title: The changing clinical presentation of recurrent primary biliary cirrhosis after liver transplantation.
abstract: BACKGROUND
  Recurrent disease after liver transplant is a significant problem. Recurrent primary biliary cirrhosis (RPBC) is a histologic diagnosis. Clinical data is unreliable in predicting or diagnosing recurrence. RPBC appears to have a changing clinical presentation in recent years.
  
  
  METHODS
  The diagnosis of RPBC after liver transplantation was made histologically. Data were obtained from our prospectively maintained liver-transplant database and evaluated statistically.
  
  
  RESULTS
  Between 1985 and 1999, 1,835 liver transplants were performed, 169 for PBC. One hundred fifty-six patients were evaluated (one patient received retransplantation, and 13 were excluded). Seventeen (10.9%) experienced recurrence. Median posttransplantation follow-up time was 72.1 months. Median time to recurrence was 49.6 months. Median follow-up time after recurrence was 11.5 months. Neither acute rejection episodes (P=0.34) nor OKT3 use (P=0.36) before diagnosis of recurrence was significant. The combination of cyclosporine, azathioprine, and prednisolone demonstrated recurrence in 6 of 71 (8.4%). Six of 49 (12.2%) patients treated with cyclosporine with or without mycophenolate mofetil and prednisolone experienced recurrence. Six of 36 (16.7%) patients treated with tacrolimus and prednisolone with or without mycophenolate mofetil experienced recurrence. Patients treated with cyclosporine had numerically fewer recurrences than those treated with tacrolimus (P=0.11).
  
  
  CONCLUSIONS
  Patients with RPBC demonstrated prolonged survival. Clinical factors did not aid in predicting RPBC. The clinical course of RPBC appears to be different than in the earlier years of liver transplantation. Immunosuppression may play a role. The use and type of antimetabolite drugs had no affect on recurrence. RPBC demonstrated a different clinical course with tacrolimus treatment (shorter time to recurrence) and increased incidence when compared with cyclosporine treatment. Controlled randomized studies are necessary to determine differences between tacrolimus and cyclosporine treatment, if any.
authors.affiliation: Baylor University Medical Center, Transplantation Services, Dallas, TX 75246, USA.
authors.forename: Edmund Q
authors.initials: EQ
authors.lastname: Sanchez
authors.forename: Marlon F
authors.initials: MF
authors.lastname: Levy
authors.forename: Robert M
authors.initials: RM
authors.lastname: Goldstein
authors.forename: Carlos G
authors.initials: CG
authors.lastname: Fasola
authors.forename: Glenn W
authors.initials: GW
authors.lastname: Tillery
authors.forename: George J
authors.initials: GJ
authors.lastname: Netto
authors.forename: David L
authors.initials: DL
authors.lastname: Watkins
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Weinstein
authors.forename: Natalie G
authors.initials: NG
authors.lastname: Murray
authors.forename: Derek
authors.initials: D
authors.lastname: Byers
authors.forename: Laura L
authors.initials: LL
authors.lastname: Christensen
authors.forename: Goran B
authors.initials: GB
authors.lastname: Klintmalm
mesh_terms: D004359:Drug Therapy, Combination; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology; D006680:HLA Antigens / Q000032:analysis; D006650:Histocompatibility Testing / Q000379:methods; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000097:blood; D008105:Liver Cirrhosis, Biliary / Q000453:epidemiology* / Q000473:pathology*; D016031:Liver Transplantation / Q000276:immunology / Q000401:mortality / Q000706:statistics & numerical data*; D008285:Major Histocompatibility Complex; D018579:Patient Selection; D011237:Predictive Value of Tests; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors
chemical_list: D006680:HLA Antigens; D007166:Immunosuppressive Agents; D007518:Isoantibodies