Recurrent primary biliary cholangitis after liver transplantation: A global meta-analysis of epidemiology and risk factors.

Recurrent primary biliary cholangitis (rPBC) after liver transplantation (LT) is thought to influence graft survival and long-term outcomes, yet its global burden and determinants remain poorly defined. We aimed to quantify the prevalence and incidence of histologically confirmed rPBC after LT and identify associated risk factors. We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines. The protocol was registered on PROSPERO. We searched PubMed, EMBASE, and Cochrane Central up to January 2025 for cohort and cross-sectional studies reporting histologically defined rPBC after LT. We pooled prevalence and incidence (per 1000 person-years) using generalized linear mixed models and synthesized hazard ratios (HRs) with 95% confidence intervals (CIs) for risk factors via random-effects meta-analysis. Fifty-four studies encompassing 5710 patients were included. The pooled incidence of rPBC was 28.5 per 1000 person-years (95% CI, 23.3-35.0), and the prevalence was 15% (95% CI, 12%-19%), with substantial heterogeneity. Country of study moderated prevalence, with the highest and lowest being in Kazakhstan and the Netherlands, respectively. Use of cyclosporine (HR, 0.53; 95% CI, 0.34-0.80) and corticosteroids (HR, 0.65; 95% CI, 0.50-0.84) in maintenance therapy were protective for rPBC, whereas tacrolimus increased risk (HR, 1.80; 95% CI, 1.24-2.61). Each additional year of age at transplant reduced hazard by 3% (HR per year 0.97; 95% CI, 0.96-0.99). An era effect subanalysis found that, in studies published after 1994, cyclosporine maintenance was still superior in preventing rPBC, but tacrolimus was superior for initial immunosuppression (HR, 0.35; 95% CI, 0.22-0.58). rPBC did not significantly affect overall survival (HR, 1.27; 95% CI, 0.67-2.33). rPBC affects a notable proportion of LT recipients and is shaped by immunosuppressive regimen and recipient age. Tailoring immunosuppressive therapy may mitigate recurrence risk. These findings inform clinical decision making and the design of future studies.