Liver transplantation and inflammatory bowel disease

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.

The liver in pediatric gastrointestinal disease

Hepatic involvement is often encountered in gastrointestinal (GI) diseases, in part because of the close anatomic and physiologic relations between the liver and GI tract. Drainage of the mesenteric blood supply to the portal vein permits absorbed and/or translocated nutrients, toxins, bacterial elements, cytokines, and immunocytes to gain hepatic access. Liver problems in digestive disorders may range from nonspecific hepatocellular enzyme elevations to significant pathologic processes that may progress to end-stage liver disease. Hepatobiliary manifestations of primary GI diseases in childhood and adolescence are not uncommon and include several well-described associations, such as sclerosing cholangitis with inflammatory bowel disease. Liver damage may also result from the effects of drugs used to treat GI diseases, for example, the hepatotoxicity of immunomodulatory therapies. This review highlights the important features of the hepatic and biliary abnormalities associated with 3 common pediatric GI conditions: inflammatory bowel disease, celiac disease, and cystic fibrosis.

Inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis

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.

Inflammatory bowel disease after liver transplantation: risk factors for recurrence and de novo disease

Inflammatory bowel disease (IBD) is associated with primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) and can recur or develop de novo after orthotopic liver transplantation (OLT). The aim of this study was to investigate the incidence and severity of IBD after liver transplantation and to perform a multivariate analysis for possible risk factors. In this retrospective study, 91 patients transplanted for PSC or AIH, without prior colectomy, were included. Sixty patients were transplanted for PSC, 31 for AIH. IBD activity before and after OLT and other possible risk factors were analysed in a multivariate model. Forty-nine patients (54%) had IBD before OLT. Forty patients (44%) had active IBD after transplantation: recurrence in 32 and de novo in 8. Cumulative risk for IBD after OLT was 15, 39 and 54% after 1, 5 and 10 years, respectively. In 59% of patients with IBD prior to OLT the disease was more active after transplantation. Risk factors for recurrent disease were: symptoms at time of OLT, short interval of IBD before OLT and use of tacrolimus. 5-aminosalicylates were protective. A cytomegalovirus positive donor/negative recipient combination increased the risk for de novo IBD.

Colorectal cancer in patients with inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis

BACKGROUND

Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) may have an increased risk of developing colorectal cancer (CRC) after liver transplantation (LT). We evaluated our patients with PSC after LT to identify risk factors for CRC and its impact on survival.

PATIENTS AND METHODS

A total of 152 patients (108 men, 100 with IBD) with PSC who underwent 173 LTs between 1986 and May 2000 were analyzed in three groups: (1) PSC without IBD (n=52); (2) PSC with colectomy (pre-LT and at LT) (n=17, colectomy pre-LT in 13 and simultaneous colectomy at LT in four); and (3) PSC with IBD and an intact colon (n=83). The following factors were studied: age, gender, liver, and renal biochemistry, international normalized ratio, Child-Pugh stage, operative time, blood use, hospital stay, immunosuppression, risk of CRC, retransplantation rate, and mortality.

RESULTS

The incidence of CRC after LT was 5.3% (8/152) compared with 0.6% (7/1,184) in non-PSC cases (P<0.001). All CRCs in the PSC group were in patients with IBD and an intact colon. The cumulative risk of developing CRC in the 83 patients with an intact colon and IBD was 14% and 17% after 5 and 10 years, respectively (PSC non-IBD group 0% risk after 10 years, P<0.06). The multivariate analysis showed three significant variables related to the risk of developing CRC: colonic dysplasia after LT (P<0.0003), duration of colitis more than 10 years (P<0.002), and pancolitis (P<0.004). The cause of death in patients with CRC was cancer related in 75% of cases with a reduced 5-year survival of 55% versus 75% without CRC (not significant).

CONCLUSION

Patients with PSC undergoing LT with a long history of ulcerative colitis and pancolitis have an increased risk of developing CRC with reduced survival. We advocate long-term aggressive colonic surveillance and colectomy in selected high-risk patients with longstanding severe colitis.

Inflammatory bowel disease and liver transplantation for primary sclerosing cholangitis

OBJECTIVES

To compare the outcome of liver transplantation in primary sclerosing cholangitis (PSC) patients with and without inflammatory bowel disease (IBD), and to analyse the influence of the transplantation on the course of IBD.

METHODS

Retrospective analysis of the data regarding PSC, IBD, and liver transplantation in all patients transplanted for PSC.

SETTING

Single university transplantation centre.

RESULTS

Thirty-one patients were transplanted for PSC, of whom 18 had IBD before liver transplantation. There were no differences in complication rate and outcome between patients with and patients without IBD. Before liver transplantation, the IBD course was active in three patients and quiescent in 14 patients (one patient was not evaluable). After liver transplantation, the course was active in five (one de-novo IBD) patients and quiescent in 13 patients. Exacerbations of IBD occurred in ten patients during treatment with steroids and a calcineurin blocker. Five patients with long-standing and extensive colitis developed colorectal neoplasia after liver transplantation (two colorectal cancer, two extensive dysplasia, one leiomyosarcoma).

CONCLUSIONS

Concomitant IBD had no detrimental influence on the outcome of liver transplantation in patients with PSC. The course of IBD was not altered after liver transplantation. Immunosuppression including steroids did not prevent exacerbations of IBD. The development of colorectal neoplasia is a serious threat to patients with IBD and PSC after liver transplantation.

Effect of liver transplantation on inflammatory bowel disease in patients with primary sclerosing cholangitis

This report investigates the influence of liver transplantation and concomitant immunosuppression on the course of progression of inflammatory bowel disease (IBD) and discusses statistical methodology appropriate for such settings. The data on 303 patients who underwent liver transplantation for primary sclerosing cholangitis (PSC) were analyzed using person-time analysis and Cox regression, with the duration of IBD as the time variable and transplantation as a segmented time-dependent covariate, to take into account both posttransplant and pretransplant history of IBD. The need for colectomy and appearance of colorectal cancer were taken as outcome measures. The only significant risk factor in the multivariate model for colectomy was transplantation itself, which increased the risk of colectomy due to intractable disease (Wald statistic; P =.001). None of the variables available for analysis were found to influence the risk of colon cancer significantly. Graphs showing the dependence of the instantaneous risk of cancer on the time from onset of IBD and its independence from the latter in the case of colectomy are presented. The use of a unique statistical methodology described for the first time in this setting led us to the somewhat surprising conclusion that transplantation and concomitant use of immunosuppression accelerate the progression of IBD. At the same time, transplantation does not affect the incidence of colorectal cancer. These results confirm the findings of some recent studies and can potentially shed new light on the disease pathogenesis.

Sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that progresses to death as a result of liver failure or cholangiocarcinoma. Susceptibility to PSC is associated with the HLA A1-B8-DR3 haplotype, and new associations with HLA C and tumor necrosis factor genes have been detected. A circulating antineutrophil cytoplasmic antibody is found in many patients with PSC, but its antigen or antigens have not been identified. Some studies suggest that this antigen may be an anti-nuclear membrane protein rather than cytoplasmic. Diagnosis of PSC is based on endoscopic retrograde cholangiography, but magnetic resonance cholangiography is a promising noninvasive alternative. Medical treatment remains elusive. In highly selected patients, endoscopic or even surgical treatment can be tried. Orthotopic liver transplantation remains the only effective therapy, but inflammatory bowel disease may run a more aggressive clinical course after this procedure. Sclerosing cholangitis may recur after transplantation, but this has had no clinical implications to date.

Follow-up after liver transplantation for primary sclerosing cholangitis: effects on survival, quality of life, and colitis

BACKGROUND

Except for primary biliary cirrhosis, primary sclerosing cholangitis (PSC) is now the commonest indication for liver transplantation in Sweden. There are several specific problems related to post-transplantation life in these patients.

METHODS

We analyzed a 10-year cohort of 47 patients transplanted at our center.

RESULTS

Incidental biliary carcinoma was diagnosed in 13%,, with a 2-year survival of only 17%, compared with 70% in the other patients. The 2-year survival has improved considerably (to 82%) in recent years. Quality of life was much or slightly improved in 80%. The colitis was much or slightly improved in 65%, with some deterioration in only 6%. No patient developed colonic carcinoma. Previous biliary tract surgery was identified as a risk factor for a worse 1-year mortality.

CONCLUSIONS

Liver transplantation for PSC is now associated with a high survival rate and an improvement in the quality of life and course of ulcerative colitis. Previous biliary tract surgery is a risk factor for non-survival.