Fulminant ulcerative colitis despite maximal immunosuppression following liver transplantation: a case report and literature review

Use of IBD Drugs in Patients With Hepatobiliary Comorbidities: Tips and Tricks

Advanced therapies (biologic agents and small molecules) for inflammatory bowel diseases (IBD) have radically changed the management of these diseases during the last decade. Data about these drugs in patients with hepatic disorders derive mainly from real-life studies, as these conditions often represent an exclusion criterion from pivotal drug developmental trials. However, IBD patients sometimes have concomitant liver diseases. Nonalcoholic fatty liver disease is the most prevalent hepatic comorbidity, whereas viral hepatitis, primary sclerosing cholangitis, primary biliary cholangitis, autoimmune hepatitis, and hepatic vascular disorders are less frequent. This review aimed at describing the real-life data about the use of advanced therapies for IBD in patients with concomitant hepatobiliary disorders. Hepatitis B virus and hepatitis C virus infections do not represent an absolute contraindication for novel IBD therapeutic agents. Data from the literature suggest a safe hepatobiliary profile of biologic agents and small molecules in the case of nonalcoholic fatty liver disease, autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cholangitis, and portal vein thrombosis. Consequently, although the liver disease does not affect a different therapeutic approach in patients with concomitant IBD and liver disease, a close risk/benefit analysis for each drug should be performed in these patients, especially in cirrhotic patients and in the postliver transplant setting.

Safety of Combination Biologic and Antirejection Therapy Post-Liver Transplantation in Patients With Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) post-liver transplant (LT) may have bowel inflammation requiring biologic therapy. We aimed to evaluate the safety of combination biologic and antirejection therapy in IBD patients after LT from a tertiary center case series and an updated literature review.

METHODS

Inflammatory bowel disease patients undergoing LT between 1985 and 2018 and requiring combination biologic and antirejection therapy post-LT were identified from the London Health Sciences Transplant Registry (Ontario, Canada). Safety outcomes were extracted by medical chart review. For an updated literature review, EMBASE, Medline, and CENTRAL were searched to identify studies evaluating the safety of combination biologic and antirejection therapy in IBD patients.

RESULTS

In the case series, 19 patients were identified. Most underwent LT for primary sclerosing cholangitis (PSC; 14/19, 74%) treated with anti-integrins (8/19, 42%) or tumor necrosis factor α (TNF) antagonists (6/19, 32%). Infections occurred in 11/19 (58%) patients, most commonly Clostridium difficile (4/19, 21%). Two patients required colectomy, and 1 patient required re-transplantation. In the literature review, 13 case series and 8 case reports reporting outcomes for 122 IBD patients treated with biologic and antirejection therapy post-LT were included. PSC was the indication for LT in 97/122 (80%) patients, and 91/122 (75%) patients were treated with TNF antagonists. Infections occurred in 32/122 (26%) patients, primarily Clostridium difficile (7/122, 6%).

CONCLUSIONS

Inflammatory bowel disease patients receiving combination biologic and antirejection therapy post-LT appeared to be at increased risk of Clostridium difficile. Compared with the general liver transplant population in the published literature, there was no increased risk of serious infection.

Clinical Course of Ulcerative Colitis After Liver Transplantation in Patients with Concomitant Primary Sclerosing Cholangitis and Ulcerative Colitis

BACKGROUND

The natural history of ulcerative colitis (UC) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) remains ill defined. This study aimed to evaluate the course of UC after LT for PSC.

METHODS

The course of UC, including the clinical colitis severity index, was evaluated in patients with concomitant PSC and UC who received LT for PSC-induced end-stage liver disease. A total of 167 (55.4%) patients with PSC had concurrent inflammatory bowel disease (IBD). Of 159 cases of IBD that started before LT, 152 (95.5%) had UC and 7 (4.5%) had Crohn's disease.

RESULTS

The mean duration of patient follow-up after LT was 47.7 ± 33.5 months. The simple clinical colitis activity index scores after LT showed no change in 15.8% of patients, decreased in 78.3%, and increased in 5.9%. Seventy-one (46.7%) patients required no change in their specific UC treatment after LT, whereas 12 (7.9%) had to use more aggressive treatments after LT. In 69 (45.4%) patients, treatment could be tapered although not discontinued. Multiple logistic regression analysis demonstrated that the duration of LT (odds ratio = 1.02; 95% confidence interval, 1.00-1.05, P = 0.03) was significantly associated with aggravation in the clinical course of UC after LT. Posttransplant cyclosporine exposure (odds ratio = 0.14; 95% confidence interval, 0.015-0.79, P = 0.028) and pretransplant body weight (odds ratio = 0.81; 95% confidence interval, 0.71-0.93, P = 0.003) demonstrated a protective effect.

CONCLUSIONS

Although the clinical course of UC remains unchanged or even improves in the majority of patients after LT, some may experience an aggressive course. The type of immunosuppression after transplantation can affect UC activity after LT. Cyclosporine may have some protective effects post-LT.

Management of ulcerative colitis pre- and post-liver transplant for primary sclerosing cholangitis: two case reports and review of literature

INTRODUCTION

Management of ulcerative colitis (UC) pre- and post-liver transplant for primary sclerosing cholangitis (PSC) can be challenging and complex. There are no formal guidelines, but there is a plethora of data regarding the use of medical and surgical treatment options, mainly from case series, retrospective data, and experience from transplant centers.

DISCUSSION

We present two cases of UC-PSC with variable severity of liver disease and discuss the available data on the management of UC pre- and post-liver transplant. A PubMed search was conducted using various keyword combinations looking for studies involving patients with UC-PSC pre- and post-liver transplant. We reviewed and summarized the available literature on the course of UC in patients with PSC-related cirrhosis pre- and post-transplant and risk of colorectal neoplasia post-transplant. Finally, we summarize the available data on the medical and surgical management of UC pre- and post-liver transplant and the effect of transplant on pouchitis. Current literature supports the use of medical therapies, including immunomodulators and biologic agents, following liver transplant. There is also literature supporting surgical management including total colectomy. A multidisciplinary, patient-centered approach is important when managing UC pre- and post-liver transplantation.

First case report of de novo ulcerative colitis developing after orthotopic liver transplantation successfully treated by granulocyte and monocyte apheresis

BACKGROUND

Immunosuppressants such as tacrolimus and cyclosporine are prescribed long-term after orthotopic liver transplantation (OLT) to prevent allograft rejection. Although these immunosuppressants are known to effectively control ulcerative colitis (UC), some post-OLT patients develop exacerbation of preexisting UC or de novo UC. Although aminosalicylates and corticosteroid courses are usually effective to treat such UC, several patients have developed uncontrollable disease and required colectomies.

CASE REPORT

We have reported a patient who developed de novo UC after OLT to treat liver cirrhosis and hepatocellular carcinoma associated with hepatitis B virus (HBV) infection. Existence of the HBV infection made us avoid to increase the corticosteroid dose or to use other immunosuppressants such as azathioprine or infliximab.

CONCLUSIONS

In this patient, granulocyte and monocyte apheresis was highly effective in terms of inducing remission of de novo UC. No adverse event was noted.

The safety and efficacy of antitumour necrosis factor-alpha therapy for inflammatory bowel disease in patients post liver transplantation: a case series

BACKGROUND

The role of antitumour necrosis factor-alpha (anti-TNF) therapy for inflammatory bowel disease (IBD) among liver transplant recipients is largely unknown given the rarity of this population and the paucity of literature on the subject.

AIM

To investigate the safety and efficacy of anti-TNF therapy for refractory IBD in the post liver transplant population.

METHODS

The liver transplant database at London Health Sciences Centre was searched to identify adult patients with IBD treated with anti-TNF therapy post transplantation.

RESULTS

Six patients (five men, one woman) were identified, aged 28-65. All patients had cadaveric orthotopic liver transplants. Four patients required transplantation due to primary sclerosing cholangitis, one due to autoimmune hepatitis, and one due to biliary atresia. Five patients suffered from Crohn's disease and the remaining patient from indeterminate colitis. All patients were treated with infliximab 5 mg/kg every 8 weeks after undergoing induction at weeks 0, 2 and 6, with the exception of one patient. The duration of infliximab therapy ranged from 8 weeks to 4 years. Four patients treated with infliximab experienced sustained improvement of their IBD symptoms post transplantation, as documented by Harvey-Bradshaw Index scores demonstrating clinical remission. Of the remaining two patients, neither had sustained improvement of their IBD with infliximab or subsequent adalimumab. One patient was diagnosed with systemic lupus erythematosus and another with colorectal adenocarcinoma following anti-TNF therapy. Otherwise, no side effects were attributed to anti-TNF therapy.

CONCLUSIONS

Based on this case series, anti-TNF therapy appears to be safe and effective for treating refractory IBD in patients post liver transplantation. These patients respond to anti-TNF therapy similar to those who have not been previously transplanted.