New Data Supports Liver Retransplantation for Patients with PSC Recurrence

Retransplantation in patients originally transplanted due to primary sclerosing cholangitis (PSC) offers good graft and patient survival and yields similar or better outcomes compared with patients transplanted for other liver diseases, according to findings from a recent study.1

Leveraging data from the Nordic Liver Transplant Registry (NLTR) for transplants completed between 1982 and 2022, the study found liver retransplantation in patients with PSC and recurrent PSC does not represent a futile use of liver grafts and should therefore be encouraged in national and international liver transplant programs.1

A chronic liver disease in which the bile ducts inside and outside the liver become inflamed and scarred, there is currently no cure for PSC. Treatment seeks to address narrowed or blocked bile ducts and relieve associated symptoms and complications of PSC, but liver transplantation may be necessary for cases leading to liver failure. However, PSC can recur after liver transplantation, potentially leading to graft failure and requiring retransplantation.2

“A liver retransplant can be technically demanding and raises questions related to both health economics and ethical aspects in organ allocation policies. Given the challenges with recurrent PSC, it is important to establish whether the outcomes following retransplantation in patients originally transplanted for PSC are acceptable and comparable to retransplantation for other etiologies,” Espen Melum, MD, PhD, a professor of medicine at the University of Oslo and a senior consultant at Oslo University Hospital, and colleagues wrote.1 “Outcomes of retransplantation in patients with PSC have not been well documented, and recent findings are not consistent between cohorts and may be affected by study size and selection of the appropriate comparison groups.”

To address this gap in knowledge, investigators assessed data from the NLTR for adult liver transplant recipients in Denmark, Estonia, Finland, Iceland, Norway, and Sweden between 1982 and 2022. They compared data for patients listed with PSC as the primary transplant indication to patients transplanted due to nonviral, non-malignant, and non-acute liver diseases.1

Between 1982 and 2022, 8486 patients recorded in NLTR received a first liver transplant and 866 (10.2%) also underwent retransplantation. Of these patients, 185 had PSC and 208 had other liver disease etiologies, including alcoholic (22%), autoimmune (17%), metabolic-cryptogenic (23%), and other cholestatic liver diseases (25%).1

Investigators observed an increased rate of retransplantation in the PSC group versus the comparison group (18.9% vs 10.1%, respectively; P = .011). Additionally, the PSC group had longer graft survival following the first liver transplant than the comparison group (log-rank P <.001), with a median survival of 4.1 years versus 0.4 years. Urgent retransplantation after the primary transplant was also less frequent in the PSC group (10% vs 34%; P <.001).1

Patients undergoing retransplantation in the PSC group had better graft survival than the comparison group. The graft survival at 1, 5, 10, 15, and 20 years post retransplantation in the PSC group were 85%, 73%, 61%, 41%, and 36%, respectively, while the numbers in the comparison group were 66%, 54%, 44%, 33%, and 17% (log-rank P <.001).1

Investigators called attention to a significant difference between PSC and the comparison group for patient survival (log-rank P <.001). In multivariate analysis, donor age was a significant predictor of graft survival, while blood group mismatch and transplant year were significant predictors of patient survival.1

Of note, retransplantation for recurrence of PSC had similar and better outcomes for graft and patient survival compared to other etiologies. Specifically, patients in the recurrent PSC group had survival rates of 87%, 79%, 59%, and 43% at 1, 5, 10, and 15 years post retransplantation versus 69%, 60%, 56%, and 47% in the comparison group (log-rank P = .09). Additionally, patients with PSC recurrence had statistically significantly improved survival compared with the comparison group (log-rank P = .023).1

Investigators also pointed out the mortality rates following retransplantation in the PSC group were 5% at 90 days and 33% at 5 years while the corresponding rates in the comparison group were 10% and 52% (P = .06 and P <.001). The 90-day mortality was similar in the recurrent PSC group and the comparison group (P = .35), while the 5-year mortality in the recurrent PSC group was significantly lower (P = .041).1

“Our data suggest that retransplantation in PSC has a good performance in terms of graft and patient survival compared to other etiologies and does not represent futile use of liver grafts,” investigators concluded.1 “While we seek new and effective treatment strategies for PSC and rPSC, retransplantation in patients originally transplanted for PSC should be performed when needed and encouraged in the national and international liver transplant programs.”

References

1. Molinaro A, Engesæter LK, Jorns C, et al. Outcome of Liver Retransplantation in Patients With Primary Sclerosing Cholangitis. Liver International. https://doi.org/10.1111/liv.16214
2. National Institutes of Health. Primary Sclerosing Cholangitis. February 2022. Accessed December 19, 2024. https://www.niddk.nih.gov/health-information/liver-disease/primary-sclerosing-cholangitis