MRI scans catch early signs of PSC recurrence after liver transplant
Study finds scans better than standard blood tests
Written by |
Scheduled MRI scans one to three years after a liver transplant may detect signs of returning primary sclerosing cholangitis (PSC) earlier than standard blood-based liver function tests, a single-center study suggested.
Researchers using a specialized MRI technique called magnetic resonance cholangiopancreatography (MRCP) found that nearly half of patients showed early signs of recurrent PSC (rPSC), often before abnormalities appeared in routine tests that measure liver enzyme levels.
“Protocol-driven MRCP surveillance demonstrates that rPSC is frequent and often detectable early after liver transplantation, identifying a potential therapeutic window before clinical manifestations occur,” the researchers wrote. “The high proportion of … biochemically silent recurrence in our [group of patients] underscores the limitations of [liver] enzyme-based surveillance alone and supports the value of protocol-driven MRCP follow-up after LT [liver transplant].”
The study, “Early MRCP surveillance for recurrent primary sclerosing cholangitis after liver transplantation: a prospective imaging study,” was published in Scientific Reports.
PSC is an autoimmune disease marked by inflammation and scarring (fibrosis) of the bile ducts, the tubes that carry the digestive fluid bile from the liver to the intestines. This damage can disrupt bile flow, a condition known as cholestasis, and over time may lead to liver failure, making liver transplant the only treatment option.
Detecting disease return before symptoms appear
“Although [liver transplant] is the only curative option for end-stage PSC, disease recurrence in the graft [transplanted organ] … remains one of the major long-term complications,” the researchers wrote.
Imaging tests such as MRCP that help visualize the bile ducts are often performed only after symptoms appear or when blood tests suggest liver damage. This approach may miss early (subclinical) disease, leading to an underestimation of the true occurrence of rPSC.
“Early identification of subclinical disease may allow closer surveillance and optimization of post-transplant management and could be particularly relevant in the context of emerging antifibrotic and disease-modifying therapies,” the researchers wrote.
To better understand how often PSC returns, which patients are at higher risk, and how the disease progresses over time, the team of researchers in Poland followed 102 adults who underwent liver transplants for PSC at their center from January 2017 to September 2024.
Participants, most of whom were men (63.7%), had a median age of 35.5 at the time of liver transplant, and had been living with PSC for a median of 6.3 years.
Inflammatory bowel disease (IBD), a condition frequently seen in people with PSC, was present in most patients, particularly before transplant. Ulcerative colitis (UC), the most common form of IBD, accounted for the majority of cases.
Nine patients had cytomegalovirus (CMV) infection, a common viral infection that can reactivate with standard immunosuppressive treatments after transplant.
Participants underwent MRCP scans one and three years after transplant to monitor for disease recurrence. At the time of the analysis, 79.4% had undergone both scans, while the rest had completed only the first.
Overall, rPSC was detected in 50 patients (49%), with 30.4% of them already showing bile duct abnormalities at the first scan. By the second scan, 58% of those assessed showed signs of recurrence.
Advanced rPSC occurred in 14.7% of participants, including cases needing another transplant or that resulted in death. The median time to advanced rPSC was 59 months, or nearly five years, after transplant.
Recurrence was significantly more frequent among individuals with UC (83.3% vs. 65.4%), those who developed IBD after transplant (16.7% vs. 3.9%), and those with post-transplant IBD flares (50% vs. 28.9%). These results suggest that gastrointestinal inflammation may “trigger early biliary injury” that drives rPSC, the researchers wrote.
Statistical analyses accounting for multiple factors identified male sex and post-transplant CMV detection as independent predictors of advanced rPSC. Additional analyses showed that patients with detectable CMV were significantly more likely to progress to advanced disease more rapidly, regardless of IBD status, while those without CMV generally had lower recurrence rates and milder disease courses.
These findings add “biologic plausibility to the hypothesis that viral infection may contribute to graft injury” that drives faster progression “from radiologic to clinically significant recurrence,” the team wrote.
Imaging often showed signs of recurrence in the absence of biochemical abnormalities. At the first MRCP, 38.7% of participants with radiological features of rPSC had normal liver enzyme levels commonly used to assess cholestasis; this proportion rose to 59.6% by the second scan.
Still, “biochemical cholestasis at the time of the first MRCP was strongly associated with faster progression to advanced rPSC,” suggesting that “integrating biochemical parameters into risk stratification, alongside systematic imaging, may help recognize patients at imminent risk of clinically significant progression,” the team wrote.
Larger studies are needed to confirm the study’s findings, the researchers said. Such data could help tailor post-transplant monitoring and treatment strategies, including closer imaging surveillance, improved IBD control, and optimized CMV infection prevention and management.
