Liver transplant and autoimmune liver diseases: An up-to-date review

Table 4 Recurrence after liver transplantation in autoimmune liver diseases

Disease	Estimated recurrence rate and main risk factors	Post-transplant surveillance and management considerations	Ref.
AIH	Recurrence in 10%-35% of recipients; risk increases with younger age, high pre-LT inflammatory activity, rapid corticosteroid withdrawal, and use of tacrolimus-based regimens (evidence moderate)	Monitor AST, ALT, IgG levels every 3 months in first year; consider protocol biopsy at 12 months in high-risk cases; maintain low-dose corticosteroid or azathioprine in selected patients to reduce recurrence	[97,101]
PBC	Recurrence in 15%-25% of cases; higher risk with female sex, younger age, persistent cholestasis, and shorter duration of UDCA therapy pre-LT (evidence moderate)	Routine monitoring of ALP and GGT; early recognition of cholestasis patterns; UDCA prophylaxis may be considered in centers with historically higher recurrence or in patients with biochemical cholestasis - not mandatory per EASL/AASLD guidelines	[71,73,74]
PSC	Recurrence in 20%-30% of recipients; increased risk with active IBD, male sex, younger age, and biliary anastomotic strictures (evidence moderate-high)	Surveillance with MRCP or ultrasound every 6-12 months and liver biochemistry every 3 months; aggressive management of IBD activity; prompt treatment of biliary strictures or infections to prevent graft injury	[17,95,99]

AIH: Autoimmune hepatitis; PBC: Primary biliary cholangitis; PSC: Primary sclerosing cholangitis; IBD: Inflammatory bowel disease; LT: Liver transplantation; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; UDCA: Ursodeoxycholic acid; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transferase; EASL: European Association for the Study of the Liver; AASLD: American Association for the Study of Liver Diseases; MRCP: Magnetic resonance cholangiopancreatography.