Abstract
Abstract
Background
Despite anti-rejection immunosuppressive therapies post-liver transplantation (LT), patients with concurrent inflammatory bowel disease (IBD) may have persistent bowel inflammation that requires addition of biologic therapy.
Aims
To evaluate the safety of combination biologic and anti-rejection therapy in IBD patients after LT.
Methods
The LT Registry at London Health Sciences Centre (LHSC) was searched to identify all patients undergoing LT from 1985–2018. IBD patients initiated on biologic treatment post-LT, in addition to anti-rejection therapy, were eligible for inclusion. Medical chart review was conducted to extract safety outcomes, including rates of infections, malignancy, colectomy and death.
Results
19 patients were included (78.9% male, mean age 46.0 years, 8 patients with ulcerative colitis), followed for a median duration of 19 months (IQR 5.8, 30.8). Indications for LT included: primary sclerosing cholangitis (PSC) (14/19, 73.7%), autoimmune hepatitis (AIH) (2/19, 10.5%), AIH-PSC overlap syndrome (2/19, 10.5%), and biliary atresia (1/19, 5.3%). Post-LT, six patients were treated with only TNF antagonists (infliximab in 5 patients, golimumab in 1 patient); eight patients with only anti-integrin therapies (vedolizumab in 7 patients, natalizumab in 1 patient); and five patients with sequential TNF antagonists followed by either ustekinumab (n=2) or vedolizumab (n=3). Six patients required long-term prednisone. The most commonly used anti-rejection therapies were tacrolimus and mycophenolate mofetil. Disease course was complicated by infections in nine patients (47.4%), most commonly Clostridium difficile colitis (4/19, 31.6%). One patient had recurrent C. difficile infection and one patient had CMV colitis and viremia. Other infections included cholangitis (n=2), perianal abscess (n=1), JC virus seroconversion but without progressive multifocal leukoencephalopathy (n=1) and hospital-acquired pneumonia (n=1). Two patients required colectomy for refractory colitis. One patient required re-transplantation due to PSC recurrence. No deaths or malignancies were reported although one patient developed low grade colonic dysplasia.
Conclusions
This is the largest reported case series from a single center to date evaluating the safety of combination biologic therapy with anti-rejection regimens in IBD patients post-LT. Whilst there appeared to be an increased risk of enteric infections, especially Clostridium difficile,there were no life-threatening infections reported. Active screening for enteric infections should be pursued in these patients presenting with increased IBD symptoms.
Funding Agencies
None