p = 0.004) and 2.58 (p = 0.046), respectively]. CONCLUSIONS Survival rate of PSC patients in Israel is longer than reported rates worldwide and is independent of coexisting IBD.
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Harimoto N, Ikegami T, Nakagawara H, Yamashita YI, Yoshizumi T, Uchiyama H, Soejima Y, Ikeda T, Shirabe K, Aishima S, Oda Y, Maehara Y. Chronic Immune-Mediated Reaction Syndrome as the Cause of Late Graft Mortality in Living-Donor Liver Transplantation for Primary Biliary Cirrhosis. Transplant Proc 2014; 46:1438-43. [DOI: 10.1016/j.transproceed.2014.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 02/27/2014] [Indexed: 12/22/2022]
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Sakai H, Ishiyama K, Tanaka Y, Ide K, Ohira M, Tahara H, Abe T, Hirata F, Morimoto H, Hashimoto S, Tanimine N, Saeki Y, Shimizu S, Yano T, Kobayashi T, Tashiro H, Ohdan H. Potential Benefit of Mixed Lymphocyte Reaction Assay-based Immune Monitoring After Living Donor Liver Transplantation for Recipients With Autoimmune Hepatitis. Transplant Proc 2014; 46:785-9. [DOI: 10.1016/j.transproceed.2013.11.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/07/2013] [Indexed: 12/22/2022]
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45
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Sasaki K, Matsuda M, Ohkura Y, Kawamura Y, Inoue M, Suzuki Y, Hashimoto M, Ikeda K, Kumada H, Watanabe G. Clinical significance of hepatectomy for primary biliary cirrhosis patients with hepatocellular carcinoma: Report of a single center case series and review of the published work. Hepatol Res 2014; 44:474-80. [PMID: 23607898 DOI: 10.1111/hepr.12134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/08/2013] [Accepted: 04/08/2013] [Indexed: 02/08/2023]
Abstract
AIM Hepatectomy for hepatocellular carcinoma (HCC) in patients with primary biliary cirrhosis (PBC) has seldom been reported, and the clinical significance of this procedure remains unclear, although HCC has often been observed in end-stage PBC patients. METHODS To understand the characteristics of hepatectomy on HCC in PBC patients, we examined seven cases at our institute, as well as 22 reported hepatectomy cases in the English-language and Japanese published work. Furthermore, to assess the treatment efficacy of hepatectomy for HCC in PBC patients, we compared these patients with viral hepatitis patients who underwent hepatectomies at our institute during the same period. RESULTS In the review of 29 cases, more than 70% of the patients were aged over 65 years, and the mean Mayo risk score was low at 5.17. The resected tumors were mainly solitary (79%), and the median maximum tumor size was 37 mm. Approximately two-thirds of the patients met the Milan criteria. In the comparison between the PBC and viral hepatitis cases, there were no differences in the postoperative prognoses, although the tumor size was greater in the PBC cases. CONCLUSION Hepatectomy for HCC in selected PBC cases is a feasible and potentially curative treatment option, similar to hepatectomy for HCC in viral hepatitis patients. This procedure is particularly useful for patients with preserved liver function who are not ideal candidates for liver transplantation.
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Affiliation(s)
- Kazunari Sasaki
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital, Tokyo, Japan
| | - Masamichi Matsuda
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital, Tokyo, Japan
| | - Yu Ohkura
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital, Tokyo, Japan
| | | | - Masafumi Inoue
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Masaji Hashimoto
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital, Tokyo, Japan
| | - Kenji Ikeda
- Department of Hepatology, Toranomon Hospital, Tokyo, Japan
| | | | - Goro Watanabe
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital, Tokyo, Japan
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Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 2014; 59:1144-65. [PMID: 24716201 DOI: 10.1002/hep.26972] [Citation(s) in RCA: 620] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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47
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Singh S, Varayil JE, Loftus EV, Talwalkar JA. Incidence of colorectal cancer after liver transplantation for primary sclerosing cholangitis: a systematic review and meta-analysis. Liver Transpl 2013; 19:1361-9. [PMID: 24019127 DOI: 10.1002/lt.23741] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/08/2013] [Accepted: 08/27/2013] [Indexed: 12/15/2022]
Abstract
Patients with primary sclerosing cholangitis (PSC) and associated inflammatory bowel disease (IBD) have an increased risk of colorectal cancer (CRC). We estimated the pooled incidence of CRC after liver transplantation (LT) in patients with PSC as well as in a subset of patients with associated IBD (PSC-IBD). Through a systematic review of major bibliographic databases up to April 1, 2013, we identified cohort studies reporting the incidence of de novo CRC after LT for PSC. The main outcome measure was CRC incidence rate (IR) per 1000 person-years after LT in all patients with PSC and in a subset of patients with PSC-IBD with an intact colon. According to a meta-analysis of 18 independent cohorts (69 cases of CRC among 1987 patients), the pooled IR of de novo CRC in patients with PSC after LT was 5.8 per 1000 person-years [95% confidence interval (CI) = 3.8-7.8]. According to a meta-analysis of 16 independent cohort studies (66 cases of CRC among 1017 patients), the IR of CRC in patients with PSC-IBD and an intact colon at the time of LT was 13.5 per 1000 person-years (95% CI = 8.7-18.2). A long duration of IBD and extensive colitis were identified as risk factors for CRC. Specific transplant-related factors that can increase the risk of CRC have not been identified. In conclusion, the risk of CRC remains high for patients who undergo LT for PSC, particularly in the subset of patients with associated IBD and an intact colon at the time of LT. Aggressive colonoscopic surveillance for CRC would be prudent for patients with PSC-IBD even after LT.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester MN
| | | | - Edward V. Loftus
- Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester MN
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48
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Liberal R, Zen Y, Mieli-Vergani G, Vergani D. Liver transplantation and autoimmune liver diseases. Liver Transpl 2013; 19:1065-77. [PMID: 23873751 DOI: 10.1002/lt.23704] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 06/23/2013] [Indexed: 12/16/2022]
Abstract
Liver transplantation (LT) is an effective treatment for patients with end-stage autoimmune liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis. Indications for LT for these diseases do not differ substantially from those used for other acute or chronic liver diseases. Despite the good outcomes reported, the recurrence of autoimmune liver disease is relatively common in the allograft. In addition, it has become apparent that autoimmunity and autoimmune liver disease can arise de novo after transplantation for nonautoimmune liver disorders. An awareness of the existence of recurrent autoimmune liver diseases and de novo autoimmune hepatitis after LT has important clinical implications because their management differs from the standard antirejection treatment and is similar to the management of classic autoimmune liver diseases in the native liver.
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Affiliation(s)
- Rodrigo Liberal
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, London, United Kingdom; Faculty of Medicine, University of Porto, Porto, Portugal
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49
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Singh S, Loftus EV, Talwalkar JA. Inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis. Am J Gastroenterol 2013; 108:1417-25. [PMID: 23896954 DOI: 10.1038/ajg.2013.163] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023]
Abstract
The course of inflammatory bowel disease (IBD) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is complex, with several IBD-, PSC-, and transplant-related factors interplaying with each other. Approximately one-third of patients with known IBD improve, and one-third paradoxically worsen, after LT for PSC. Active IBD, discontinuation of 5-aminosalicylates (5-ASA) at time of LT and tacrolimus-based immunosuppression may be associated with an unfavorable course of IBD after LT. Approximately 14-30% patients with PSC may develop de novo IBD 10 years after LT. LT confers a high risk of pouchitis after ileal pouch-anal anastomosis, although it may not be higher than baseline rates for PSC patients. The risk of colorectal cancer continues to be high after LT for PSC, and is higher in this cohort of patients with PSC-IBD, compared with patients undergoing LT for other indications. IBD does not adversely affect patient survival after LT, although the risk of recurrent PSC in the allograft may be higher in patients with IBD and an intact colon at time of LT. Standard therapy with 5-ASA and/or azathioprine may be appropriate for treatment of active IBD after LT and maintenance of remission. Anti-tumor necrosis factor-α agents are effective, but should be used with caution because of high risk of adverse events. The management of IBD after LT requires close coordination between transplant hepatologists and IBD experts.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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50
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Ohdan H. Is living donor liver transplantation really equivalent to deceased donor liver transplantation? Transpl Int 2013; 26:778-9. [PMID: 23855656 DOI: 10.1111/tri.12141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/10/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
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