Recurrence of autoimmune liver disease after liver transplantation: A systematic review

Abstract

Recurrence of autoimmune liver disease in allografts has long been a topic of debate. We conducted a systematic review of the literature to examine the reported incidence of recurrence after liver transplantation of primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH). The MEDLINE, EMBASE, and Cochrane electronic databases were used to identify articles. The inclusion criteria used were articles on patients with at least 90 days of posttransplantation follow-up, histologic criteria for diagnosis of PBC and AIH recurrence, radiologic or histologic criteria or both for diagnosis of PSC recurrence, and exclusion of other causes of liver disease causing similar histologic findings. Incidence in individual studies was combined to calculate the overall recurrence. Risk factors were analyzed whenever crude data were available. Funnel plots were used to assess publication bias. Out of 90 articles identified, 43 met criteria for systematic review (PBC, 16; PSC, 14; AIH, 13). The calculated weighted recurrence rate was 18% for PBC, 11% for PSC, and 22% for AIH. No difference was found in PBC and AIH recurrence by type of primary immunosuppression. There were not enough data to assess this issue in PSC studies. There was evidence of publication bias among PSC and AIH studies but not among PBC studies. In conclusion, recurrence of autoimmune liver disease after liver transplantation appears to be a real concern. As these patients are followed long-term, recurrence of disease may become the primary cause of morbidity.

Survival Without Biliary Complications After Liver Transplant for Primary Sclerosing Cholangitis

“…The frequency of recurrent primary sclerosing cholangitis varies because of differences in duration of follow-up and protocols to detect biliary strictures between different studies. 2,7,30,31 The definition of recurrent primary sclerosing cholangitis usually is based on published criteria 3 including biopsy and cholangiographic findings. 4,5 In selected cases, partial resection of liver graft tissue that has limited biliary injury may be possible to prevent complete loss of the transplanted liver and revision transplant.…”

“…Yet, primary sclerosing cholangitis can recur in 2% to 40% patients. 2 The varied frequency of recurrence results from differences in follow-up protocols and duration in different studies. Published criteria for recurrent primary sclerosing cholangitis are frequently used.…”

Autoimmune hepatitis: new paradigms in the pathogenesis, diagnosis, and management

“…The survival rate among patients and grafts 5 years after liver transplantation is approximately 80-90% [171,173]. The overall success rate of liver transplantation is high, but a proportion of patients, up to 25% in some series [173][174][175][176][177], are at risk of developing recurrent disease despite maintenance immunosuppression to prevent graft rejection. Recurrent AIH is characterized by the persistence of autoantibodies, elevated IgG levels, and typical features on liver biopsy [173,178].…”

Autoimmune Hepatitis After Liver Transplantation

“…Patients with recurrent AIH have a higher frequency of rejection during the first 3, 6 and 12 months after transplantation than patients without recurrent disease, but previous rejection is not a requisite for recurrence (Molmenti et al, 2002). Another factor that has been implicated in recurrence has been the calcineurin inhibitors used in the immunosuppressive regimen after transplantation (Schreuder et al, 2009;Gautam et al, 2006). Cyclosporine and tacrolimus may have paradoxical effects which can promote the autoreactive response.…”