Risk of PSC recurrence 4 times higher with living donor transplant: Study
Researchers stress need for individual monitoring after liver transplant
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Receiving a liver transplant from a living donor is associated with an increased risk — as much as four times higher — of disease recurrence in people with primary sclerosing cholangitis (PSC), according to the findings of a multicenter study in Turkey.
The researchers also identified other factors that may serve as independent predictors of PSC recurrence after a living donor liver transplant. Among them was having inflammatory bowel disease (IBD), a group of chronic disorders marked by inflammation of the digestive tract, which often occurs alongside PSC.
Biliary complications, including the narrowing of bile ducts, the tubes that carry the digestive fluid bile from the liver to the intestines, and bile leakage — both also common in people with PSC — were another independent predictor. So too was an acute rejection of the transplanted liver, or graft.
Overall, the study results highlight the importance of patient monitoring both during and after a liver transplant from a living donor, the researchers say.
“These findings underscore the need for individualized post-transplant surveillance and provide important considerations for graft selection and perioperative [around the time of surgery] management in patients with PSC, particularly in settings where LDLT [living donor liver transplant] is predominant,” the team wrote.
The study, “Risk Factors for Primary Sclerosing Cholangitis Recurrence Following Liver Transplantation: A Multicenter Retrospective Analysis,” was published in the journal Clinical Transplantation.
PSC is an autoimmune disease that causes chronic cholangitis, or inflammation in the bile ducts. As a result, bile flow can be slowed (a condition called cholestasis) and bile can build up in the liver. This causes damage and, eventually, permanent scarring and liver failure.
Liver transplant currently is only effective PSC treatment
As of right now, the only effective treatment is a liver transplant. However, PSC may recur after the procedure, impacting the transplanted liver’s survival and increasing the need for a new transplant.
To identify the risk factors for PSC recurrence after transplant, a team of researchers from institutions across Turkey retrospectively analyzed data from 174 PSC patients. All had undergone a liver transplant between 2000 and 2024 across 11 centers in the country. Each had at least about six months of follow-up after the liver transplant.
The patients had a mean age of 34 at PSC diagnosis and 40 at liver transplant; 13 were younger than age 18 at the time of liver transplant. A total of 60% of the patients were male.
Disease recurrence after transplant occurred in 33 patients (19%) within a median of 28 months, or slightly longer than two years. Among these individuals, 11 underwent a second liver transplant. The median interval since liver transplant was longer in people with recurrent disease than in those without (11.5 vs. 7 years), the team noted.
Patients with recurrent disease were significantly younger at PSC diagnosis (28 vs. 35 years), the data showed. They also were significantly more likely to have coexisting IBD before transplant (55% vs. 33%) and biliary complications after transplant (70% vs. 26%), the researchers noted.
Acute cellular rejection, an immune response against transplanted tissue, was more frequent in patients with disease recurrence (33% vs. 18%). Cholangiocarcinoma, a cancer that forms in the bile ducts inside or outside the liver, was less frequent in these patients (3.1% vs. 15%). However, these differences failed to reach statistical significance.
PSC recurrence linked to IBD, biliary complications in patients
Further statistical analysis indicated that receiving a liver transplant from a living donor was significantly linked to a nearly four times higher chance of PSC recurrence after liver transplant. Coexisting IBD, post-transplant biliary complications, and acute cellular rejection were each significantly associated with a twice as high likelihood of recurrence.
Additionally, patients with coexisting IBD or post-transplant biliary complications had significantly lower rates of survival without PSC recurrence. For instance, five years after the transplant, 22.9% of people with biliary complications had a recurrence compared with 11.8% of those without. After 10 years, the recurrence was 31.8% and 14.5%, respectively.
People who received a liver from a living donor were significantly younger (49.5 vs. 59.5 years) and had significantly less severe liver disease, as reflected by lower scores in the Model for End-Stage Liver Disease (MELD; 16 vs. 19) than those receiving a liver from a deceased donor. MELD predicts three-month mortality risk for patients with chronic liver disease; higher scores indicate more severe disease.
Undergoing a deceased donor liver transplant was significantly associated with higher rates of survival without PSC recurrence. For instance, 10 years after the transplant, 18% of the patients undergoing a living donor liver transplant experienced disease recurrence, compared with 10% of those with a deceased donor.
Structured surveillance protocols targeting high-risk subgroups, particularly [living donor liver transplant] recipients with IBD or prior rejection, may enable earlier detection and intervention, and enhance long-term outcomes in this patient population.
Overall, these findings show a need to monitor patients individually before, during, and after a living donor liver transplant, the researchers noted.
“Structured surveillance protocols targeting high-risk subgroups, particularly LDLT recipients with IBD or prior rejection, may enable earlier detection and intervention, and enhance long-term outcomes in this patient population,” the team wrote.
The researchers noted that the study results are “particularly relevant” in Turkey, where a lack of deceased donor livers make LDLT the primary treatment.
