2nd liver transplant linked to good outcomes in PSC
Graft, patient survival better than in non-PSC cases, study finds
A second liver transplant results in transplant and patient outcomes in people with primary sclerosing cholangitis (PSC) that are comparable or better than those observed in people with other liver diseases, a study showed.
Transplanted liver (graft) and patient survival were significantly better in PSC patients than in those with non-PSC conditions. In cases where a second liver transplant, or retransplantation, was due to recurrent PSC, graft survival was generally comparable to that seen in non-PSC patients, while patient survival was significantly better.
“Our findings strongly support the practice of offering retransplantation to PSC patients, even for those with recurrent disease after transplantation,” the researchers wrote.
The study, “Outcome of Liver Retransplantation in Patients With Primary Sclerosing Cholangitis,” was published in Liver International.
PSC is a chronic, autoimmune form of cholangitis, a condition characterized by inflammation and scarring of the bile ducts, which transport the digestive fluid bile from the liver to the intestines. As a result, bile can build up in the liver, causing damage and, eventually, permanent scarring (cirrhosis) and liver failure. No approved treatments for slowing or stopping liver damage caused by PSC exist.
Only cure for PSC
Liver transplant is the sole cure for PSC. The condition is the leading indication for the procedure in Nordic countries, with “increasing trends also in North America and in Europe,” the researchers wrote.
In up to 30% of cases, however, PSC recurs after a liver transplant. Because there are no treatments to prevent recurrent PSC, a second liver transplant is often indicated. Still, little is known about the outcomes of liver retransplantation in PSC patients.
A team led by scientists at Oslo University Hospital analyzed data from the Nordic Liver Transplant Registry, which comprises data from all patients undergoing liver transplantation in Norway, Sweden, Denmark, Finland, Iceland, and Estonia.
Of the 8,486 adult patients who underwent liver transplants from 1982 to 2022, 10.2% had a second transplant, 185 of whom had PSC. As a comparison group, the researchers looked at data from 208 people undergoing retransplantation due to nonacute liver failure, nonviral, noncancer, nonurgent liver conditions other than PSC.
When comparing data from both groups, the team found that graft survival after retransplantation was significantly better among PSC patients than the comparison group at one year (85% vs. 66%), five years (73% vs. 54%), 10 years (61% vs. 44%), 15 years (41% vs. 33%), and 20 years (36% vs. 17%).
Significant predictors of graft survival in PSC included a patient’s age, the liver donor’s age, dialysis at the time of transplant, PSC as the first transplant indication, and split liver transplant.
Dialysis is a procedure that replicates the kidney’s functions when the organ is not working properly. A split liver transplant involves dividing a single liver graft into two partial grafts that are transplanted into two different patients.
Patient survival was significantly better in the PSC group, with dialysis, split grafts, and PSC as the first transplant indication as significant predictors. However, PSC patients had a higher rate of multiple retransplantations than the comparison group (19% vs. 10%).
When compared with people with certain non-PSC liver conditions, such as alcohol-related liver disease, primary biliary cholangitis, and autoimmune hepatitis, PSC patients had better graft and patient survival.
Similar results were found when comparing PSC patients with those originally transplanted for a viral or cancer indication, who were excluded from the comparison group.
Liver transplant outcomes
Researchers then selected patients (PSC and comparisons) who underwent retransplantation at least five years after the first transplant to assess the impact of recurrent PSC (rPSC) on the outcomes of the second transplant.
Recurrent PSC patients survived significantly longer than the comparison group, as predicted by donor age and scores on the model for end-stage liver disease assessment, a measure of the severity of chronic liver disease. However, rPSC itself did not appear to predict patient survival.
There was also a trend toward better graft survival among rPSC patients than the comparison group at one year (87% vs. 69%), five years (79% vs. 60%), and 10 years (59% vs. 56%). Here, dialysis before the transplant was the sole significant predictor of graft survival.
Finally, the team assessed the futility of liver retransplantation in PSC and rPSC patients, as indicated by 90-day and five-year mortality rates exceeding 50%.
Compared with respective comparison groups, mortality rates at 90 days tended to be lower in PSC patients (5.4% vs. 10.1%) and rPSC patients (5.9% vs. 9.3%), while five-year mortality rates were significantly lower in the PSC group (32.6% vs. 51.7%) and the rPSC group (27.6% vs. 50%).
“Our data suggest that re-LTX [liver retransplantation] in PSC has a good performance in terms of graft and patient survival compared to other [indications] and does not represent futile use of liver grafts,” the scientists wrote. “While we seek new and effective treatment strategies for PSC and rPSC, re-LTX in patients originally transplanted for PSC should be performed when needed and encouraged in the national and international liver transplant programmes.”
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