Lina Lindström1, Kristin K Jørgensen2,3, Kirsten M Boberg2,4, Maria Castedal5, Allan Rasmussen6, Andreas Arendtsen Rostved6, Helena Isoniemi7, Matteo Bottai8, Annika Bergquist1. 1. a Centre for Digestive Diseases, Division of Hepatology , Karolinska University Hospital, Karolinska Institutet , Stockholm , Sweden. 2. b Department of Transplantation Medicine, Section for Gastroenterology and Norwegian PSC Research Center, Division of Surgery, Inflammatory Diseases and Transplantation , Oslo University Hospital Rikshospitalet , Oslo , Norway. 3. c Department of Gastroenterology , Akershus University Hospital , Lørenskog , Norway. 4. d Institute of Clinical Medicine , University of Oslo , Oslo , Norway. 5. e Transplant Institute , Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden. 6. f Department of Surgery and Liver Transplantation , Rigshospitalet , Copenhagen , Denmark. 7. g Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki , Finland. 8. h Unit of Biostatistics, Institute of Environmental Medicine , Karolinska Institutet , Stockholm , Sweden.
Abstract
OBJECTIVES: The risk for recurrent primary sclerosing cholangitis (rPSC) after liver transplantation is associated with inflammatory bowel disease (IBD). We assessed the frequency of rPSC and studied risk factors for recurrent disease with special focus on IBD. We also evaluated the importance of rPSC for prognosis. MATERIALS AND METHODS: All liver transplanted PSC patients in the Nordic countries between 1984 and 2007 (n = 440), identified by the Nordic Liver Transplant Registry, were studied. Data were retrieved from patients' chart reviews. Multivariable Cox regression models were used to calculate risk factors for rPSC and death. RESULTS: Of the 440 patients with a follow-up time after liver transplantation of 3743 patient years, rPSC was diagnosed in 19% (n = 85). Colectomy before liver transplantation was associated with a reduced risk of rPSC (HR 0.49; 95% CI, 0.26-0.94, p = 0.033). Neither high IBD activity nor presence of IBD flares before or after liver transplantation was associated with rPSC. Treatment with tacrolimus was an independent risk factor associated with increased risk for rPSC (HR, 1.81; 95% CI, 1.15-2.86, p = 0.010). The risk of dying or needing a re-transplantation after rPSC was increased in all age groups, but highest in patients transplanted before 40 years of age (HR 7.3; 95% CI, 4.1-12.8, p = 0.0001). CONCLUSIONS: This study confirms that colectomy before liver transplantation is associated with a decreased risk of rPSC. Inflammatory activity of IBD was not associated with the risk of rPSC. Tacrolimus was an independent risk factor for PSC recurrence and its use as first line immunosuppression in PSC needs further study.
OBJECTIVES: The risk for recurrent primary sclerosing cholangitis (rPSC) after liver transplantation is associated with inflammatory bowel disease (IBD). We assessed the frequency of rPSC and studied risk factors for recurrent disease with special focus on IBD. We also evaluated the importance of rPSC for prognosis. MATERIALS AND METHODS: All liver transplanted PSC patients in the Nordic countries between 1984 and 2007 (n = 440), identified by the Nordic Liver Transplant Registry, were studied. Data were retrieved from patients' chart reviews. Multivariable Cox regression models were used to calculate risk factors for rPSC and death. RESULTS: Of the 440 patients with a follow-up time after liver transplantation of 3743 patient years, rPSC was diagnosed in 19% (n = 85). Colectomy before liver transplantation was associated with a reduced risk of rPSC (HR 0.49; 95% CI, 0.26-0.94, p = 0.033). Neither high IBD activity nor presence of IBD flares before or after liver transplantation was associated with rPSC. Treatment with tacrolimus was an independent risk factor associated with increased risk for rPSC (HR, 1.81; 95% CI, 1.15-2.86, p = 0.010). The risk of dying or needing a re-transplantation after rPSC was increased in all age groups, but highest in patients transplanted before 40 years of age (HR 7.3; 95% CI, 4.1-12.8, p = 0.0001). CONCLUSIONS: This study confirms that colectomy before liver transplantation is associated with a decreased risk of rPSC. Inflammatory activity of IBD was not associated with the risk of rPSC. Tacrolimus was an independent risk factor for PSC recurrence and its use as first line immunosuppression in PSC needs further study.
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