Bile acids for liver-transplanted patients.
BACKGROUND
Liver transplantation has become a widely accepted form of treatment for numerous end-stage liver diseases. Bile acids may decrease allograft rejection after liver transplantation by changing the expression of major histocompatibility complex class molecules in bile duct epithelium and central vein endothelium.


OBJECTIVE
To assess the beneficial and harmful effects of bile acids for liver-transplanted patients.


METHODS
We performed searches of The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Expanded to September, 2009.


METHODS
Randomised clinical trials comparing any dose of bile acids or duration of treatment in liver-transplanted patients versus placebo, no intervention, or another intervention. We included randomised clinical trials irrespective of blinding, language, and publication status.


METHODS
Two review authors extracted and checked data independently. We evaluated the risk of bias of the trials from the method of allocation sequence generation, allocation concealment, blinding, outcome data analysis, outcome data reporting, and other potential sources of bias. We used the intention-to-treat principle to perform meta-analyses and presented the outcomes as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI).


RESULTS
The updated search resulted in no new trials meeting the inclusion criteria of this review, thus leaving it to the seven already included randomised trials (six evaluating ursodeoxycholic acid versus placebo or no intervention, and one evaluating tauro-ursodeoxycholic acid versus no intervention) enrolling a total of 335 participants. The administration of bile acids began one day or more after liver transplantation. All patients received the standard triple-drug immunosuppressive regimen (steroids, azathioprine, and cyclosporine or tacrolimus) to suppress the allograft rejection response after liver transplantation. Bile acids compared with placebo or no intervention did not significantly change all-cause mortality (RR 0.85, 95% CI 0.53 to 1.36), mortality related to allograft rejection (RR 0.30, 95% CI 0.01 to 7.12), retransplantation (RR 0.76, 95% CI 0.20 to 2.86), acute cellular rejection, or number of patients with steroid-resistant rejection. Bile acids significantly reduced the number of patients who had chronic rejection in a fixed-effect model but not in a random-effects model meta-analysis. Bile acids were safe and well tolerated by liver-transplanted patients. However, this observation is based on data analysis from three trials with only 187 patients.


CONCLUSIONS
We did not find evidence to support or refute bile acids for liver-transplanted patients. Further randomised trials are necessary before bile acids can be recommended to liver-transplanted patients.
Department of Gastroenterology, Clinical Hospital Centre Rijeka, Kresimirova 42, Rijeka, Croatia, 51000.
Goran
G
Poropat
Vanja
V
Giljaca
Davor
D
Stimac
Christian
C
Gluud
D002756:Cholagogues and Choleretics / Q000627:therapeutic use*; D006084:Graft Rejection / Q000517:prevention & control*; D006801:Humans; D016031:Liver Transplantation; D016032:Randomized Controlled Trials as Topic; D013655:Taurochenodeoxycholic Acid / Q000627:therapeutic use*; D014580:Ursodeoxycholic Acid / Q000627:therapeutic use*
D002756:Cholagogues and Choleretics; D013655:Taurochenodeoxycholic Acid; D014580:Ursodeoxycholic Acid