Liver and Bile
J Hepatol. 2024;80(1):99–108
Cyclosporine vs. tacrolimus after liver transplantation for primary sclerosing cholangitis – A propensity score-matched intention-to-treat analysis
Background and aims: There is controversy regarding the optimal calcineurin inhibitor type after liver transplant(ation) (LT) for primary sclerosing cholangitis (PSC). The authors compared tacrolimus with cyclosporine in a propensity score-matched intention-to-treat analysis based on registries representing nearly all LTs in Europe and the US.
Methods: From the European Liver Transplant Registry (ELTR) and Scientific Registry of Transplant Recipients (SRTR), they included adult patients with PSC undergoing a primary LT between 2000–2020. Patients initially treated with cyclosporine were propensity score-matched 1:3 with those initially treated with tacrolimus. The primary outcomes were patient and graft survival rates.
Results: The propensity score-matched sample comprised 399 cyclosporine-treated and 1197 tacrolimus-treated patients with PSC. During a median follow-up of 7.4 years (IQR, 2.3–12.8, 12,579.2 person-years), there were 480 deaths and 231 re-LTs. The initial tacrolimus treatment was superior to cyclosporine in terms of patient and graft survival, with 10-year patient survival estimates of 72.8% for tacrolimus and 65.2% for cyclosporine (p < 0.001) and 10-year graft survival estimates of 62.4% and 53.8% (p < 0.001), respectively. These findings were consistent in the subgroups according to age, sex, registry (ELTR vs. SRTR), time period of LT, MELD score, and diabetes status. The acute rejection rates were similar between groups. In the multivariable Cox regression analysis, tacrolimus (hazard ratio [HR] = 0.72, p < 0.001) and mycophenolate use (HR = 0.82, p = 0.03) were associated with a reduced risk of graft loss or death, whereas steroid use was not significant.
Conclusions: Tacrolimus is associated with better patient and graft survival rates than cyclosporine and should be the standard calcineurin inhibitor used after liver transplantation for patients with primary sclerosing cholangitis.