PSC-IBD: Liver transplantation & CRC

July 8, 2025

Issue 13

Clinical Question

Does liver transplantation modify the risk of colorectal cancer and dysplasia in patients with primary sclerosing cholangitis and IBD?

Editor’s Bottom Line

Liver transplantation is associated with a reduced risk of subsequent colorectal dysplasia in patients with PSC and IBD. However the risk remains high, and surveillance should be continued.

Reference

Coelho-Prabhu N, Ohri A, Benatzky C, et al. Liver Transplantation Is Associated With a Reduced Risk of Colorectal Dysplasia in Patients with IBD and Concomitant PSC. Clin Gastroenterol Hepatol. Epub ahead of print May 9, 2025. https://www.cghjournal.org/article/abstract

Synopsis

To determine whether liver transplantation reduces the risk of colorectal neoplasia risk in patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD), researchers from the Mass General Brigham healthcare system and Mayo Clinic identified 979 patients with PSC-IBD, including 320 patients (33%) who underwent liver transplantation and 659 control patients without transplantation. Control patients were matched 2:1 at both sites and also matched for calendar period of IBD diagnosis in 5-year intervals at Mayo Clinic to ensure contemporary comparison groups.

The study population was predominantly male (66%) with ulcerative colitis (UC) (83%). The mean ages at IBD and PSC diagnosis were 32 years and 39 years, respectively, with a mean IBD disease duration of 18 years. Among patients with UC, 98% had pancolitis, while among those with Crohn’s disease (CD), 98% had colonic (41%) or ileocolonic (57%) disease. The mean interval between transplantation and end of follow-up in the liver transplant group was 10 years.

During follow-up, 239 patients (24%) developed colorectal neoplasia, including low-grade dysplasia in 19.5% (n=191), high-grade dysplasia in 7% (n=70), and colorectal cancer in 5.6% (n=55). In the liver transplant group, 21% of patients developed colorectal neoplasia compared with 26% in the non-transplanted group (Odds Ratio [OR]: 0.76; 95% Confidence Interval [CI], 0.55–1.04; p=0.086).

Multivariable analysis demonstrated that liver transplantation was associated with a 34% reduced risk of colorectal neoplasia (adjusted OR [aOR]: 0.66; 95% CI, 0.47–0.93).

When analyzed by neoplasia category, patients with PSC-IBD who underwent liver transplantation had lower risks of both low-grade dysplasia (aOR: 0.56; 95% CI, 0.38–0.83) and high-grade dysplasia (aOR: 0.56; 95% CI, 0.30–1.04). No such association was observed for colorectal cancer (aOR: 1.10; 95% CI, 0.60–2.02). There was also no association between liver transplantation and invisible dysplasia detected on random biopsies (aOR: 0.97; 95% CI, 0.62–1.51).

Among transplanted patients, a larger proportion of those who developed colorectal neoplasia had recurrent PSC in the transplanted liver (54%) compared with those who did not develop dysplasia (38%) (p=0.017). The protective association between liver transplantation and colorectal neoplasia was stronger when patients with recurrent PSC were excluded (aOR: 0.51; 95% CI, 0.32–0.79).

The association between liver transplantation and reduced dysplasia risk remained robust across multiple sensitivity analyses. Excluding patients who underwent proctocolectomy during follow-up for non-dysplastic indications did not significantly change the association (aOR: 0.59; 95% CI, 0.39–0.89). The association remained unchanged when the analysis was restricted to the contemporary era of high-definition white light endoscopy from 2006 onward (aOR: 0.59; 95% CI, 0.40–0.88) or when patients with CD were excluded (aOR: 0.69; 95% CI, 0.48–0.99).

Details

Study Design: Retrospective cohort study
Funding: Not stated
Allocation: Not applicable
Setting: Multicenter
Level of Evidence: 2b