Patients with post-transplant biliary strictures have significantly higher rates of liver transplant failure and rejection: A nationwide inpatient analysis

Background and aim: Biliary strictures are a common complication of liver transplantation. We assess the impact of post-transplant biliary strictures and describe the outcomes of endoscopic retrograde cholangiopancreatography (ERCP), interventional radiology (IR), and surgical therapies.

Methods: Using the Nationwide Readmissions Database (NRD), hospitalized liver transplant recipients were identified using the International Classification of Diseases 10th Revision codes. Patients with post-transplant biliary strictures were identified, and outcomes (inpatient mortality, 30-day readmission, transplant rejection/infection/failure, and disposition) were compared with transplant recipients without strictures. Among transplant patients with biliary strictures who underwent therapeutic intervention, corresponding outcomes were compared between IR, surgical interventions, and ERCP.

Results: Of the 8300 liver transplant recipients meeting selection criteria, 554 patients (age 48.9 ± 18.2 years, mean ± SD; 39.5% women) had biliary strictures. Compared with patients without strictures, the adjusted odds ratio (OR) for various outcomes in patients with biliary strictures were as follows: 1.46 (1.20, 1.77; P < 0.001) for 30-day non-elective readmission, 2.71 (2.04, 3.59; P < 0.001) allograft rejection, 2.32 (1.61, 3.37; P < 0.001) liver transplant failure, 3.05 (1.39, 6.73; P < 0.01) infection, and 1.41 (1.08, 1.82; P = 0.01) disposition to skilled nursing or intermediate care facility. Therapeutic interventions during index hospitalization were performed in 350 patients: ERCP 46.6% (n = 163), surgery 41% (n = 144), and IR 12.3% (n = 43) patients. Compared with ERCP, the adjusted odds for various outcomes were disposition to skilled nursing or intermediate care facility 2.72 (1.08, 6.87; P = 0.03) and 2.09 (1.05, 4.15; P = 0.036), prolongation of hospitalization 14.4 (3.7, 25.1; P = 0.008) and 15.0 (7.4, 22.7; P < 0.001), and failure of liver allograft 8.47 (1.47, 48.6; P = 0.017) and 12.23 (2.74, 54.4; P = 0.001) for IR and surgical interventions, respectively.

Conclusion: Post-liver transplant biliary strictures are associated with increased rates of allograft rejection, allograft failure/infections, and readmissions. Compared with ERCP, management of these patients with IR or surgical interventions is associated with significantly higher rates of allograft failure and hospital stay.