Graft and Patient Survival After Liver Transplantation for Primary Sclerosing Cholangitis: A French National Cohort Study

Abstract

Background: A significant proportion of patients presenting a primary sclerosing cholangitis (PSC) will require liver transplantation (LT). The present study aimed to investigate graft loss and patient death in a large cohort of patients.

Methods: We conducted a nationwide multicenter retrospective study including all adult patients transplanted for PSC in France From 1985 to 2019.

Results: Were included 571 patients; median follow-up after LT was 89.0 months (IQR, 43.0-151.0). Patient survival at 5, 10 and 20 years after LT was 88.2%, 81.2% and 62.6%. After exclusion of patients who died during the first month after LT, 37 patients (6.6%) died during the first 2 years and the main cause was malignancies (n = 15, 40.5%, including 12 cases of recurrent cholangiocellular carcinoma). After 2 years, 90 patients (17.2%) died; the two main causes were malignancies (n = 36, 40.0%, including 13 cases of colorectal cancer) and sepsis (n = 23, 25.6%, of which 7 were related to recurrent PSC). Graft survival at 5, 10 and 20 years was 89.5%,78.7% and 62.7%. Independent factors associated with late patient death (after 2 years) were an older age at LT, a bilio-digestive anastomosis and the use of preventive UDCA; independent factors associated with late graft loss were recurrent PSC, cellular rejection, a younger age at LT, and the use of tacrolimus (protective).

Conclusions: Our results emphasise that the prognosis after LT for PSC could be improved by better detection of cholangiocellular carcinoma before LT, and colorectal cancer after LT.

FIGURE 1

Overall patient and first graft survival. (A) Overall patient survival. Patient survival at 5, 10, and 20 years after LT were 88.2%, 81.2%, and 62.6% respectively. (B) Overall first graft survival. First graft survival at 5, 10, and 20 years after LT were 89.5%, 78.7%, and 62.7% respectively.

FIGURE 2

Outcome of patients with CCA (recurrence and survival).

FIGURE 3

Risk factors of patient death > 2 years after LT. (A) Late patient survival curve according to age at LT, with a threshold at 42. Patient survival at 5, 10, and 20 years after LT were 97.1%, 92.7%, and 78.0% respectively in the group of patients <42 at LT and 95.8%, 84.2%, and 56.8% respectively in the group of patients > 42 at LT. (B) Late patient survival curve according to prescription of preventive UDCA. Patient survival at 5, 10 and 20 years after LT were 93.2%, 84.4% and 60.4% respectively in the group with preventive UDCA and 97.9%, 90.9% and 75.6% respectively in the group without preventive UDCA. (C) Late patient survival curve according to biliary anastomosis type. Patient survival at 5, 10 and 20 years after LT were 96.5%, 96.5% and 89.6% respectively in the group of patients with bilio‐biliary anastomosis at LT and 97.3%, 89.8% and 67.8% respectively in the group of patients with bilio‐digestive anastomosis at LT.

FIGURE 4

Risk factors of first graft loss > 2 years after LT. (A) First graft late survival curve according to age at LT, with a threshold at 42. First graft survival at 5, 10, and 20 years after LT were respectively 96.5%, 86.4%, and 74.6% in the group of patients > 42 at LT and respectively 90.1%, 76.8%, and 56.7% in the group of patients < 42 at LT. 4B. First graft late survival curve according to rPSC.First graft survival at 5, 10, and 20 years after LT were respectively 96.4%, 94.7%, and 86.1% in the group without rPSC and respectively 86.2%, 59.2%, and 37.2% in the group with rPSC. (B) bis. First graft late survival curve according to rPSC (with time‐dependent covariate modelling). First graft survival at 5, 10, and 20 years after LT were respectively 87.4%, 78.6%, and 68.1% in the group without rPSC and respectively 55.9%, 26.5%, and 12.3% in the group with rPSC, with time‐dependent covariate in Cox model. (C) First graft late survival curve according to acute cellular rejection. First graft survival at 5, 10, and 20 years after LT were respectively 95.1%, 86.7%, and 79.3% in the group without acute cellular rejection and respectively 90.5%, 73.7%, and 51.3% in the group with acute cellular rejection.