Risk factors and outcomes in post-liver transplantation bile duct stones and casts: A case-control study

Abstract

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post-liver transplant. A case-control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t-tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre-and post-OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18-year-period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow-up of 1530 days. Use of ursodeoxycholic acid was protective (P ϭ 0.005), whereas bile duct pathology (P ϭ 0.003), total cholesterol Ն 200 mg/dL (P ϭ 0.008), and triglyceride Ն 150 mg/dL (P ϭ 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients.

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

“…29 The study presented here by Spier et al 7 shows a statistically significant effect of the ursodeoxycholic acid (UDCA) treatment on stone prevention post-LT. UDCA prevents sludge formation as a precursor of stones and casts. UDCA helps in targeting the transporters BSEP and multidrug resistance-associated protein 2 to the canalicular membrane via at least two different signaling cascades.…”

“…However, an independent association at multivariate analysis has been shown in the Shah et al 6 study. The study population presented by Spier et al 7 in this issue of Liver Transplantation fits much better into this second pathogenetic profile. Most patients presented stones more than pure casts and the timing of diagnosis (median Ͼ600 days) was longer than that widely reported for casts of inflammatory/necrotic genesis, which is usually less than 1 year posttransplantation.…”

“…In the Spier et al 7 study, in almost 50% of the cases, abdominal ultrasound (US) was ineffective in diagnosing biliary pathology. Nevertheless, US should still be the first diagnostic tool.…”

“…[6][7][8] Such a distinction, in fact, may have important implications in the interpretation of the scientific data published, which often presents conflicting results.…”

Biliary Complications After Liver Transplantation

“…Endoscopic treatment responding to non-transplant conditions should be primarily preferred followed, alternatively, by the transhepatic approach or surgery in the case of failure. Nevertheless, the long-term outcome reflecting the underlying conditions may be limited when multiple stones or casts with diffuse bile duct damage occur (Sheng et al, 1996;Spier et al, 2008).…”