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 (interquartile range, 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, Model for End-stage Liver Disease (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.