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Patients with primary sclerosing cholangitis with and without end-stage liver disease have similar outcomes after liver transplantation
Mojmir Hlavaty, Jan Brezina, Pavel Wohl, Istvan Modos, Lukas Bajer, Ondrej Fabian, Andrea Vajsova, Tomas Hucl, Pavel Drastich
Mojmir Hlavaty, Jan Brezina, Pavel Wohl, Lukas Bajer, Tomas Hucl, Pavel Drastich, Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic
Istvan Modos, Department of Data Science, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic
Lukas Bajer, Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague 15000, Czech Republic
Ondrej Fabian, Andrea Vajsova, Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic
Ondrej Fabian, Department of Pathology and Molecular Medicine, 3rd Faculty of Medicine and Thomayer Hospital, Prague 14059, Czech Republic
Andrea Vajsova, Institute of Pathology, First Faculty of Medicine and General Teaching Hospital, Prague 12800, Czech Republic
Author contributions: Hlavaty M, Brezina J, Bajer L, Fabian O, and Vajsova A acquired the data; Hlavaty M, Brezina J, Bajer L, Fabian O, Hucl T, and Drastich P contributed to the conceptualization and investigation; Hlavaty M and Modos I performed the data curation and formal analysis; Hlavaty M, Bajer L, and Drastich P drafted the manuscript; Hlavaty M, Brezina J, Wohl P, Modos I, Bajer L, Fabian O, Vajsova A, Hucl T, and Drastich P reviewed and edited the final manuscript; Brezina J, Bajer L, Fabian O, Hucl T, and Drastich P supervised the study; All authors read and approved the final manuscript.
Supported by the Ministry of Health of the Czech Republic in cooperation with the Czech Health Research Council, No. NU21J-06-00027 and No. NU22-06-00269; and Ministry of Health, Czech Republic (Institute for Clinical and Experimental Medicine), No. IN 00023001.
Institutional review board statement: This study was approved by the Medical Ethics Committee of Clinical and Experimental Medicine and Thomayer University Hospital, Prague, Czech Republic (Approval No. 31869/20).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: The data that support the findings of this study are available from the corresponding author, Pavel Drastich, upon reasonable request.
Corresponding author: Pavel Drastich, MD, PhD, Associate Professor, Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Videnska 1958/9, Prague 14021, Czech Republic.
padr@ikem.cz
Received: August 11, 2025
Revised: September 25, 2025
Accepted: January 8, 2026
Published online: March 27, 2026
Processing time: 228 Days and 10.9 Hours
BACKGROUND
Liver transplantation (LT) is the most effective treatment for the advanced stages of primary sclerosing cholangitis (PSC). However, up to 30% of patients develop recurrence of PSC (rPSC), which negatively affects graft and patient outcomes. Given the heterogeneous nature of PSC, patients undergo LT either due to end-stage liver disease (ESLD) or to symptoms that significantly reduce quality of life (non-ESLD), such as recurrent bacterial cholangitis or refractory pruritus. However, it remains unclear whether these indicators influence post-LT outcomes.
AIM
To compare post-LT outcomes between PSC recipients with ESLD and non-ESLD indications, and identify rPSC and graft failure risk factors.
METHODS
This single-center retrospective study comprised 131 adult LT recipients for PSC (including PSC/autoimmune overlap). Patients were grouped by listing indication for comparison of ESLD vs non-ESLD. ESLD was defined as model for ESLD score ≥ 15 and Child-Pugh score ≥ 8, or ≥ 1 sign of decompensated cirrhosis. Time-to-event outcomes were analyzed using Kaplan-Meier and Cox models with time-updated covariates.
RESULTS
No significant difference was found in the incidence of rPSC, graft survival, or overall survival between patients indicated for LT for ESLD and those with non-advanced symptomatic disease. Cytomegalovirus infection (hazard ratio [HR] = 2.16; 95% confidence interval [CI]: 1.05-4.46), acute cellular rejection (ACR) (HR = 3.95; 95%CI: 1.44-10.8), and length of hospitalization after LT (HR = 1.02; 95%CI: 1.01-1.04) were significantly associated with risk of rPSC. In addition, multiple episodes of ACR (HR = 4.93; 95%CI: 1.22-19.9) and the length of hospitalization after LT (HR = 1.04; 95%CI: 1.01-1.06) were significantly associated with graft failure.
CONCLUSION
Patients with PSC with advanced liver cirrhosis before LT did not have worse post-transplant outcomes than those without ESLD. Cytomegalovirus infection, ACR, and prolonged hospitalization after LT were associated with worse outcomes after LT in PSC.
Core Tip: This study demonstrated the outcomes of liver transplantation (LT) recipients with primary sclerosing cholangitis (PSC) and risk factors for recurrence of PSC (rPSC) and graft failure. Patients with PSC undergoing LT for end-stage liver disease have similar rPSC rates, graft failure rates, and overall survival comparable to those undergoing LT for non-end-stage liver disease indications (e.g., recurrent bacterial cholangitis). Acute cellular rejection, cytomegalovirus infection, and longer postoperative hospitalization were associated with both rPSC and graft failure. Identification of risk factors is necessary to better understand the pathogenesis of rPSC.
