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Sierra L, Marenco-Flores A, Barba R, Goyes D, Ferrigno B, Diaz W, Medina-Morales E, Saberi B, Patwardhan VR, Bonder A. Influence of socioeconomic factors on liver transplant survival outcomes in patients with autoimmune liver disease in the United States. Ann Hepatol 2024; 29:101283. [PMID: 38151060 DOI: 10.1016/j.aohep.2023.101283] [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: 08/29/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES Autoimmune liver diseases (AILDs): autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) have different survival outcomes after liver transplant (LT). Outcomes are influenced by factors including disease burden, medical comorbidities, and socioeconomic variables. MATERIALS AND METHODS Using the United Network for Organ Sharing database (UNOS), we identified 13,702 patients with AILDs listed for LT between 2002 and 2021. Outcomes of interest were waitlist removal, post-LT patient survival, and post- LT graft survival. A stepwise multivariate analysis was performed adjusting for transplant recipient gender, race, diabetes mellitus, model for end-stage liver disease (MELD) score, and additional social determinants including the presence of education, reliance on public insurance, working for income, and U.S. citizenship status. RESULTS Lack of college education and having public insurance increased the risk of waitlist removal (HR, 1.13; 95 % CI, 1.05-1.23, and HR, 1.09; 95 % CI, 1.00-1.18; respectively), and negatively influenced post-LT patient survival (HR, 1.16; 95 % CI, 1.06-1.26, and HR, 1.15; 95 % CI, 1.06-1.25; respectively) and graft survival (HR, 1.13; 95 % CI, 1.05-1.23, and HR, 1.15; 95 % CI, 1.06-1.25; respectively). Not working for income proved to have the greatest detrimental impact on both patient survival (HR, 1.41; 95 % CI, 1.24-1.6) and graft survival (HR, 1.21; 95 % CI, 1.09-1.35). CONCLUSIONS Our study highlights that lack of college education and public insurance have a detrimental impact on waitlist mortality, patient survival, and graft survival. Not working for income negatively affects post-LT survival outcomes. Not having U.S. citizenship does not affect survival outcomes in AILDs patients.
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Affiliation(s)
- Leandro Sierra
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Ana Marenco-Flores
- 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
| | - Daniela Goyes
- Division of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, USA
| | - Bryan Ferrigno
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Wilfor Diaz
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Esli Medina-Morales
- Department of Medicine, Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology, and Nutrition, 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
| | - Alan Bonder
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Grancini V, Cogliati I, Alicandro G, Gaglio A, Gatti S, Donato MF, Orsi E, Resi V. Assessment of hepatic fibrosis with non-invasive indices in subjects with diabetes before and after liver transplantation. Front Endocrinol (Lausanne) 2024; 15:1359960. [PMID: 38505744 PMCID: PMC10948411 DOI: 10.3389/fendo.2024.1359960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/21/2024] [Indexed: 03/21/2024] Open
Abstract
Introduction One of the most common complications of cirrhosis is diabetes, which prevalence is strictly related to severity of hepatopathy. Actually, there are no data on the persistence of post-transplant glucose abnormalities and on a potential impact of diabetes on development of fibrosis in the transplanted liver. To this aim, we evaluated liver fibrosis in cirrhotic subjects before and after being transplanted. Methods The study included 111 individuals who had liver transplantation. The assessment was performed before and two years after surgery to investigate a potential impact of the persistence of diabetes on developing de novo fibrosis in the transplanted liver. The degree of fibrosis was assessed using the Fibrosis Index Based on 4 Factors (FIB-4) and the Aspartate to Platelet Ratio Index (APRI). Results At pre-transplant evaluation, 63 out of 111 (56.8%) subjects were diabetic. Diabetic subjects had higher FIB-4 (Geometric mean, 95% confidence interval: 9.74, 8.32-11.41 vs 5.93, 4.71-7.46, P<0.001) and APRI (2.04, 1.69-2.47 vs 1.18, 0.90-1.55, P<0.001) compared to non-diabetic subjects. Two years after transplantation, 39 out of 111 (35.1%) subjects remained with diabetes and continued to show significantly higher FIB-4 (3.14, 2.57-3.82 vs 1.87, 1.55-2.27, P<0.001) and APRI (0.52, 0.39-0.69 vs 0.26, 0.21-0.32, P<0.001) compared to subjects without diabetes. Discussion Thus, persistence of diabetes after surgery is a possible risk factor for an evolution to fibrosis in the transplanted liver, potentially leading to worsened long-term outcomes in this population.
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Affiliation(s)
- Valeria Grancini
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Cogliati
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianfranco Alicandro
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Department of Pediatrics, Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessia Gaglio
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Francesca Donato
- Hepatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuela Orsi
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Resi
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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3
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Adjei M, Kim IK. Current Use of Immunosuppression in Liver Transplantation. Surg Clin North Am 2024; 104:11-25. [PMID: 37953030 DOI: 10.1016/j.suc.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Since the first successful liver transplant in 1967, immunosuppression has allowed liver transplantation to become the standard treatment of end-stage liver disease. Over the decades, the rates of rejection have decreased, and patient survival outcomes have significantly improved in large part due to the introduction and advancements of immunosuppression medications. However, the adverse effects associated with long-term immunosuppression have created new challenges facing liver transplantation and added significantly to posttransplantation morbidity. This review presents the data and rationale for immunosuppression approaches, addresses the main controversies related to immunosuppression in liver transplantation, and explores some of the newer advancements in immunosuppressive drug therapy.
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Affiliation(s)
- Michie Adjei
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8900 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Irene K Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8900 Beverly Boulevard, Los Angeles, CA 90048, USA.
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4
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Lee DU, Ponder R, Sandlow S, Yoo A, Lee KJ, Chou H, Fan GH, Urrunaga NH. The impact of recipient and donor gender-match and mismatch on the post-liver transplant outcomes of patients with primary biliary cholangitis. Dig Liver Dis 2023; 55:1242-1252. [PMID: 37085440 PMCID: PMC10524091 DOI: 10.1016/j.dld.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/05/2023] [Accepted: 03/25/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND & AIMS In this study, we evaluate the effects of donor gender on post-liver transplant (LT) prognosis. We specifically consider patients with primary biliary cholangitis (PBC). METHODS The 2005 to 2019 UNOS transplant registry was used to select patients with PBC. The study cohort was stratified by donor gender. All-cause mortality and graft failure hazards were compared using iterative Cox regression analysis. Subanalyses were performed to evaluate gender mismatch on post-LT prognosis. RESULTS There were 1885 patients with PBC. Of these cases, 965 entries had male donors and 920 had female donors. Median follow-up was 4.82 (25-75% IQR 1.83-8.93) years. Having a male donor was associated with higher all-cause mortality (aHR 1.28 95%CI 1.03-1.58) and graft failure (aHR 1.70 95%CI 1.02-2.82). Corresponding incidence rates were also relatively increased. In the sub-analysis of female recipients (n = 1581), those with gender-mismatch (male donors, n = 769) were associated with higher all-cause mortality (aHR 1.41 95%CI 1.11-1.78) but not graft failure. In the male recipient subanalysis (n = 304), no associations were found between gender-mismatch (female donors, n = 108) and all-cause mortality or graft failure. CONCLUSION This study shows that recipients who have male donors experienced higher rates of all-cause mortality following LT. This finding was consistent in the female recipient-male donor mismatch cohort.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA.
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Sarah Sandlow
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Ashley Yoo
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Harrison Chou
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Gregory Hongyuan Fan
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Nathalie Helen Urrunaga
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA
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5
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Oden-Brunson H, McDonald MF, Godfrey E, Keeling SS, Cholankeril G, Kanwal F, O'Mahony C, Goss J, Rana A. Is Liver Transplant Justified at Any MELD Score? Transplantation 2023; 107:680-692. [PMID: 36367923 DOI: 10.1097/tp.0000000000004345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Assessing the survival benefit of transplantation in patients with end-stage liver disease is critical in guiding the decision-making process for liver allocation. Previous studies established increased mortality risk for those transplanted below Model for End-Stage Liver Disease (MELD) 18 compared with candidates who remained on the waitlist; however, improved outcomes of liver transplantation and a changing landscape in the donor supply warrant re-evaluation of this idea. METHODS Using the United Network for Organ Sharing database, we analyzed 160 290 candidates who were waitlisted for liver transplantation within MELD cohorts. We compared patients who were transplanted in a MELD cohort with those listed but not transplanted in that listed MELD cohort with an intent-to-treat analysis. RESULTS Those transplanted at a MELD between 6 and 11 showed a 31% reduction in adjusted mortality (HR = 0.69 [95% confidence interval [CI], 0.66-0.75]; P < 0.001) compared with the intent-to-treat cohort in a Cox multivariate regression. This mortality benefit increased to a 37% adjusted reduction for those transplanted at MELD between 12 and 14 (HR = 0.63 [95% CI, 0.60-0.66]; P < 0.001) and a 46% adjusted reduction for those transplanted at a MELD between 15 and 17 (HR = 0.54 [95% CI, 0.52-0.57]; P < 0.001), effects that remained in sensitivity analyses excluding patients with hepatocellular carcinoma, encephalopathy, ascites, and variceal bleeds. A multivariate analysis of patients transplanted at MELD < 18 found younger age and cold ischemia time were protective, whereas older age, lower functional status, and socioeconomic factors increased mortality risk. CONCLUSIONS These findings challenge the current practice of deferring liver transplants below a particular MELD score by demonstrating survival benefits for most transplant patients at the lowest MELD scores and providing insight into who benefits within these subgroups.
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Affiliation(s)
| | - Malcolm F McDonald
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX
| | | | | | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Christine O'Mahony
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - John Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
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6
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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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Do Patients with Autoimmune Conditions Have Less Access to Liver Transplantation despite Superior Outcomes? J Pers Med 2022; 12:jpm12071159. [PMID: 35887656 PMCID: PMC9320508 DOI: 10.3390/jpm12071159] [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] [Received: 06/15/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
Orthotopic liver transplantation (OLT) is a lifesaving therapy for patients with irreversible liver damage caused by autoimmune liver diseases (AutoD) including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). Currently, it is unclear how access to transplantation differs among patients with various etiologies of liver disease. Our aim is to evaluate the likelihood of transplant and the long-term patient and graft survival after OLT for each etiology for transplantation from 2000 to 2021. We conducted a large retrospective study of United Network for Organ Sharing (UNOS) liver transplant patients in five 4-year eras with five cohorts: AutoD (PBC, PSC, AIH cirrhosis), alcohol-related liver disease (ALD), hepatocellular carcinoma (HCC), viral hepatitis, and nonalcoholic steatohepatitis (NASH). We conducted a multivariate analysis for probability of transplant. Intent-to-treat (ITT) analysis was performed to assess the 10-year survival differences for each listing diagnosis while accounting for both waitlist and post-transplant survival. Across all eras, autoimmune conditions had a lower adjusted probability of transplant of 0.92 (0.92, 0.93) compared to ALD 0.97 (0.97, 0.97), HCC 1.08 (1.07, 1.08), viral hepatitis 0.99 (0.99, 0.99), and NASH 0.99 (0.99, 1.00). Patients with AutoD had significantly better post-transplant patient and graft survival than ALD, HCC, viral hepatitis, and NASH in each and across all eras (p-values all < 0.001). Patients with AutoD had superior ITT survival (p-value < 0.001, log rank test). In addition, the waitlist survival for patients with AutoD compared to other listing diagnoses was improved with the exception of ALD, which showed no significant difference (p-value = 0.1056, log rank test). Despite a superior 10-year graft and patient survival in patients transplanted for AutoD, patients with AutoD have a significantly lower probability of receiving a liver transplant compared to those transplanted for HCC, ALD, viral hepatitis, and NASH. Patients with AutoD may benefit from improved liver allocation while maintaining superior waitlist and post-transplant survival. Decreased access in spite of appropriate outcomes for patients poses a significant risk for increased morbidity for patients with AutoD.
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9
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Zhou K, Dodge JL, Xu E, Emamaullee J, Kahn JA. Excess liver transplant waitlist mortality for patients with primary biliary cholangitis under MELD-Na allocation. Clin Transplant 2021; 36:e14527. [PMID: 34731515 DOI: 10.1111/ctr.14527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/30/2021] [Accepted: 10/22/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Historically, patients with primary biliary cholangitis (PBC) experience waitlist mortality and low rates of liver transplant (LT). Herein, the impact of MELD-Na based allocation on PBC waitlist mortality was examined. METHODS Adult patients with PBC were compared to those with alcohol-related liver disease (ALD) or non-alcoholic steatohepatitis (NASH) listed for LT from 2013 to 2019 in OPTN. Competing risk regression evaluated waitlist mortality in the MELD and MELD-Na eras using propensity score weights. RESULTS Overall, 1508 patients with PBC, 13581 with ALD, and 10455 with NASH were examined. In the MELD-Na era, 24-month cumulative incidence of waitlist mortality for PBC was 23.0% (95%CI 19.7-26.5%), ALD 13.9% (95%CI 13.1-14.8%), and NASH 20.0% (95%CI 18.9-21.2%). Using propensity score weights, adjusted risk of waitlist mortality was higher for PBC versus ALD (HR = 1.45, 95%CI 1.22-1.71) and NASH (HR = 1.32, 95%CI 1.14-1.55). Furthermore, among PBC, waitlist mortality risk per five-point elevation in MELD-Na (HR = 1.22, 95%CI 1.11-1.35) and Karnofsky score ≤30% (HR = 2.02, 95%CI 1.39-2.92) was significantly higher than among ALD (HR = 1.08, 95%CI 1.04-1.13; HR = 1.28, 95%CI 1.10-1.49) and NASH (HR = 1.05, 95%CI 1.00-1.09; HR = 1.16, 95%CI .99-1.37; all P-interactions < .05). CONCLUSIONS The MELD-Na score continues to underestimate risk of waitlist death for patients with PBC relative to ALD and NASH and highlights need for additional score modifications or exceptions.
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Affiliation(s)
- Kali Zhou
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer L Dodge
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Edison Xu
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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10
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Trivedi PJ, Hirschfield GM. Recent advances in clinical practice: epidemiology of autoimmune liver diseases. Gut 2021; 70:1989-2003. [PMID: 34266966 DOI: 10.1136/gutjnl-2020-322362] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/24/2021] [Indexed: 12/13/2022]
Abstract
Autoimmune liver diseases are chronic inflammatory hepatobiliary disorders that when classically defined encompass three distinctive clinical presentations; primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH). Meaningful changes in disease epidemiology are reported, with increasing incidence and prevalence of AIH and PSC in Europe, and rising prevalence of PBC across Europe, North America and the Asia-Pacific region. However, there appears to be very significant global variation with contemporary incidence rates of disease per 100 000 ranging from 0.84 to 2.75 for PBC, 0.1 to 4.39 for PSC and 0.4 to 2.39 for AIH. Prevalence corresponds, and per 100 000 estimates for PBC range from 1.91 to 40.2, for PSC between 0.78 and 31.7 and for AIH from 4.8 to 42.9. Population-based studies and multicentre observational cohort series provide improved understanding of the clinical course that patients experience, highlighting variations in presenting phenotypes geographically and temporally. Collectively, while autoimmune liver diseases are rare, the clinical burden is disproportionately high relative to population incidence and prevalence. Age, sex and race also impact clinical outcomes, and patient morbidity and mortality are reflected by high need for gastroenterology, hepatology and organ transplant services.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
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11
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Pedersen MR, Greenan G, Arora S, Murali AR, Mayo MJ. Ursodeoxycholic Acid Decreases Incidence of Primary Biliary Cholangitis and Biliary Complications After Liver Transplantation: A Meta-Analysis. Liver Transpl 2021; 27:866-875. [PMID: 33185320 DOI: 10.1002/lt.25935] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
After liver transplantation (LT), the role of ursodeoxycholic acid (UDCA) is not well characterized. We examine the effect of UDCA after LT in the prophylaxis of biliary complications (BCs) in all-comers for LT and the prevention of recurrent primary biliary cholangitis (rPBC) in patients transplanted for PBC. Two authors searched PubMed/MEDLINE and Embase from January 1990 through December 2018 to identify all studies that evaluate the effectiveness of UDCA prophylaxis after LT for BCs in all LT recipients and rPBC after LT in patients transplanted for PBC. Odds ratios (ORs) were calculated for endpoints of the BC study. Pooled recurrence rates were calculated for rPBC. The study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A total of 15 studies were included, comprising 530 patients in the analysis for BCs and 1727 patients in the analysis for rPBC. UDCA was associated with decreased odds of BCs (OR, 0.70; 95% confidence interval [CI], 0.52-0.93; P = 0.01) and biliary stones and sludge (OR, 0.49; 95% CI, 0.24-0.77; P = 0.004). Prophylactic use of UDCA did not affect the odds of biliary stricture. For patients transplanted for PBC, the rate of rPBC was lower with the prophylactic use of UDCA (IR 16.7%; 95% CI, 0.114%-22.0%; I2 = 36.1%) compared with not using prophylactic UDCA (IR 23.1%; 95% CI, 16.9%-29.3%; I2 = 86.7%). UDCA after LT reduces the odds of BC and bile stones and sludge in all-comer LT recipients and reduces or delays the incidence of rPBC in patients transplanted for PBC. UDCA use after LT could be considered in all LT recipients to reduce the odds of BC and may be particularly beneficial for patients transplanted for PBC by reducing the incidence of rPBC.
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Affiliation(s)
- Mark R Pedersen
- Division of Digestive and Liver Diseases, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Garrett Greenan
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Sumant Arora
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
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12
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Abstract
Autoimmune liver diseases are characterized by immune-mediated inflammation and eventual destruction of the hepatocytes and the biliary epithelial cells. They can progress to irreversible liver damage requiring liver transplantation. The post-liver transplant goals of treatment include improving the recipient’s survival, preventing liver graft-failure, and decreasing the recurrence of the disease. The keystone in post-liver transplant management for autoimmune liver diseases relies on identifying which would be the most appropriate immunosuppressive maintenance therapy. The combination of a steroid and a calcineurin inhibitor is the current immunosuppressive regimen of choice for autoimmune hepatitis. A gradual withdrawal of glucocorticoids is also recommended. On the other hand, ursodeoxycholic acid should be initiated soon after liver transplant to prevent recurrence and improve graft and patient survival in primary biliary cholangitis recipients. Unlike the previously mentioned autoimmune diseases, there are not immunosuppressive or disease-modifying agents available for patients with primary sclerosing cholangitis. However, colectomy and annual colonoscopy are key components during the post-liver transplant period.
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13
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Li X, Peng J, Ouyang R, Yang Y, Yu C, Lin H. Risk factors for recurrent primary biliary cirrhosis after liver transplantation: A systematic review and meta-analysis. Dig Liver Dis 2021; 53:309-317. [PMID: 33380381 DOI: 10.1016/j.dld.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/03/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recurrent primary biliary cirrhosis (PBC) is frequently observed in patients with PBC after liver transplantation (LT). We performed a meta-analysis to evaluate the risk factors for PBC recurrence. METHODS We searched the EMBASE, PubMed and the Cochrane Library databases for studies published before August 2020. Studies that identified the risk factors of PBC recurrence were eligible for inclusion. We extracted the hazard ratio (HR) data with 95% confidence intervals (CI) for the risk factors. RESULTS Our meta-analysis included 6 studies, which comprised 3184 patients (88.5% females) who underwent liver transplantation from 1982 to 2017, and of these patients, 935 (29.4%) developed PBC recurrence. The use of tacrolimus (HR = 2.62, 95% CI = 1.35, 5.09) and preventive ursodeoxycholic acid (UDCA) (HR = 0.40, 95% CI = 0.28, 0.57) were significantly associated with the risk of PBC recurrence based on the pooled analysis of the results obtained from the multivariate analysis. CONCLUSIONS The use of tacrolimus is associated with an increased risk of PBC recurrence. Preventive UDCA after LT for PBC can help to prevent disease recurrence.
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Affiliation(s)
- Xiaocheng Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, Hunan, PR China
| | - Jing Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, Hunan, PR China
| | - Renbin Ouyang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, Hunan, PR China
| | - Yaowei Yang
- Department of General Surgery, University-Town Hospital of Chongqing Medical University, Chongqing, PR China
| | - Chengdong Yu
- Department of Epidemiology & Medical Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, PR China
| | - Huapeng Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China.
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14
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Abstract
Primary biliary cholangitis (PBC) causes chronic and persistent cholestasis in the liver, eventually resulting in cirrhosis and hepatic failure without appropriate treatment. PBC mainly develops in middle-aged women, but it is also common in young women and men. PBC is considered a model of autoimmune disease because of the presence of disease-specific autoantibodies, that is, antimitochondrial antibodies (AMAs), intense infiltration of mononuclear cells into the bile ducts, and a high prevalence of autoimmune diseases such as comorbidities. Histologically, PBC is characterized by degeneration and necrosis of intrahepatic biliary epithelial cells surrounded by a dense infiltration of mononuclear cells, coined as chronic non-suppurative destructive cholangitis, which leads to destructive changes and the disappearance of small- or medium-sized bile ducts. Since 1990, early diagnosis with the detection of AMAs and introduction of ursodeoxycholic acid as first-line treatment has greatly altered the clinical course of PBC, and liver transplantation-free survival of patients with PBC is now comparable to that of the general population.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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15
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Dyson JK, Jones DEJ. UDCA prophylaxis for post-transplant PBC recurrence prevention: Time to change practice. J Hepatol 2020; 73:499-501. [PMID: 32576471 DOI: 10.1016/j.jhep.2020.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/04/2022]
Affiliation(s)
- Jessica K Dyson
- Translational and Clinical Research Institute, Newcastle University & Liver Unit, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - David E J Jones
- Translational and Clinical Research Institute, Newcastle University & Liver Unit, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK.
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16
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Corpechot C, Chazouillères O, Belnou P, Montano-Loza AJ, Mason A, Ebadi M, Eurich D, Chopra S, Jacob D, Schramm C, Sterneck M, Bruns T, Reuken P, Rauchfuss F, Roccarina D, Thorburn D, Gerussi A, Trivedi P, Hirschfield G, McDowell P, Nevens F, Boillot O, Bosch A, Giostra E, Conti F, Poupon R, Parés A, Reig A, Donato MF, Malinverno F, Floreani A, Russo FP, Cazzagon N, Verhelst X, Goet J, Harms M, van Buuren H, Hansen B, Carrat F, Dumortier J. Long-term impact of preventive UDCA therapy after transplantation for primary biliary cholangitis. J Hepatol 2020; 73:559-565. [PMID: 32275981 DOI: 10.1016/j.jhep.2020.03.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/06/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Recurrence of primary biliary cholangitis (PBC) after liver transplantation (LT) is frequent and can impair graft and patient survival. Ursodeoxycholic acid (UDCA) is the current standard therapy for PBC. We investigated the effect of preventive exposure to UDCA on the incidence and long-term consequences of PBC recurrence after LT. METHODS We performed a retrospective cohort study in 780 patients transplanted for PBC, between 1983-2017 in 16 centers (9 countries), and followed-up for a median of 11 years. Among them, 190 received preventive UDCA (10-15 mg/kg/day). The primary outcome was histological evidence of PBC recurrence. The secondary outcomes were graft loss, liver-related death, and all-cause death. The association between preventive UDCA and outcomes was quantified using multivariable-adjusted Cox and restricted mean survival time (RMST) models. RESULTS While recurrence of PBC significantly shortened graft and patient survival, preventive exposure to UDCA was associated with reduced risk of PBC recurrence (adjusted hazard ratio [aHR] 0.41; 95% CI 0.28-0.61; p <0.0001), graft loss (aHR 0.33; 95% CI 0.13-0.82; p <0.05), liver-related death (aHR 0.46; 95% CI 0.22-0.98; p <0.05), and all-cause death (aHR 0.69; 95% CI 0.49-0.96; p <0.05). On RMST analysis, preventive UDCA led to a survival gain of 2.26 years (95% CI 1.28-3.25) over a period of 20 years. Exposure to cyclosporine rather than tacrolimus had a complementary protective effect alongside preventive UDCA, reducing the cumulative incidence of PBC recurrence and all-cause death. CONCLUSIONS Preventive UDCA after LT for PBC is associated with a reduced risk of disease recurrence, graft loss, and death. A regimen combining cyclosporine and preventive UDCA is associated with the lowest risk of PBC recurrence and mortality. LAY SUMMARY Recurrence of primary biliary cholangitis after liver transplantation is frequent and can impair graft and patient survival. We performed the largest international study of transplanted patients with primary biliary cholangitis to date. Preventive administration of ursodeoxycholic acid after liver transplantation was associated with reduced risk of disease recurrence, graft loss, liver-related and all-cause mortality. A regimen combining cyclosporine and preventive ursodeoxycholic acid was associated with the best outcomes.
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Affiliation(s)
- Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France.
| | - Olivier Chazouillères
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Pierre Belnou
- Public Health Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris; Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Paris, France
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Andrew Mason
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Maryam Ebadi
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Dennis Eurich
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Sascha Chopra
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Dietmar Jacob
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Christoph Schramm
- Department of Medicine I and Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Medicine I and Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tony Bruns
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany; Department of Internal Medicine IV, Integrated Research and Treatment Center for Sepsis Control and Care, University Hospital, Jena, Germany
| | - Philipp Reuken
- Department of Internal Medicine IV, Integrated Research and Treatment Center for Sepsis Control and Care, University Hospital, Jena, Germany
| | - Falk Rauchfuss
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Davide Roccarina
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Douglas Thorburn
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Alessio Gerussi
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Gideon Hirschfield
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom; Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Patrick McDowell
- Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Frederik Nevens
- Division Liver and Biliopancreatic Disorders, University Hospitals KU, Leuven, Belgium
| | - Olivier Boillot
- Transplant Hepatology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
| | - Alexie Bosch
- Transplant Hepatology Unit, Croix Rousse Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
| | - Emiliano Giostra
- Hepatology and Gastroenterology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Filomena Conti
- Transplant Hepatology Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Raoul Poupon
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Albert Parés
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain
| | - Anna Reig
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain
| | - Maria Francesca Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Federica Malinverno
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Jorn Goet
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maren Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Fabrice Carrat
- Public Health Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris; Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Paris, France
| | - Jérôme Dumortier
- Transplant Hepatology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
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17
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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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18
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Yoshino K, Taura K, Okuda Y, Ikeno Y, Uemoto Y, Nishio T, Yamamoto G, Tanabe K, Koyama Y, Seo S, Kaido T, Okajima H, Imai T, Tanaka S, Uemoto S. Efficiency of acoustic radiation force impulse imaging for the staging of graft fibrosis after liver transplantation. Hepatol Res 2019; 49:394-403. [PMID: 30471140 DOI: 10.1111/hepr.13289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023]
Abstract
AIM Liver biopsy is the gold standard for assessing liver fibrosis (LF) after liver transplantation (LT), but its invasiveness limits its utility. This study aimed to evaluate the usefulness of liver stiffness measurement (LSM) using acoustic radiation force impulse (ARFI) imaging to assess LF after LT. METHODS Between September 2013 and January 2017, 278 patients who underwent liver biopsy after LT in Kyoto University Hospital (Kyoto, Japan) were prospectively enrolled. Liver stiffness measurement was carried out using ARFI imaging; its value was expressed as shear wave velocity (Vs) [m/s]. The LF was evaluated according to METAVIR score (F0-F4). The diagnostic performance of Vs for F2≤ and F3≤ was assessed and compared with that of laboratory tests using receiver operating characteristic (ROC) analysis. RESULTS The median Vs values increased according to the progression of LF (F0, 1.18 (0.78-1.92); F1, 1.35 (0.72-3.54); F2, 1.55 (1.05-3.37); F3, 1.84 (1.41-2.97)). The Vs had the highest area under the ROC curve (AUROC) for the prediction of both F2 ≤ and F3 ≤ fibrosis (F2, 0.77; and F3, 0.85). With the cut-off value of Vs >1.31, sensitivity, specificity, positive predictive value, and negative predictive value were 89.4%, 53.3%, 37.3%, and 94.2% in predicting F2≤, respectively. Shear wave velocity diagnosed LF better than any laboratory tests regardless of the type of primary disease. CONCLUSIONS Acoustic radiation force impulse helps to assess graft LF after LT. The high sensitivity suggested that ARFI might reduce the frequency of liver biopsies by detecting patients who are unlikely to have significant fibrosis after LT. (Unique trial no. UMIN R000028296.).
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Affiliation(s)
- Kenji Yoshino
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Yukihiro Okuda
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Yoshinobu Ikeno
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Yusuke Uemoto
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Takahiro Nishio
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Gen Yamamoto
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Kazutaka Tanabe
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Yukinori Koyama
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
| | - Takumi Imai
- Department of Clinical Biostatistics/Clinical Biostatistics Course, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics/Clinical Biostatistics Course, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan
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20
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Montano-Loza AJ, Hansen BE, Corpechot C, Roccarina D, Thorburn D, Trivedi P, Hirschfield G, McDowell P, Poupon R, Dumortier J, Bosch A, Giostria E, Conti F, Parés A, Reig A, Floreani A, Russo FP, Goet JC, Harms MH, van Buuren H, Van den Ende N, Nevens F, Verhelst X, Donato MF, Malinverno F, Ebadi M, Mason AL. Factors Associated With Recurrence of Primary Biliary Cholangitis After Liver Transplantation and Effects on Graft and Patient Survival. Gastroenterology 2019; 156:96-107.e1. [PMID: 30296431 DOI: 10.1053/j.gastro.2018.10.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 09/18/2018] [Accepted: 10/02/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) frequently recurs after liver transplantation. We evaluated risk factors associated with recurrence of PBC and its effects on patient and graft survival in a multicenter, international cohort (the Global PBC Study Group). METHODS We collected demographic and clinical data from 785 patients (89% female) with PBC who underwent liver transplantation (mean age, 54 ± 9 years) from February 1983 through June 2016, among 13 centers in North America and Europe. Results from biochemical tests performed within 12 months of liver transplantation were analyzed to determine whether markers of cholestasis could identify patients with recurrence of PBC (based on histologic analysis). Patients were followed for a median 6.9 years (interquartile range, 6.1-7.9 years). RESULTS PBC recurred in 22% of patients after 5 years and 36% after 10 years. Age at diagnosis <50 years (hazard ratio [HR], 1.79; 95% CI, 1.36-2.36; P < .001), age at liver transplantation <60 years (HR, 1.39; 95% CI, 1.02-1.90; P = .04), use of tacrolimus (HR, 2.31; 95% CI, 1.72-3.10; P < .001), and biochemical markers of severe cholestasis (bilirubin ≥100 μmol or alkaline phosphatase >3-fold the upper limit of normal) at 6 months after liver transplantation (HR, 1.79; 95% CI, 1.16-2.76; P = .008) were associated with higher risk of PBC recurrence, whereas use of cyclosporine reduced risk of PBC recurrence (HR, 0.62; 95% CI, 0.46-0.82; P = .001). In multivariable Cox regression with time-dependent covariate, recurrence of PBC significantly associated with graft loss (HR, 2.01; 95% CI, 1.16-3.51; P = .01) and death (HR, 1.72; 95% CI, 1.11-2.65; P = .02). CONCLUSIONS Younger age at the time of diagnosis with PBC or at liver transplantation, tacrolimus use, and biochemical markers of cholestasis after liver transplantation are associated with PBC recurrence. PBC recurrence reduces odds of graft and patient survival. Strategies are needed to prevent PBC recurrence or reduce its negative effects.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada.
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases, Saint-Antoine Hospital, Paris, France
| | - Davide Roccarina
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Douglas Thorburn
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Gideon Hirschfield
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom; Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Patrick McDowell
- Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Raoul Poupon
- Reference Center for Inflammatory Biliary Diseases, Saint-Antoine Hospital, Paris, France
| | - Jerome Dumortier
- Liver Transplant Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexie Bosch
- Liver Transplant Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Emiliano Giostria
- Hepatology and Gastroenterology Department, University Hospitals of Geneva, Geneva, Switzerland
| | - Filomena Conti
- Liver Transplant Unit, Pitié-Salpêtrière Hôpital, Paris France
| | - Albert Parés
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona Spain
| | - Anna Reig
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Jorn C Goet
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Frederik Nevens
- Division Liver and Biliopancreatic Disorders, Leuven, Belgium
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Maria Francesca Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Federica Malinverno
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Maryam Ebadi
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew L Mason
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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21
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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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Nevens F. PBC-transplantation and disease recurrence. Best Pract Res Clin Gastroenterol 2018; 34-35:107-111. [PMID: 30343704 DOI: 10.1016/j.bpg.2018.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/04/2018] [Indexed: 02/08/2023]
Abstract
Despite near universal use of ursodeoxycholic acid (UDCA) several patients with PBC still progress to liver transplant (LT) or death. Pruritus and fatigue are the most common symptoms. Liver transplantation for pruritus is highly effective but fatigue will not disappear in the majority of the patients. In contrast to other liver diseases, portal hypertension may develop in pre-cirrhotic patients with PBC. Patients with PBC have an incidence rate of 3.4 hepatocellular carcinoma cases for every 1000 patient-years and risk factors are advanced stage of the disease and male sex. For the appropriate timing of LT the utility of prognostic models (bilirubin, Mayo risk score and MELD, in particular) and standard exception points in case of HCC are established. However, recent data from different part of the world demonstrated that PBC patients compared to patients with PSC have higher waiting-list mortality. Hyperlipidemia can be present in up to 80% of the patients but there is no evidence for an elevated cardiovascular risk, certainly not in relationship with LT. Patients transplanted for PBC suffer more frequently from acute cellular and also late cellular rejection. However, 5-year patient survival rates after LT of 80-85% is better than for most other indications. Recurrent PBC is reported in a range from 14% up to 42% after LT but in contrast to other autoimmune diseases graft loss due to recurrent disease is not a major issue. The type of immunosuppression after LT was found to be associated with the incidence of recurrence but since mediate-term impact on overall and graft survival is negligible, tacrolimus-based regimens remain standard at most centers. Observational studies suggest that long-term administration of UDCA following LT has a beneficial effect on recurrence of PBC. Therefore biomarkers after LT that may identify patients at risk for recurrence should be further explored to allows early medical intervention.
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Affiliation(s)
- Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Belgium.
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23
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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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Outcomes of Liver Transplant Recipients With Autoimmune Liver Disease Using Long-Term Dual Immunosuppression Regimen Without Corticosteroid. Transplant Direct 2017; 3:e178. [PMID: 28706981 PMCID: PMC5498019 DOI: 10.1097/txd.0000000000000693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 04/15/2017] [Accepted: 05/01/2017] [Indexed: 12/26/2022] Open
Abstract
Background Liver transplant (LT) recipients with autoimmune liver disease (primary sclerosing cholangitis, primary biliary cholangitis, autoimmune hepatitis) are at increased risk of developing acute cellular rejection (ACR), and in many cases graft failure due to recurrent disease. We describe our experience with dual immunosuppression without steroid maintenance and analyze its effect on disease recurrence; ACR; patient and graft survivals; and complications, such as sepsis and de novo malignancy. Methods We included 74 consecutive LT recipients (April 2006 to April 2013) with autoimmune liver disease (primary sclerosing cholangitis, 20; primary biliary cholangitis, 23; autoimmune hepatitis, 31) from a single transplant center. Immunosuppression protocol included rabbit antithymocyte globulin for induction and mycophenolate mofetil with tacrolimus or sirolimus/everolimus indefinitely for maintenance. Results Overall 1-, 3-, 5-, and 7-year patient survival was 95.9%, 90.4%, 82,2% and 74.9%, re–graft-free survival was 93.2%, 86.3%, 79.9%, and 72.8%, respectively (median follow-up, 5.5 years). In a multivariate Cox regression analysis, sepsis during post-LT period (P = 0.040; hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.04-6.11), steroid use for ACR (P = 0.037; HR, 2.60; 95% CI, 1.06-6.34), and younger age (<40 years) at LT (P = 0.038; HR, 2.53; 95% CI, 1.05-6.10) predicted graft survival, whereas steroid use for ACR was the only variable that was predictive of overall patient survival (P = 0.004; HR, 4.10; 95% CI, 1.59-10.52). Overall, 34 biopsy-proven ACR was noted in 22 LT recipients (30%), 13 (17.5%) had disease recurrence, and 34 episodes of sepsis occurred in 19 patients. Conclusions Dual immunosuppression protocol in LT recipients with autoimmune liver disease without corticosteroid maintenance had acceptable rates of survival and ACR without predisposing patients to the adverse effects of long-term steroid therapy.
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Kogiso T, Egawa H, Teramukai S, Taniai M, Hashimoto E, Tokushige K, Sakisaka S, Sakabayashi S, Yamamoto M, Umeshita K, Uemoto S. Risk factors for recurrence of primary biliary cholangitis after liver transplantation in female patients: A Japanese multicenter retrospective study. Hepatol Commun 2017; 1:394-405. [PMID: 29404468 PMCID: PMC5721413 DOI: 10.1002/hep4.1037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/26/2017] [Indexed: 12/31/2022] Open
Abstract
Primary biliary cholangitis (PBC) is diagnosed mainly in female individuals, and risk factors for PBC recurrence (rPBC) after liver transplantation (LT) from cadaveric donors have been reported. We conducted a retrospective multicenter study of rPBC in female patients after living‐donor LT (LDLT). A total of 388 female patients undergoing LDLT for end‐stage PBC were enrolled, and the effects of preoperative and operative factors were evaluated. Postoperative factors were evaluated in 312 patients who survived for more than 1 year post‐LDLT. rPBC was defined as abnormal hepatic enzyme levels with typical histological findings in liver biopsies. Fifty‐eight patients (14.9%) developed rPBC with a median of 4.6 (0.8‐14.5) years post‐LT. Cox hazard analysis (P < 0.05) showed that younger recipient age (hazard ratio, 0.95; 95% confidence interval, 0.920‐0.982), shorter operative time (1.00; 0.995‐0.999), higher serum immunoglobulin M level (1.00; 1.001‐1.002), donor sex mismatch (2.45; 1.268‐4.736), human leukocyte antigen B60 (2.56; 1.336‐4.921) and DR8 (1.98; 1.134‐3.448), and initial treatment with cyclosporine A (3.14; 1.602‐6.138) were significantly associated with rPBC. The frequencies of Child‐Turcotte‐Pugh class C (0.46; 0.274‐0.775), the model of end‐stage liver disease score (0.96; 0.914‐0.998), and updated Mayo risk score (1.02; 1.005‐1.033) were significantly lower in rPBC. Posttransplantation use of steroids decreased and that of antimetabolites increased the frequency of rPBC. Conclusion: The timing of LT, recipient conditions, donor characteristics, and immunosuppressive medications may be associated with rPBC in LT recipients. (Hepatology Communications 2017;1:394–405)
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Affiliation(s)
- Tomomi Kogiso
- Department of Internal Medicine, Tokyo Women's Medical University Tokyo Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology Tokyo Women's Medical University Tokyo Japan
| | - Satoshi Teramukai
- Department of Biostatistics Kyoto Prefectural University of Medicine Graduate School of Medical Science Kyoto Japan
| | - Makiko Taniai
- Department of Internal Medicine, Tokyo Women's Medical University Tokyo Japan
| | - Etsuko Hashimoto
- Department of Internal Medicine, Tokyo Women's Medical University Tokyo Japan
| | | | | | - Satomi Sakabayashi
- Center for Quality Assurance in Research and Development Kyoto Prefectural University of Medicine Kyoto Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology Tokyo Women's Medical University Tokyo Japan
| | - Koji Umeshita
- Department of Surgery, Graduate School of Medicine Osaka University Osaka Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine Kyoto University Kyoto Japan
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26
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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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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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28
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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: 61] [Impact Index Per Article: 8.7] [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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29
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Abstract
Liver transplantation (LT) is the most effective treatment modality for end stage liver disease caused by many etiologies including autoimmune processes. That said, the need for transplantation for autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC), but not for primary sclerosing cholangitis (PSC), has decreased over the years due to the availability of effective medical treatment. Autoimmune liver diseases have superior transplant outcomes than those of other etiologies. While AIH and PBC can recur after LT, recurrence is of limited clinical significance in most, but not all cases. Recurrent PSC, however, often progresses over years to a stage requiring re-transplantation. The exact incidence and the predisposing factors of disease recurrence remain debated. Better understanding of the pathogenesis and the risk factors of recurrent autoimmune liver diseases is required to develop preventive measures. In this review, we discuss the current knowledge of incidence, diagnosis, risk factors, clinical course, and treatment of recurrent autoimmune liver disease (AIH, PBC, PSC) following LT.
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30
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Bosch A, Dumortier J, Maucort-Boulch D, Scoazec JY, Wendum D, Conti F, Morard I, Rubbia-Brandt L, Terris B, Radenne S, Abenavoli L, Poupon R, Chazouillères O, Calmus Y, Boillot O, Giostra E, Corpechot C. Preventive administration of UDCA after liver transplantation for primary biliary cirrhosis is associated with a lower risk of disease recurrence. J Hepatol 2015; 63:1449-58. [PMID: 26282232 DOI: 10.1016/j.jhep.2015.07.038] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/16/2015] [Accepted: 07/29/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Recurrence of primary biliary cirrhosis (PBC) after liver transplantation (LT) is not rare and can occasionally lead to severe graft dysfunction and retransplantation. Ursodeoxycholic acid (UDCA) is a safe and effective treatment for PBC. However, whether preventive administration of UDCA after LT could lower the incidence of PBC recurrence is unknown. METHODS Patients transplanted for PBC in five French and Swiss centers from 1988 to 2010 were included. Most patients from a single center received UDCA (10-15 mg/kg/d) preventively. Recurrence of PBC was histologically defined from biopsies routinely performed at 1, 5, 10, and 15 years of follow-up, and at any time when clinically indicated. RESULTS A total of 90 patients with a 1-year minimum follow-up were studied retrospectively, including 19 (21%) patients receiving preventive UDCA. The mean follow-up was 12 years. Recurrence was diagnosed in 48 (53%) patients. The recurrence rates at 5, 10, and 15 years were 27%, 47%, and 61%, respectively. In a multivariate proportional hazards model adjusted for potential confounders and risk factors, preventive UDCA was the only factor affecting the risk of recurrence significantly (HR=0.32; 95% CI: 0.11-0.91). The 5, 10, and 15-year rates of recurrence were 11%, 21%, and 40%, respectively, under preventive UDCA, and 32%, 53%, and 70%, respectively, without preventive UDCA. Seven patients with recurrence (15%) progressed to cirrhosis, requiring retransplantation in one. However, neither recurrence nor preventive UDCA had a significant impact on survival. CONCLUSIONS Preventive treatment with UDCA reduces the risk of PBC recurrence after LT.
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Affiliation(s)
- Alexie Bosch
- Unité de Transplantation Hépatique, Fédération des Spécialités Digestives, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Jérôme Dumortier
- Unité de Transplantation Hépatique, Fédération des Spécialités Digestives, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique, Hospices civils de Lyon et CNRS UMR5558, Laboratoire de Biométrie et Biologie évolutive, Equipe biostatistique Santé, Université Claude-Bernard, Lyon, France
| | - Jean-Yves Scoazec
- Service Central d'Anatomie et de Cytologie Pathologiques, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Dominique Wendum
- Service d'Anatomie et de Cytologie Pathologiques, Assistance Publique - Hôpitaux de Paris (APHP), Hôpital Saint-Antoine, Paris, France
| | - Filomena Conti
- Service de Transplantation Hépatique, APHP, Hôpital Saint-Antoine, Paris, France
| | - Isabelle Morard
- Centre des Affections Hépato-Biliaires et Pancréatiques, Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Laura Rubbia-Brandt
- Service de Pathologie clinique, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Benoit Terris
- Service d'Anatomie et de Cytologie Pathologiques, APHP, Hôpital Cochin, Paris, France
| | - Sylvie Radenne
- Service de Gastroentérologie et Hépatologie et INSERM U1052, Hospices civils de Lyon, Hôpital de la Croix-Rousse, Lyon, France
| | - Ludovico Abenavoli
- Dipartimento di Scienze della Salute, Università Magna Graecia, Catanzaro, Italy; Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des Voies biliaires, APHP, Hôpital Saint-Antoine, Paris, France
| | - Raoul Poupon
- Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des Voies biliaires, APHP, Hôpital Saint-Antoine, Paris, France
| | - Olivier Chazouillères
- Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des Voies biliaires, APHP, Hôpital Saint-Antoine, Paris, France
| | - Yvon Calmus
- Service Central d'Anatomie et de Cytologie Pathologiques, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Olivier Boillot
- Unité de Transplantation Hépatique, Fédération des Spécialités Digestives, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Emiliano Giostra
- Centre des Affections Hépato-Biliaires et Pancréatiques, Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Christophe Corpechot
- Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des Voies biliaires, APHP, Hôpital Saint-Antoine, Paris, France.
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31
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Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management. Hepatol Int 2015; 10:106-14. [PMID: 26603541 DOI: 10.1007/s12072-015-9685-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 11/06/2015] [Indexed: 12/14/2022]
Abstract
Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.
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32
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Haack T, Staufner C, Köpke M, Straub B, Kölker S, Thiel C, Freisinger P, Baric I, McKiernan P, Dikow N, Harting I, Beisse F, Burgard P, Kotzaeridou U, Kühr J, Himbert U, Taylor R, Distelmaier F, Vockley J, Ghaloul-Gonzalez L, Zschocke J, Kremer L, Graf E, Schwarzmayr T, Bader D, Gagneur J, Wieland T, Terrile C, Strom T, Meitinger T, Hoffmann G, Prokisch H. Biallelic Mutations in NBAS Cause Recurrent Acute Liver Failure with Onset in Infancy. Am J Hum Genet 2015; 97:163-9. [PMID: 26073778 PMCID: PMC4572578 DOI: 10.1016/j.ajhg.2015.05.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/11/2015] [Indexed: 11/24/2022] Open
Abstract
Acute liver failure (ALF) in infancy and childhood is a life-threatening emergency. Few conditions are known to cause recurrent acute liver failure (RALF), and in about 50% of cases, the underlying molecular cause remains unresolved. Exome sequencing in five unrelated individuals with fever-dependent RALF revealed biallelic mutations in NBAS. Subsequent Sanger sequencing of NBAS in 15 additional unrelated individuals with RALF or ALF identified compound heterozygous mutations in an additional six individuals from five families. Immunoblot analysis of mutant fibroblasts showed reduced protein levels of NBAS and its proposed interaction partner p31, both involved in retrograde transport between endoplasmic reticulum and Golgi. We recommend NBAS analysis in individuals with acute infantile liver failure, especially if triggered by fever.
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33
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Ali AH, Carey EJ, Lindor KD. Diagnosis and management of primary biliary cirrhosis. Expert Rev Clin Immunol 2014; 10:1667-78. [DOI: 10.1586/1744666x.2014.979792] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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34
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Abstract
Many nonviral diseases that cause liver failure may recur after liver transplantation. Although most studies have shown that a recurrent disease does not negatively affect patient and graft survival in the intermediate postoperative course, there is growing evidence that, especially in patients with primary sclerosing cholangitis and in patients with recurrent abusive alcohol drinking, disease recurrence is a significant risk factor for graft dysfunction and graft loss. Therefore, the recurrence of nonviral diseases has become a clinically important and prognostically relevant issue in the long-term management of recipients of liver transplantation.
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Affiliation(s)
- Ivo W Graziadei
- Department of Internal Medicine II (Gastroenterology and Hepatology), Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria; Department of Internal Medicine, District Hospital Hall, Milserstraße 10, A-6060 Hall, Austria.
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35
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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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36
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Karlsen TH, Vesterhus M, Boberg KM. Review article: controversies in the management of primary biliary cirrhosis and primary sclerosing cholangitis. Aliment Pharmacol Ther 2014; 39:282-301. [PMID: 24372568 DOI: 10.1111/apt.12581] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/09/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite considerable advances over the last two decades in the molecular understanding of cholestasis and cholestatic liver disease, little improvement has been made in diagnostic tools and therapeutic strategies. AIMS To critically review controversial aspects of the scientific basis for common clinical practice in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) and to discuss key ongoing challenges to improve patient management. METHODS We performed a literature search using PubMed and by examining the reference lists of relevant review articles related to the clinical management of PBC and PSC. Articles were considered on the background of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) practice guidelines and clinical experience of the authors. RESULTS Ongoing challenges in PBC mainly pertain to the improvement of medical therapy, particularly for patients with a suboptimal response to ursodeoxycholic acid. In PSC, development of medical therapies and sensitive screening protocols for cholangiocarcinoma represent areas of intense research. To rationally improve patient management, a better understanding of pathogenesis, including complications like pruritis and fatigue, is needed and there is a need to identify biomarker end-points for treatment effect and prognosis. Timing of liver transplantation and determining optimal regimens of immunosuppression post-liver transplantation will also benefit from better appreciation of pre-transplant disease mechanisms. CONCLUSION Controversies in the management of PBC and PSC relate to topics where evidence for current practice is weak and further research is needed.
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Affiliation(s)
- T H Karlsen
- Norwegian PSC Research Center, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Shetty S, Adams DH, Hubscher SG. Post-transplant liver biopsy and the immune response: lessons for the clinician. Expert Rev Clin Immunol 2014; 8:645-61. [DOI: 10.1586/eci.12.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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38
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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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Abstract
Primary biliary cirrhosis (PBC) is a chronic and slowly progressive cholestatic liver disease characterized by destruction of the interlobular bile ducts, which, if untreated, leads to fibrosis, biliary cirrhosis, and liver failure. Because liver transplantation remains the only curative option for PBC, the goals of treatment are to slow the rate of progression, to alleviate related symptoms, and to prevent complications. Ursodeoxycholic acid is the only US Food and Drug Administration-approved medical treatment of PBC. Several agents are undergoing evaluation as monotherapy or as an adjuvant to ursodeoxycholic acid. This review summarizes current therapeutic advances in the care of patients with PBC.
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Affiliation(s)
- Frank Czul
- Department of Medicine, University of Miami Miller School of Medicine, Room 600D, Central Building, 1611 NW 12th Avenue, Miami, FL 33101, USA
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Wasilenko ST, Montano-Loza AJ, Mason AL. Is there a role for cyclophilin inhibitors in the management of primary biliary cirrhosis? Viruses 2013; 5:423-38. [PMID: 23348060 PMCID: PMC3640509 DOI: 10.3390/v5020423] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 12/17/2022] Open
Abstract
Autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) are poorly understood autoimmune liver diseases. Immunosuppression is used to treat AIH and ursodeoxycholic acid is used to slow the progression of PBC. Nevertheless, a proportion of patients with both disorders progress to liver failure. Following liver transplantation, up to a third of patients with PBC experience recurrent disease. Moreover a syndrome referred to as "de novo AIH" occurs in a proportion of patients regardless of maintenance immunosuppression, who have been transplanted for disorders unrelated to AIH. Of note, the use of cyclosporine A appears to protect against the development of recurrent PBC and de novo AIH even though it is a less potent immunosuppressive compared to tacrolimus. The reason why cyclosporine A is protective has not been determined. However, a virus resembling mouse mammary tumor virus (MMTV) has been characterized in patients with PBC and AIH. Accordingly, we hypothesized that the protective effect of cyclosporine A in liver transplant recipients may be mediated by the antiviral activity of this cyclophilin inhibitor. Treatment of the MMTV producing MM5MT cells with different antivirals and immunosuppressive agents showed that both cyclosporine A and the analogue NIM811 inhibited MMTV production from the producer cells. Herein, we discuss the evidence supporting the role of MMTV-like human betaretrovirus in the development of PBC and de novo AIH and speculate on the possibility that the agent may be associated with disease following transplantation. We also review the mechanisms of how both cyclosporine A and NIM811 may inhibit betaretrovirus production in vitro.
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Affiliation(s)
- Shawn T Wasilenko
- Department of Medicine, Zeidler Ledcor Centre, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Cholongitas E, Burroughs AK. Recurrence of autoimmune liver diseases after liver transplantation: clinical aspects. AUTOIMMUNITY HIGHLIGHTS 2012; 3:113-8. [PMID: 26000134 PMCID: PMC4389079 DOI: 10.1007/s13317-012-0040-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/03/2012] [Indexed: 12/12/2022]
Abstract
Autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis are autoimmune liver diseases characterized by progressive immune-mediated inflammation leading to the destruction of the hepatocytes and the biliary epithelial cells, and eventually to cirrhosis and liver failure. The ultimate treatment of these diseases, upon the establishment of end-stage liver disease, includes liver transplantation (LT). Recurrence of autoimmune liver diseases after LT is an entity increasingly recognized in the last few decades. The mechanisms driving recurrence remain poorly understood. The accurate diagnosis of the recurrence and the proper management of the affected patients remains a clinical challenge. This review discusses clinical aspects related to the recurrence of autoimmune liver diseases after LT. The main goals of this review are to discuss the reasons explaining the variability of the incidence rates of recurrent autoimmune disease and the outcome and risk factors for recurrent disease. We discuss in detail the diagnostic criteria and the treatment options of these disorders.
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Affiliation(s)
- Evangelos Cholongitas
- 4th Department of Internal Medicine, Aristotle University Medical School, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Andrew K Burroughs
- The Sheila Sherlock Liver Centre, University College Institute of Digestive and Liver Health, Royal Free Hospital, London, UK
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Smyk D, Rigopoulou EI, Zen Y, Abeles RD, Billinis C, Pares A, Bogdanos DP. Role for mycobacterial infection in pathogenesis of primary biliary cirrhosis? World J Gastroenterol 2012; 18:4855-65. [PMID: 23002357 PMCID: PMC3447267 DOI: 10.3748/wjg.v18.i35.4855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 04/16/2012] [Accepted: 05/06/2012] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease characterized by the immune-mediated destruction of biliary epithelial cells in small intrahepatic bile ducts. The disease is characterized by circulating antimitochondrial antibodies (AMAs) as well as disease-specific antinuclear antibodies, cholestatic liver function tests, and characteristic histological features, including granulomas. A variety of organisms are involved in granuloma formation, of which mycobacteria are the most commonly associated. This has led to the hypothesis that mycobacteria may be involved in the pathogenesis of PBC, along with other infectious agents. Additionally, AMAs are found in a subgroup of patients with mycobacterial infections, such as leprosy and pulmonary tuberculosis. Antibodies against species-specific mycobacterial proteins have been reported in patients with PBC, but it is not clear whether these antibodies are specific for the disease. In addition, data in support of the involvement of the role of molecular mimicry between mycobacterial and human mitochondrial antigens as triggers of cross-reactive immune responses leading to the loss of immunological tolerance, and the induction of pathological features have been published. Thus, antibodies against mycobacterial heat shock protein appear to cross-recognize AMA-specific autoantigens, but it is not clear whether these autoantibodies are mycobacterium-species-specific, and whether they are pathogenic or incidental. The view that mycobacteria are infectious triggers of PBC is intriguing, but the data provided so far are not conclusive.
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Akamatsu N, Sugawara Y. Primary biliary cirrhosis and liver transplantation. Intractable Rare Dis Res 2012; 1:66-80. [PMID: 25343075 PMCID: PMC4204562 DOI: 10.5582/irdr.2012.v1.2.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 04/28/2012] [Accepted: 05/11/2012] [Indexed: 12/13/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is an immune-mediated chronic progressive inflammatory liver disease, predominantly affecting middle-aged women, characterized by the presence of antimitochondrial antibodies (AMAs), which can lead to liver failure. Genetic contributions, environmental factors including chemical and infectious xenobiotics, autoimmunity and loss of tolerance have been aggressively investigated in the pathogenesis of PBC, however, the actual impact of these factors is still controversial. Survival of PBC patients has been largely improved with the widespread use of ursodeoxycholic acid (UDCA), however, one third of patients still do not respond to the treatment and proceed to liver cirrhosis, requiring liver transplantation as a last resort for cure. The outcome of liver transplantation is excellent with 5- and 10-year survival rates around 80% and 70%, respectively, while along with long survival, the recurrence of the disease has become an important outcome after liver transplantation. Prevalence rates of recurrent PBC rage widely between 1% and 35%, and seem to increase with longer follow-up. Center-specific issues, especially the use of protocol biopsy, affect the variety of incidence, yet, recurrence itself does not affect patient and graft survival at present, and retransplantation due to recurrent disease is extremely rare. With a longer follow-up, recurrent disease could have an impact on patient and graft survival.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Address correspondence to: Dr. Yasuhiko Sugawara, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
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Ilyas JA, O'Mahony CA, Vierling JM. Liver transplantation in autoimmune liver diseases. Best Pract Res Clin Gastroenterol 2011; 25:765-82. [PMID: 22117641 DOI: 10.1016/j.bpg.2011.09.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 09/30/2011] [Indexed: 01/31/2023]
Abstract
Liver transplantation is indicated for terminal phases of autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis. Indications for transplantation in autoimmune liver diseases are similar to those used in other acute or chronic liver diseases. Therapeutic advances have reduced the need for transplantation for autoimmune hepatitis and primary biliary cirrhosis but not for primary sclerosing cholangitis. Overall, outcomes of transplantation for autoimmune liver diseases are excellent. However, recurrence of autoimmune liver diseases in the allograft has variable impacts on graft and patient survivals. Treatment of recurrent diseases requires changes in immunosuppression or addition of ursodeoxycholic acid. Among autoimmune liver diseases, only autoimmune hepatitis occurs de novo in recipients transplanted for other diseases. Patients transplanted for autoimmune hepatitis or primary sclerosing cholangitis are at risk for reactivation or de novo onset of ulcerative colitis. Better understanding of the pathogenesis of recurrent autoimmune liver diseases is needed to devise effective means of prevention and treatment.
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Affiliation(s)
- Jawad A Ilyas
- Fellow in Hepatology and Liver Transplantation, Liver Center, Baylor College of Medicine and St. Luke's Episcopal Hospital, 1709 Dryden, Suite 1500, Houston, TX 77030, USA
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Abstract
Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH) each account for approximately 5% of liver transplants per year performed in the United States and Europe. Even though outcomes are excellent, with reported 5-year patient and graft survival exceeding 90% and 80%, 80% and 75%, 72% and 65% for PBC, PSC, and AIH, respectively, the issue of recurrent autoimmune liver disease after orthotopic liver transplantation is increasingly recognized as a cause of graft dysfunction, death, and need for retransplantation. This article reviews diagnostic criteria, epidemiology, risk factors, and outcomes of recurrent PBC, PSC, and AIH after liver transplantation.
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Affiliation(s)
- Flavia Mendes
- Division of Hepatology, Miami VA Medical Center, FL 33125, USA
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Kaneko J, Sugawara Y, Tamura S, Aoki T, Hasegawa K, Yamashiki N, Kokudo N. Long-term outcome of living donor liver transplantation for primary biliary cirrhosis. Transpl Int 2011; 25:7-12. [PMID: 21923804 DOI: 10.1111/j.1432-2277.2011.01336.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In living donor liver transplantation (LDLT) for primary biliary cirrhosis (PBC), the majority of donors are genetically related to their recipients, leading to concerns of an earlier recurrence of PBC and a poorer prognosis due to genetic susceptibility. Totally 81 patients who underwent LDLT for PBC were the subjects of the present study. Immunosuppressive agents consisted of tacrolimus and methylprednisolone. In the outpatient clinic, when the aspartate and alanine aminotransferase level exceeded the upper limit of the normal range, the dose of methylprednisolone was increased from 4 to 6 mg/day for several months. Blood was examined every 2 weeks for 3 months and a liver biopsy was performed when aminotransferase levels did not decrease to the upper limit of the normal range after more than 3 months. Five-year survival and recurrence rates were estimated and the prognostic factors were analyzed. The mean observation period was 6.2 years. Five years after LDLT for PBC, the biopsy-proven PBC recurrence rate was 1%. The 5-year patient survival rate was 80%. The nonrelated or blood-related donor factor and number of human leukocyte antigen matches did not correlate with prognosis. PBC recurrence rate after LDLT in our series was lower than that in previous studies.
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Affiliation(s)
- Junichi Kaneko
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Liver transplantation in PBC and PSC: indications and disease recurrence. Clin Res Hepatol Gastroenterol 2011; 35:446-54. [PMID: 21459072 DOI: 10.1016/j.clinre.2011.02.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 02/09/2011] [Indexed: 02/07/2023]
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) represent major indications for liver transplantation (LT). Despite the steady increase in the incidence and prevalence of PBC, the number of liver transplants for PBC has fallen in recent years, whereas the number of transplants for PSC has remained stable. Indications for LT for PBC and PSC are no different from those of other causes of chronic liver disease, apart from some disease-specific indications. PBC and PSC have more favourable outcomes after LT, compared to viral hepatitis and alcohol-associated liver disease. Numerous studies have clearly demonstrated that PBC and PSC recur after LT. The diagnosis of recurrent disease should be made on agreed criteria. The impact of recurrent disease on survival is unclear. Study of recurrent PBC and PSC may provide a better understanding of the mechanisms of these diseases in the native liver.
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El-Masry M, Puig CA, Saab S, Saab S. Recurrence of non-viral liver disease after orthotopic liver transplantation. Liver Int 2011; 31:291-302. [PMID: 21281429 DOI: 10.1111/j.1478-3231.2010.02434.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplant remains the ultimate treatment for decompensated liver disease. However, many diseases do recur after orthotopic liver transplant, which may affect recipients' quality of life and survival rate. We performed a systematic review of relevant epidemiological studies available on Medline that provided information on the recurrence of non-viral hepatitis after orthotopic liver transplantation in adult patients published until August 2010. All data were compiled from either review articles or retrospective studies. Primary sclerosing cholangitis, primary biliary cirrhosis, autoimmune hepatitis, non-alcoholic steatohepatitis, alcoholic steatohepatitis and haemochromatosis can recur after liver transplantation. The rates for disease recurrence varied according to the indication for transplantation, and ranged from 7 to 50%. Although the survival rate of patients with liver disease has increased with the advent of liver transplantation and novel immunosuppressive protocols, recurrence of the primary liver disease remains a concern. The recurrence rates differ not only according to the cause of underlying liver disease but also vary within the indication for transplant. Further studies are needed to elucidate the risk factors for varied disease recurrence.
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Affiliation(s)
- Monica El-Masry
- Department of Medicine, Olive View - UCLA Medical Center, Sylmar, CA, USA
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Kashyap R, Safadjou S, Chen R, Mantry P, Sharma R, Patil V, Maloo M, Ryan C, Marroquin C, Barry C, Ramaraju G, Maliakkal B, Orloff M. Living donor and deceased donor liver transplantation for autoimmune and cholestatic liver diseases--an analysis of the UNOS database. J Gastrointest Surg 2010; 14:1362-9. [PMID: 20617395 DOI: 10.1007/s11605-010-1256-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 06/07/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Autoimmune hepatitis and cholestatic liver diseases have more favorable outcomes after liver transplantation as compared to viral hepatitis and alcoholic liver diseases. However, there are only few reports comparing outcomes of both living donor liver transplants (LDLT) and deceased donor liver transplants (DDLT) for these conditions. AIM We aim to study the survival outcomes of patients undergoing LT for autoimmune and cholestatic diseases and to identify possible risk factors influencing survival. Survival outcomes for LDLT vs. DDLT are also to be compared for these diseases. PATIENTS AND METHODS A retrospective analysis of the UNOS database for patients transplanted between February 2002 until October 2006 for AIH, PSC, and PBC was performed. Survival outcomes for LDLT and DDLT patients were analyzed and factors influencing survival were identified. RESULTS Among all recipients the estimated patient survival at 1, 3, and 5 years for LDLT was 95.5%, 93.6%,and 92.5% and for DDLT was 90.9%, 86.5%, and 84.9%, respectively (p = 0.002). The estimated graft survival at 1, 3, and 5 years for LDLT was 87.9%, 85.4%, and 84.3% and for DDLT 85.9%, 80.3%, and 78.6%, respectively (p = 0.123). On multivariate proportional hazard regression analysis after adjusting for age and MELD score, the effect of donor type was not found to be significant. CONCLUSION The overall survival outcomes of LDLT were similar to DDLT in our patients with autoimmune and cholestatic liver diseases. It appears from our study that after adjusting for age and MELD score donor type does not significantly affect the outcome.
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Affiliation(s)
- Randeep Kashyap
- Department of Surgery, Division of Solid Organ Transplantation, University of Rochester Medical Center, P.O. Box SURG, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Montano-Loza AJ, Wasilenko S, Bintner J, Mason AL. Cyclosporine A inhibits in vitro replication of betaretrovirus associated with primary biliary cirrhosis. Liver Int 2010; 30:871-7. [PMID: 20492501 DOI: 10.1111/j.1478-3231.2010.02257.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIM Up to one-third of patients with primary biliary cirrhosis (PBC) experience recurrent disease following liver transplantation, which is associated with earlier and more severe recurrence in patients treated with tacrolimus as compared with cyclosporine A (CsA). As the latter has known antiviral activity, we hypothesized that CsA has the ability to inhibit the betaretrovirus characterized from patients with PBC. METHODS We investigated whether CsA, the cyclosporine analogue NIM811, tacrolimus and other compounds can modulate the mouse mammary tumour virus production from Mm5MT cells. Viral load was evaluated in the cell supernatants by quantifying reverse transcriptase (RT) levels and betaretrovirus RNA. RESULTS A significant correlation was observed with increasing concentrations of CsA and NIM811, and decreasing of RT levels (rho-0.59, P=0.04 and rho-0.74, P=0.006 respectively), whereas tacrolimus had no significant effect (rho-0.27, P=0.4). At a dose of 3 microg/ml, CsA, NIM811 and the human immunodeficiency virus aspartyl protease inhibitor, lopinavir, were all associated with greater than three-fold reduction in the betaretrovirus RNA production from Mm5MT cells as compared with tacrolimus (P<0.005). CONCLUSIONS These studies demonstrate that the cyclophilin inhibitors CsA and NIM811 have antiviral activity against betaretrovirus production in vitro.
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Affiliation(s)
- Aldo J Montano-Loza
- Zeidler Ledcor Centre, Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
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