Impact of Inflammatory Bowel Disease Subtypes on the Post-liver Transplant Outcomes of Patients with Primary Sclerosing Cholangitis

Abstract

Background and aims: Liver transplant patients with primary sclerosing cholangitis often present with concurrent inflammatory bowel disease. The effect of comorbid conditions on post-transplant prognosis was evaluated.

Methods: The 2005-2019 United Network of Organ Sharing Standard Transplant Analysis and Research database was used to identify patients with primary sclerosing cholangitis. Patients were categorized as having Crohn's Disease, ulcerative colitis, unclassified inflammatory bowel disease, or no inflammatory bowel disease. Baseline characteristics were assessed between cohorts, and outcomes were examined using Cox regression. Outcomes included all-cause mortality, graft failure, infection-induced mortality, and organ system-delineated mortality. Supplementary analyses with unique exclusion and stratification criteria were also performed.

Results: Among 2829 patients undergoing transplant, 1360 were considered to have ulcerative colitis, 372 were considered to have Crohn's Disease, and 69 were considered to have an unclassified form of inflammatory bowel disease. Primary sclerosing cholangitis patients with some form of inflammatory bowel disease had no increased risk for any outcomes. However, patients with ulcerative colitis had lower risks of general infectious (aHR 0.65 95%CI 0.44-0.95) and sepsis-induced (aHR 0.56 95%CI 0.35-0.91) mortality, whereas patients with Crohn's Disease had higher risks of sepsis-induced mortality (aHR 2.13 95%CI 1.22-3.70). Supplementary analyses showed effect modification by abdominal surgery history and era.

Conclusion: The type of inflammatory bowel disease in liver transplant patients with primary sclerosing cholangitis was found to portend risk difference for infection-induced mortality, with ulcerative colitis found to be protective and Crohn's Disease predictive of increased mortality secondary to infectious etiologies. These associations warrant further investigation.

Keywords: Inflammatory bowel disease; Liver transplant; Outcome assessment; Primary sclerosing cholangitis.

Figure 1.

This figure shows the patient selection process of this study.

Figure 2.. Comparison of Cumulative Hazards With All-cause Mortality and Graft Failure as Endpoints Ulcerative Colitis vs Without Ulcerative Colitis

(A) and (B) represent the cumulative hazard curves for all-cause mortality and graft failure in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by ulcerative colitis diagnosis. (C) and (D) represent the cumulative hazard curves for all-cause mortality and graft failure in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by Crohn's Disease diagnosis. (E) and (F) represent the cumulative hazard curves for all-cause mortality and graft failure in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by inflammatory bowel disease diagnosis. (G) and (H) represent the cumulative hazard curves for all-cause mortality and graft failure in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by inflammatory bowel disease subtype.

Figure 3:. Comparison of Cumulative Hazards With Infectious Causes of Death as Endpoints Ulcerative Colitis vs Without Ulcerative Colitis

(A) and (B) represent the cumulative hazard for general infectious causes and sepsis as causes of death in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by ulcerative colitis diagnosis. (C) and (D) represent the cumulative hazard for general infectious causes and sepsis as causes of death in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by Crohn's Disease diagnosis. (E) and (F) represent the cumulative hazard for general infectious causes and sepsis as causes of death in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by inflammatory bowel disease diagnosis. (G) and (H) represent the cumulative hazard for general infectious causes and sepsis as causes of death in liver transplant recipients indicated for primary sclerosing cholangitis, stratified by inflammatory bowel disease subtype diagnosis.