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THE COURSE OF INFLAMMATORY BOWEL DISEASE (IBD) AND PRIMARY SCLEROSING CHOLANGITIS (PSC) AFTER LIVER TRANSPLANTATION FOR PSC
K Moncrief, A Savu, MM Ma, VG Bain, P Tandon
Department of Medicine, University of Alberta, Edmonton, Alberta
BACKGROUND: PSC is associated with IBD in over 70% of cases. Although the natural history of IBD and PSC in the non-transplant setting has been established, there is little consensus on the post transplant course or impact of immunosuppression on IBD. As well, the natural history of PSC post-transplant and predictors of PSC recurrence (rPSC) are not firmly established. We aimed therefore to clarify these areas of controversy using our center’s existing transplant experience.
METHODS: We performed a retrospective review of all patients with an established diagnosis of PSC receiving a liver transplant at the University of Alberta hospital (1989 until 2006). Demographics were summarized using the mean (standard deviation) or median (interquartile range). Cumulative incidence curves were used for survival analysis. Multivariate logistic regression and Cox regression models were utilized to determine predictors for recurrent PSC and relapse of IBD post-transplant.
RESULTS: 3/68 patients were excluded due to minimal follow-up information, leaving 65 patients for the analysis. The mean follow-up was 74 ± 50 months. 72% of patients had IBD pre-transplant. 5/18 (28%) of the patients without pre-transplant IBD developed de novo post-transplant IBD. There was no significant difference in the pre- or post-transplant activity of IBD as measured by the number of flares or the disease severity. Unlike some previous reports, the type of immunosuppression did not impact IBD recurrence. The median time to the first flare of IBD post-transplant (in the 26/55 patients at risk) was 10.9 (3.5, 44.4) months. 16% of patients required post-transplant colectomy. There was no survival difference between patients with or without pre-transplant IBD (p=0.15). 28% of patients had rPSC as defined by established criteria (Graziadei et al. 1999) with a median time to recurrence of 36.5 (20.2, 66.1) months. The occurrence of acute cellular rejection was the only independent predictor of PSC recurrence (Hazard ratio 4.5, p=0.02). In the 4/9 patients re-transplanted for recurrent PSC, the median time to re-transplant was 87 (63, 125) months. 1, 5 &10 year survival for the whole group were excellent (96.9%, 87.2% and 80.9% respectively). Analysis of the impact of rPSC on survival is pending.
CONCLUSIONS: Patient survival after liver transplantation for PSC is excellent. Using strict criteria 28% of patients have rPSC of which acute cellular rejection is an independent predictor. There was no significant difference in IBD activity pre- and post-transplant and no impact of immunosuppression on the course of post-transplant IBD in our series.