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World J Gastroenterol. May 28, 2014; 20(20): 6159-6169
Published online May 28, 2014. doi: 10.3748/wjg.v20.i20.6159
Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation
Moustafa Mabrouk Mourad, Abdullah Algarni, Christos Liossis, Simon R Bramhall
Moustafa Mabrouk Mourad, Abdullah Algarni, Christos Liossis, Simon R Bramhall, Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom
Author contributions: Mourad MM designed the study; Mourad MM, Algarni A, Liossis C collected, analysed, interpreted the data, and drafted the article; Bramhall SR designed the conception, critically revised the manuscript for important intellectual content, and made the final approval of the version to be published.
Correspondence to: Moustafa Mabrouk Mourad, MS, MRCS, Liver Unit, Queen Elizabeth Hospital, Nuffield House 3rd Floor, Edgbaston, Birmingham B15 2TH, United Kingdom.
Telephone: +44-742-7365931 Fax: +44-121-4141833
Received: October 28, 2013
Revised: January 26, 2014
Accepted: March 19, 2014
Published online: May 28, 2014

Liver transplantation (LT) is the best treatment for end-stage hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis. It commonly presents with cholestasis and cholangitis resulting in higher readmission rates, longer length of stay, repeated therapeutic interventions, and eventually re-transplantation with consequent effects on the patient’s quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (DCD), rejection, and cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in DCD grafts compared to between 3% and 17% in donation after brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in DCD compared to 90 d in DBD grafts following transplantation. However, there are many other risk factors for IC that should be considered. The benefits of DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-transplantation. Careful donor selection and procurement might help to optimize the utilization of DCD grafts.

Keywords: Ischaemic cholangiopathy, Biliary complications, Orthotopic liver transplantation, Donation after circulatory death, Reperfusion injury, Cold ischaemia time

Core tip: Biliary complications after liver transplantation represent a major challenge. Ischaemic cholangiopathy is a set of disorders characterized by multiple diffuse intrahepatic strictures. Ischaemic cholangiopathy can cause a late graft loss. It becomes more evident after the widespread usage of grafts after circulatory deaths. Awareness of predisposing factors, presentation, diagnosis, and management is mandatory. Prophylaxis is essential by controlling risk factors. Management varies from simple radiological interventions to re-transplantation.