Primary Sclerosing Cholangitis Recurrence After Liver Transplantation: A Systematic Review and Updated Meta-Analysis.

BACKGROUND AND AIMS: Primary sclerosing cholangitis (PSC) is an immune-mediated cholestatic liver disease. Liver transplantation (LT) remains the only definitive treatment for patients with advanced disease. However, recurrence of PSC (rPSC) after LT is still a significant clinical challenge. The aim of this study was to assess the prevalence and incidence of rPSC following transplantation and to identify factors associated with its occurrence.

METHODS

We conducted a systematic review and meta-analysis of observational cohorts by searching PubMed, Embase and Cochrane for studies. Statistical analyses were conducted using R, applying a random-effects model with 95% confidence intervals.

RESULTS

Twenty-nine studies were included, comprising 4682 patients who underwent LT for PSC (63.7% male). Most data originated from Europe (51.7%) and North America (29.2%), with additional cohorts from Asia (13.7%), South America (2.8%) and Oceania (2.6%). The worldwide pooled prevalence of rPSC was 18.66% (95% CI 15.33-22.52; I2 = 84%) between 1980 and 2024. As for the worldwide pooled incidence, rPSC occurred at 26.04 per 1000 person-years (95% CI 19.30-32.78; I2 = 76.1%). The continent with the highest rPSC prevalence was Oceania with 30.65% (95% CI 23.17-39.29; I2 = 13.8%) and South America had the highest incidence with 39.97 per 1000 person-years (95% CI 25.42-54.51). Younger recipient age (mean difference [MD] = 5.16 years, 95% CI 4.13-6.19; I2 = 51.3%), male sex (risk ratio [RR] = 0.92, 95% CI 0.87-0.98; I2 = 0%), post-LT cyclosporine use (RR = 0.56, 95% CI 0.42-0.76; I2 = 0%), acute rejection (RR = 0.64, 95% CI 0.49-0.83) and de novo IBD (RR = 0.63, 95% CI 0.40-0.99; I2 = 0%) were associated with an increased risk of recurrence.

CONCLUSIONS

Prevalence and incidence of rPSC post-LT varied according to continents. Younger recipient age, male sex, de novo IBD, cyclosporine use post-LT and acute rejection episodes were associated with a higher risk of recurrence.

TRIAL REGISTRATION: PROSPERO ID: CRD420250645485.