Safety of Biologic Therapy in Liver Transplant Recipients: Case Closed?

Patients with inflammatory bowel disease who undergo liver transplantation may be considered for biologic therapy, but providers should closely monitor for infections such as cholangitis and Clostridioides difficile infection. Further research in prospective registries with long-term outcomes is needed.

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Activity of Inflammatory Bowel Disease After Liver Transplantation for Primary Sclerosing Cholangitis Predicts Poorer Clinical Outcomes

Inflammatory Bowel Diseases ◽

10.1093/ibd/izz325 ◽

2020 ◽

Vol 26 (12) ◽

pp. 1901-1908 ◽

Cited By ~ 2

Author(s):

Matthew Peverelle ◽

Sarang Paleri ◽

Jed Hughes ◽

Peter De Cruz ◽

Paul J Gow

Keyword(s):

Colorectal Cancer ◽

Inflammatory Bowel Disease ◽

Liver Transplantation ◽

Bowel Disease ◽

Sclerosing Cholangitis ◽

High Grade ◽

Long Term Outcomes ◽

Inflammatory Bowel ◽

The Impact

Abstract Background The impact of inflammatory bowel disease (IBD) activity on long-term outcomes after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is unknown. We examined the impact of post-LT IBD activity on clinically significant outcomes. Methods One hundred twelve patients undergoing LT for PSC from 2 centers were studied for a median of 7 years. Patients were divided into 3 groups according to their IBD activity after LT: no IBD, mild IBD, and moderate to severe IBD. Patients were classified as having moderate to severe IBD if they met at least 1 of 3 criteria: (i) Mayo 2 or 3 colitis or Simple Endoscopic Score–Crohn’s Disease ≥7 on endoscopy; (ii) acute flare of IBD necessitating steroid rescue therapy; or (iii) post-LT colectomy for medically refractory IBD. Results Moderate to severe IBD at any time post-transplant was associated with a higher risk of Clostridium difficile infection (27% vs 8% mild IBD vs 8% no IBD; P = 0.02), colorectal cancer/high-grade dysplasia (21% vs 3% both groups; P = 0.004), post-LT colectomy (33% vs 3% vs 0%) and rPSC (64% vs 18% vs 20%; P < 0.001). Multivariate analysis revealed that moderate to severe IBD increased the risk of both rPSC (relative risk [RR], 8.80; 95% confidence interval [CI], 2.81–27.59; P < 0.001) and colorectal cancer/high-grade dysplasia (RR, 10.45; 95% CI, 3.55–22.74; P < 0.001). Conclusions Moderate to severe IBD at any time post-LT is associated with a higher risk of rPSC and colorectal neoplasia compared with mild IBD and no IBD. Patients with no IBD and mild IBD have similar post-LT outcomes. Future prospective studies are needed to determine if more intensive treatment of moderate to severe IBD improves long-term outcomes in patients undergoing LT for PSC.

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Impact of Inflammatory Bowel Disease and Azathioprine on Long‐Term Outcomes After Liver Transplantation for Primary Sclerosing Cholangitis

Liver Transplantation ◽

10.1002/lt.26009 ◽

2021 ◽

Author(s):

Matthew Peverelle ◽

Peter De Cruz ◽

Sarang Paleri ◽

Paul J. Gow

Keyword(s):

Inflammatory Bowel Disease ◽

Liver Transplantation ◽

Primary Sclerosing Cholangitis ◽

Bowel Disease ◽

Sclerosing Cholangitis ◽

Long Term Outcomes ◽

Inflammatory Bowel

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The interplay of Clostridioides difficile infection and inflammatory bowel disease

Therapeutic Advances in Gastroenterology ◽

10.1177/17562848211020285 ◽

2021 ◽

Vol 14 ◽

pp. 175628482110202

Author(s):

Kanika Sehgal ◽

Devvrat Yadav ◽

Sahil Khanna

Keyword(s):

Inflammatory Bowel Disease ◽

Bowel Disease ◽

Adverse Outcomes ◽

Molecular Tests ◽

Clostridioides Difficile ◽

Increased Risk ◽

Clostridioides Difficile Infection ◽

Pros And Cons ◽

Inflammatory Bowel ◽

High Index Of Suspicion

Inflammatory bowel disease (IBD) is a chronic disease of the intestinal tract that commonly presents with diarrhea. Clostridioides difficile infection (CDI) is one of the most common complications associated with IBD that lead to flare-ups of underlying IBD. The pathophysiology of CDI includes perturbations of the gut microbiota, which makes IBD a risk factor due to the gut microbial alterations that occur in IBD, predisposing patients CDI even in the absence of antibiotics. Superimposed CDI not only worsens IBD symptoms but also leads to adverse outcomes, including treatment failure and an increased risk of hospitalization, surgery, and mortality. Due to the overlapping symptoms and concerns with false-positive molecular tests for CDI, diagnosing CDI in patients with IBD remains a clinical challenge. It is crucial to have a high index of suspicion for CDI in patients who seem to be experiencing an exacerbation of IBD symptoms. Vancomycin and fidaxomicin are the first-line treatments for the management of CDI in IBD. Microbiota restoration therapies effectively prevent recurrent CDI in IBD patients. Immunosuppression for IBD in IBD patients with CDI should be managed individually, based on a thorough clinical assessment and after weighing the pros and cons of escalation of therapy. This review summarizes the epidemiology, pathophysiology, the diagnosis of CDI in IBD, and outlines the principles of management of both CDI and IBD in IBD patients with CDI.

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Peritoneal Dialysis After Liver Transplantation: A Systematic Review

Canadian Journal of Kidney Health and Disease ◽

10.1177/20543581211029722 ◽

2021 ◽

Vol 8 ◽

pp. 205435812110297

Author(s):

Jean Maxime Côté ◽

Isabelle Ethier ◽

Héloïse Cardinal ◽

Marie-Noëlle Pépin

Keyword(s):

Systematic Review ◽

Liver Transplantation ◽

Liver Transplant ◽

Kidney Failure ◽

Liver Graft ◽

Transplant Recipients ◽

Technique Survival ◽

Liver Transplant Recipients

Background: Chronic kidney disease following liver transplantation is a major long-term complication. Most liver transplant recipients with kidney failure will be treated with dialysis instead of kidney transplantation due to noneligibility and shortage in organ availability. In this population, the role of peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) remains unclear. Objective: To determine the feasibility regarding safety, technique survival, and dialysis efficiency of PD in liver transplant recipients requiring KRT for maintenance dialysis. Design: Systematic review. Setting: Interventional and observational studies reporting the use of PD after liver transplantation. Patients: Adult liver transplant recipients with kidney failure treated with maintenance KRT. Measurements: Extracted data included eligibility criteria, study design, demographics, and PD modality. The following outcomes of interest were extracted: rate of peritonitis and microorganisms involved, noninfectious peritoneal complications, technique survival, and kidney transplantation-censored technique survival. Non-PD complications included overall survival, liver graft dysfunction, and hospitalization rate. Methods: The following databases were searched until July 2020: MedLine/PubMed, EMBASE, CINAHL, and Cochrane Library. Two reviewers independently screening all titles and abstracts of all identified articles. Due to the limited sample size, observational designs and study heterogeneity expected, no meta-analysis was pre-planned. Descriptive statistics were used to report all results. Results: From the 5263 identified studies, 4 were included in the analysis as they reported at least 1 outcome of interest on a total of 21 liver transplant recipients, with an overall follow-up duration on PD of 19.0 (Interquartile range [IQR]: 9.5-29.5) months. Fifteen episodes of peritonitis occurred in a total cumulative PD follow-up of 514 patient-months, representing an incidence rate of 0.35 per year. These episodes did not result in PD technique failure, mortality, or impairment of liver graft function. Limitations: Limitations include the paucity of studies in the field and the small number of patients included in each report, a risk of publication bias and the impossibility to directly compare hemodialysis to PD in this population. These results, therefore, must be interpreted with caution. Conclusions: Based on limited data reporting the feasibility of PD in liver transplant recipients with kidney failure, no signal was associated with an increased risk of infectious complications. Long-term studies evaluating this modality need to be performed. Registration (PROSPERO): CRD42020218374.

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