Inflammatory bowel disease in liver transplanted patients

Table 1 Efficacy of immunosuppressive and inflammatory bowel disease treatment after liver transplant

Drug	Anti-rejection therapy	IBD therapy	IBD efficacy	Potential risks	Ref.
Prednisone	Yes	Induction	Reduction of flare up	Infectious, metabolic side effects risk of PSC recurrence	[40,48]
5-ASA	No	Induction/ Maintenance	80% reduction of flare up	Possible leukopenia with AzA	[15,16,41,48]
			53% induction of remission in recurrent IBD
			75% induction of remission in de novo IBD
AzA	Yes	Induction/ Maintenance	IBD-free survival at 5-years 88%	Leukopenia, pancreatitis, infections, malignancy	[43]
anti-TNF-alpha	No	Induction/ Maintenance	clinical improvement 78% (range 50%-100%) mucosal healing 33%-43%	Infective, autoimmune, neoplastic side effects	[47,91-97]
Tac	Yes	No	Up to 64% flare up (4-fold increased risk) risk of infectious side effects	Infective, metabolic, neoplastic side effects	[35,36,38,43,41]
CsA	Yes	UC induction	In combination with AZA up to 30% flare up risk of side effects	Infective, metabolic, neoplastic side effects	[41]
MMF	Yes	No	ND	Pancitopenia, GI side effects	[51]

LT: Liver transplant; IBD: Inflammatory bowel disease; TNF: Tumor necrosis factor; UC: Ulcerative colitis; CD: Crohn's disease; Tac: Tacrolimus; CsA: Cyclosporine; AZA: Azathioprine; MMF: Mycophenolate mofetil; ND: Not determined; GI: Gastrointestinal.

Table 2 Primary sclerosing cholangitis/inflammatory bowel disease patients proposed management approach in peri-transplant period

Before LT	Adequate treatment of IBD in order to achieve remission
	Annual colonoscopic surveillance screening for neoplasia
	Reconsidering colectomy in patients with refractory disease and neoplasia
	Screen donor and recipient for CMV antibodies
Preoperative	Clinical remission and cessation of smoking are important in order to reduce the risk of flare up after LT
	Consider of pre-emptive/continuation of use of 5-ASA to prevent relapse of IBD
	Consider high risk patients for CMV disease for valganciclovir prophylaxis
Post-transplant	Reconsider risk of rejection and possibility of substituting Tac with CsA in selective patients
	Avoid MMF due to possible gastrointestinal side effects
	Reconsider treatment with AzA in recurrence of IBD
	Reconsider anti-TNF-alfa in refractory IBD
	Carefully monitor for infections, autoimmune diseases and malignancy
	Annual colonoscopic surveillance for neoplasia
	Reconsidering colectomy in patients with refractory disease and neoplasia
	Treat chronic refractory pouchitis according to standard guidelines
	Perform surveillance for recurrent PSC especially in recipients with intact colon at LT
	Screen high risk patients for CMV viremia
	Positive CMV patients treat with valganciclovir or ganciclovir
	Perform surveillance for graft rejection and/or vascular thrombosis in patients with active IBD

LT: Liver transplant; IBD: Inflammatory bowel disease; CMV: Citomegalovirus; Tac: Tacrolimus; CsA: Cyclosporine; AZA: Azathioprine; MMF: Mycophenolate mofetil; TNF: Tumor necrosis factor.