Good outcomes of living donor liver transplant in primary sclerosing cholangitis: an experience from North India

Abstract

Background Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. In the absence of effective medical therapy, liver transplant is the definitive treatment for advanced stage. However, recurrence of PSC after liver transplant is of concern which can lead to graft failure and may require retransplant. There are limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are genetically related there can be an increased risk of recurrence. We conducted this retrospective study to analyze the outcomes of LDLT in PSC at a tertiary liver transplant center in north India. Methods We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients had PSC as indication for liver transplantation (PSC = 24, PSC-AIH overlap = 2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence, and survival. Results Mean age of study group was 42 (± 13.8) years and 19 patients (73.1%) were males. All patients had decompensated cirrhosis at the time of transplant. Mean CTP score and MELD score were 9.5 (± 1.8) and 18.9 (± 7.1), respectively. Sixteen patients received modified right lobe graft, seven extended right lobe graft and five patients received left lateral graft. Median graft weight and mean graft to recipient weight ratio (GRWR) were 633.5 ) grams and 1.23 (± 0.42), respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19 (73.1%) while duct to duct anastomosis was performed in 7 (26.9%) patients. Median follow-up was 96 (36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and were managed successfully with steroid pulses. Three patients died during early post-transplant period while seven deaths occurred during long-term follow-up including one death due to COVID-19. Five (21.73%) patients had recurrence of PSC of which two patients had graft loss including one after retransplantation. The one year graft and patient survival rate was 88.5%. Conclusion LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about one-fifth patients.

Liver transplant in primary sclerosing cholangitis: Current trends and future directions

“…Based on a study of 6911 LT patients from the OPTN database, the unadjusted survival rate was significantly higher among the LDLT group as compared to the DDLT group[ 102 ]. The most common factors associated with death after LT were infections, malignancies, cardiovascular diseases, graft failure (GF) due to rejection, and hepatic artery thrombosis (HAT)[ 101 , 103 , 104 ].…”

“…ACR does not affect long-term graft or survival outcomes in patients with LT, as opposed to patients with renal transplant[ 105 ]. A retrospective study of patients with a diagnosis of PSC (24 patients) and PSC-autoimmune hepatitis overlap (2 patients) without evidence of CCA at the time of LDLT showed allograft rejection successfully managed by immunosuppression in 11.5% patients, postoperative bile leak in 7.6% patients managed conservatively, and biliary stricture in 11.5% patients with successful ERCP and biliary stent placement[ 103 ]. Biliary strictures and bile leaks are other common complications after LT with an incidence of 5%-15% in patients who received DDLT and 28%-32% in recipients of right lobe LDLT[ 106 ].…”