P1172 Real world experience using advanced therapies to treat Inflammatory Bowel Disease in patients with a Liver Transplant
Authors: Campbell S , Rak A , Radia C , Frolkis A , Patel M , Dubois P , Hakeem A , Pavlidis P , Cortes-Cerisuelo M , Joshi D , Kent A 
Published: January 2025

Abstract

Background
Inflammatory Bowel Disease (IBD) with Liver Transplantation (LT) presents a complex dilemma between disease control versus immunosuppression. The association of IBD and primary sclerosing cholangitis (PSC), alongside increasing metabolic dysfunction-associated fatty liver disease (MAFLD) in the population, is likely to increase the number requiring LT. (1) While immunosuppression therapy post-transplant is standardised, the proliferation of advanced therapies for IBD have unknown efficacy and safety in the setting of LT. (2) We describe our experience of IBD patients with a LT, requiring advanced therapies (AT; biologic or small molecule).

Methods
Patients with IBD, who underwent LT at King’s College Hospital were included. Retrospective data was collated, including demographics, IBD, AT and LT details.

Results
81 IBD patients have undergone a LT, of whom 59 were diagnosed with IBD pre-LT. IBD subtypes were ulcerative colitis (UC;89.7%), Crohn’s disease (7.7%), and IBD-U (2.6%). Aetiology of liver disease was PSC (46.1%) and PSC/AIH (48.7%) and other (5.2%). Median age at first LT was 30 years (IQR 4-66), and second LT was 41 years (IQR 19-67). Anti-rejection medications were tacrolimus and low-dose steroids. There was no significant difference in immunosuppression regimens in those who developed IBD post-LT (p=0.70).
Overall, 36/81 (44%) IBD patients who have undergone LT required an AT. Pre-LT 9/59 (15%) patients required AT; mean time between starting AT and LT was 48 months with an anti-TNF being initiated in 77.7%, and Vedolizumab in 11.1% (figure 1). 26/81 (32%) required AT post-LT and first-line AT was Vedolizumab in the majority (48.2%).
17 patients (43.6%) received one AT only, and 22 patients received 2 or more. 17 patients (43.5%) required surgery for their IBD. Nine patients on AT required re-LT; 6 (66.7%) started AT post first LT.
Of the patients requiring AT during their disease course (36/81), 36.6% patients developed cholangitis post-LT; 50% were on an AT at the time of cholangitis (unable to extrapolate data in 28.5%). Acute cellular rejection (ACR) occurred in 16 patients within the first 12 months after first LT, but only 1 had AT initiated within this time frame. IBD subtype did not influence incidence of ACR.

Conclusion
In our cohort, 32% of patients required initiation of an advanced therapy after liver transplantation. It is unclear whether this reflects the natural course of IBD, or influence of LT. 37% patients developed cholangitis post-LT of whom 50% were on AT at the time of cholangitis. As the incidence of IBD AT use increases, multi-centre experience will be invaluable, to collate larger numbers to assess the safety and efficacy of patients with IBD with co-existing LT, on AT.

References
1.Rodriguez-Duque JC, Calleja JL, Iruzubieta P, Hernández-Conde M, Rivas-Rivas C, Vera MI, Garcia MJ, Pascual M, Castro B, García-Blanco A, García-Nieto E, Olmo SC, Cagigal ML, Lopez-Montejo L, Fernández-Lamas T, Rasines L, Fortea JI, Vaque JP, Frias Y, Rivero M, Arias-Loste MT, Crespo J. Increased risk of MAFLD and Liver Fibrosis in Inflammatory Bowel Disease Independent of Classic Metabolic Risk Factors. Clin Gastroenterol Hepatol. 2023 Feb;21(2):406-414.e7.
2.Westerouen van Meeteren MJ et al. Safety of anti-TNF treatment in liver transplant recipients: A systematic review and meta-analysis. Journal of Crohn's and Colitis. 2017; Vol. 11, pp. 1146-1151.