The Effect of Immunsuppressive Treatment Agents on Post-ERCP Pancreatitis in Living Donor Liver Transplant Patients

Abstract Introduction: Liver transplantation is now routine for end-stage liver disease, but biliary complications occur in ~ 5–30% of recipients. Endoscopic retrograde cholangio-pancreatography (ERCP) has become the gold standard for managing these issues, yet post-ERCP pancreatitis (PEP) remains the most common adverse event, and its risk factors in transplant patients are not well defined. We aimed to identify predictors of PEP in liver transplant recipients, with a specific focus on the association between immunosuppressive therapy and PEP. Materials and Methods. This single-center retrospective cohort included 1,338 liver-transplant recipients who subsequently underwent ERCP. The following variables were extracted from the medical record: age, sex, transplant etiology; type of biliary anastomosis at transplantation (duct-to-duct vs Roux-en-Y hepaticojejunostomy); prior endoscopic sphincterotomy (EST); use of pre-cut (needle-knife) sphincterotomy at the index ERCP; placement of a common bile duct stent; maintenance immunosuppressive regimen; post-procedure antibiotic use; ERCP indication; number of ERCP sessions; and occurrence of PEP. A multivariable logistic-regression analysis was perfomed to identify determinants of PEP. Results A total of 1,338 liver transplant recipients who underwent ERCP were screened, of whom 274 patients with complete clinical and follow-up data were included in the final analysis, comprising 1,174 ERCP sessions. Post-ERCP pancreatitis (PEP) occurred in 66 patients, yielding an overall incidence of 5.6%. Age, sex, graft lobe, biliary anastomosis type, stent placement, and maintenance immunosuppressive regimen were not associated with PEP (all p > 0.05). Precut sphincterotomy was significantly more frequent among patients who developed PEP and was independently associated with increased risk in multivariable analysis (adjusted OR 2.72, 95% CI 1.37–5.42; p = 0.004). In contrast, a history of prior endoscopic sphincterotomy was independently protective (adjusted OR 0.43, 95% CI 0.22–0.84; p = 0.013). Conclusion Post-ERCP pancreatitis occurred in about 5% of liver transplant recipients in this cohort. Precut sphincterotomy significantly increased the risk, while prior endoscopic sphincterotomy appeared protective. Immunosuppressive therapy was not associated with pancreatitis risk. These findings highlight that procedural factors, rather than immunosuppressive agents, are the main drivers of post-ERCP pancreatitis in this population and emphasize the need for careful cannulation techniques.