Recurrence of autoimmune liver diseases after liver transplantation: Review and expert opinion statement

Autoimmune liver diseases (AILD) constitute the fourth most common indication for liver transplantation (LT) across the world. In general, the outcomes after LT are acceptable, however, disease recurrence post-LT is common for all AILD which can negatively affect graft and overall survival. Several questions persist, including the risk factors associated with recurrent disease, optimal anti-rejection medications, strategies to reduce the risk of recurrence, and how to best incorporate these strategies into clinical practice. For that reason, we assembled an international group of experts to review evidence to address these outstanding questions regarding liver transplantation for AILD. Survival rates post-LT are approximately 90 and 70% at 1- and 5-years and recurrent disease occurs in 10 to 50% of patients with AILD. In patients with disease recurrence, graft survival decreased by 18% and 28% and overall survival by 8% and 12% at 5 and -10 years after LT, respectively. Recurrent AIH is associated with high aminotransferases and immunoglobulin G (IgG) before LT, lymphoplasmacytic infiltrates in the explants, and may be associated with the absence of steroids after LT. However, the efficiency and safety of triple immunosuppressive maintenance therapy is still debatable. Younger age at diagnosis with PBC or at LT are associated with PBC recurrence. Preventive use of ursodeoxycholic acid reduces the risk of recurrence and has a benefit in graft and patient survival. Episodes of systemic inflammation including T-cell mediated rejection, active ulcerative colitis and episodes of cholangitis are associated with recurrent PSC. Conclusions: Recurrent disease for AILD is associated with worse graft and patient survival. AIH patients could be considered for long-term low-dose predniso(lo)ne, whereas PBC patients should be placed on preventive UDCA after LT. There are no specific treatments for PSC recurrence; however, adequate control of inflammatory bowel disease and optimal immunosuppression to avoid T-cell-mediated rejection should be encouraged.