Inflammatory bowel disease (IBD) after liver transplantation for primary sclerosing cholangitis (PSC) is complex, with several IBD-, primary sclerosing cholangitis-, and transplant-related factors interplaying with each other.
Dr Jayant Talwalkar and colleagues from Minnesota, USA reviewed the course of IBD after liver transplantation in these patients.
The team report that approximately one-third of patients with known IBD improve, and one-third paradoxically worsen, after liver transplantation for primary sclerosing cholangitis.
Active IBD, discontinuation of 5-aminosalicylates (5-ASA) at time of liver transplantation and tacrolimus-based immunosuppression may be associated with an unfavorable course of IBD after liver transplantation.
The team found that about 14–30% patients with primary sclerosing cholangitis may develop de novo IBD 10 years after liver transplantation.
Liver transplantation confers a high risk of pouchitis after ileal pouch-anal anastomosis, although it may not be higher than baseline rates for primary sclerosing cholangitis patients.
The team noted that the risk of colorectal cancer continues to be high after liver transplantation for primary sclerosing cholangitis, and is higher in this cohort of patients with primary sclerosing cholangitis-IBD, compared with patients undergoing liver transplantation for other indications.
IBD does not adversely affect patient survival after liver transplantation, although the risk of recurrent primary sclerosing cholangitis in the allograft may be higher in patients with IBD and an intact colon at time of liver transplantation.
The researchers report that standard therapy with 5-ASA and/or azathioprine may be appropriate for treatment of active IBD after liver transplantation and maintenance of remission.
Dr Talwalkar's team concludes, "Anti-tumor necrosis factor-α agents are effective, but should be used with caution because of high risk of adverse events."
"The management of IBD after liver transplantation requires close coordination between transplant hepatologists and IBD experts."