Anti-tumour necrosis factor treatment of inflammatory bowel disease in liver transplant recipients

Background: Ulcerative colitis (UC) and Crohn's disease can sometimes relapse and be refractory to standard treatment following orthotopic liver transplantation (OLT) despite post-transplantation immunosuppressive therapy. Aim: To evaluate the efficacy and safety of anti-tumour necrosis factor (anti-TNF) agents for the management of IBD following OLT. Methods: We reviewed the records of patients with a diagnosis of IBD who underwent OLT at Mayo Clinic Rochester between 1985 and 2009. Patients were included if they had received anti-TNF therapy post-OLT. Clinical response was defined as a physician's assessment of improvement after 12 weeks of anti-TNF usage, and mucosal healing was defined as the absence of ulcerations on follow-up endoscopy. Results: The median age of the eight study patients was 42.0 years and 37.5% were female patients. All had been diagnosed with IBD prior to OLT (UC in three and Crohn's disease in five). Indication for OLT was cirrhotic stage primary sclerosing cholangitis (PSC), and three concomitantly had cholangiocarcinoma. Clinical response was demonstrated in seven of eight patients (87.5%) and mucosal healing was demonstrated in three of seven (42.9%). Four infections (oral candidiasis, Clostridium difficile colitis, bacterial pneumonia and cryptosporidiosis) in three patients were reported. One patient developed an Epstein-Barr virus-positive post-transplant lympho-proliferative disorder. One death occurred due to complications from recurrent PSC. Conclusions: Starting Anti-TNF therapy following orthotopic liver transplantation appears to be a potential option for inflammatory bowel disease management. Additional studies are needed, however, to confirm these findings and to further assess risks associated with this treatment strategy.