Risk Factors for Primary Sclerosing Cholangitis Recurrence Following Liver Transplantation: A Multicenter Retrospective Analysis

BACKGROUND AND AIMS: Primary sclerosing cholangitis recurrence (rPSC) after liver transplantation (LT) is common; however, the factors contributing to rPSC are poorly understood. This study aimed to identify the risk factors for rPSC after LT and determine whether donor type affects rPSC. METHODS: A multicenter retrospective cohort analysis was conducted on 174 patients with PSC who underwent LT between January 2000 and January 2024. Multivariable Cox models were used to evaluate risk factors for rPSC. The rPSC risk for living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) recipients was compared using Kaplan-Meier survival curves and log-rank tests. RESULTS: Of the 174 recipients, 144 (83%) underwent LDLT and 30 (17%) underwent DDLT. Sixty-four (37%) had inflammatory bowel disease (IBD) prior to LT. Thirty-three patients (19%) had rPSC after LT. The median time to rPSC was 28 months (IQR 6-252). Patients with rPSC were younger at the time of PSC diagnosis, and had a higher prevalence of biliary complications after LT and concomitant IBD than those without recurrence. Multivariable Cox regression identified LDLT (HR 3.92, 95% CI 1.06-14.51, p = 0.041), biliary complications (HR 2.18, 95% CI 1.05-4.54, p = 0.037), IBD (HR 2.42, 95% CI 1.20-4.89, p = 0.013), and acute cellular rejection (HR 2.43, 95% CI 1.08-5.48, p = 0.032) as independent risk factors for rPSC. CONCLUSIONS: This multicenter study identified LDLT, acute cellular rejection, IBD, and biliary complications as independent risk factors for rPSC. These findings underscore the need for individualized post-transplant surveillance and provide important considerations for graft selection and perioperative management in patients with PSC, particularly in settings where LDLT is predominant.