Course of inflammatory bowel disease activity in primary sclerosing cholangitis patients undergoing liver transplantation.
Parekh R, Segovia M, and Kaur N. Course of inflammatory bowel disease activity in primary sclerosing cholangitis patients undergoing liver transplantation. Am J Transplant 2017; 17:782.
Am J Transplant
Aim: Primary sclerosing cholangitis (PSC) is associated with inflammatory bowel disease (IBD). We aimed to review disease activity of IBD in patients with PSC undergoing Liver Transplantation (LT) at a tertiary referral center. Method: Between 1993 and 2015, forty-eight patients with IBD underwent LT for PSC at Henry Ford Health System. We retrospectively reviewed patients' records to obtain various clinical and demographic data, both pre-and post-transplant. We collected data on immunosuppression after LT at different intervals alongwith hospital admissions, prednisone escalation, change in treatment and surgeries for IBD. Statistical analysis was done using Chi square test. Results: Thirty-two males and 16 females with underlying IBD underwent LT for PSC. Forty (83%) patients had Ulcerative Colitis, 4 had Crohn's disease, and 2 had indeterminate colitis. Nine patients were on immunomodulators or anti-tumor necrosis factor (TNF) alpha inhibitor for treatment of IBD prior to LT. Twenty-three out of 48 patients had IBD relapses after LT, which was defined as requiring hospital admission for IBD, escalation of IBD therapy, prednisone administration for IBD, or surgery for IBD. Thirteen patients had IBD relapse within 1 year of the LT and 5 of those patients underwent colectomy due to medically refractory IBD. Majority (47 out of 48) of the patients were started on tacrolimus in the immediate postoperative period after LT. There was no statistical difference between use of various immunosuppressive regimens (including tacrolimus, cyclosporine, mycophenolate mofetil and sirolimus) and IBD relapses (p=0.52). Conclusion: Our study showed no association between the immunosuppression regimen post LT and IBD relapses. The patients who had IBD relapses within the first year post LT, had increased likelihood of having severe disease course requiring colectomy. Increased hospitalizations and colectomies post-LT in patients receiving immunomodulator therapy prior to LT would suggest that moderate-to-severe IBD before LT is predictive of worse disease after LT.Our findings suggest that early evaluation of IBD post-LT would be prudent to assess and intervene upon IBD before it becomes active; a proactive approach could prevent colectomy. With multiple novel IBD therapies on the horizon, the future of treatment in post-LT patients is still to be determined.