Rate, Risk Factors, and Outcomes of Pouchitis After Liver Transplantation for Primary Sclerosing Cholangitis

Abstract

Introduction: The presence of primary sclerosing cholangitis (PSC) is associated with an increased risk of chronic pouchitis following total proctocolectomy with ileal pouch-anal anastomosis (IPAA). It is unclear how liver transplantation (LT) for PSC modifies this risk. Aims: To determine the cumulative incidence of and risk factors for chronic pouchitis in patients (pts) with PSC undergoing LT. Methods: We identified all pts who underwent LT for advanced stage PSC for non-cholangiocarcinoma indications at our center from 1984-2012, with follow-up through December, 2015. Information on chronic pouchitis was extracted. The 1-, 5- and 10- cumulative risks of chronic pouchitis were estimated using Kaplan-Meier curves. Demographic and transplant--related features associated with risk of developing chronic pouchitis were assessed using multivariate Cox proportional hazard analysis. Results: Three hundred seventy-three pts underwent LT for PSC, of which 80 were performed for cholangiocarcinoma, and 177 had no colectomy before or after LT. One hundred and sixteen PSC pts who underwent colectomy (72 pre-LT and 44 post-LT) for refractory disease or advanced neoplasia (mean age, 45.6±11.5 yrs; 58.6% males, 2.6% smoking at time of LT, 92.2% with IBD before LT) formed our study cohort. Of 72 patients who underwent colectomy pre-LT (34 IPPA, 32 ileostomy, 6 ileoanal pull through), 44 (61.1%) developed pouchitis before or after LT; four of them were antibiotics-dependent. Of 44 pts who underwent colectomy post-LT (25 IPAA, 19 ileostomy) and were followed a median (interquartile range) of 3.0 yrs (1.5-7.2), 16 IPAA pts (64%) developed at least one episode of pouchitis after LT; three of them had antibiotics-refractory pouchitis. The 1-, 5- and 10-yr cumulative incidence of pouchitis was 20%, 60% and 60% respectively. On univariate analysis, high neutrophils counts at time of LT (hazard ratio [HR], 1.32; 95% CI, 1.004-1.734, P=0.046) increased pouchitis risk. Conclusion: The 10-year risk of pouchitis after LT for advanced stage PSC was about 60%. High neutrophil counts at time of LT increased the risk of pouchitis.