Long-term clinical and endoscopic outcomes of ulcerative colitis after liver transplantation: a multicenter cohort study on the use and safety of advanced therapies

Background Some patients with ulcerative colitis (UC) develop advanced liver disease due to conditions such as primary sclerosing cholangitis (PSC) and may require liver transplantation (LT). However, data on the long-term course of UC and the use of advanced therapies in LT recipients are limited. We aimed to evaluate UC activity before and after LT, as well as the role of advanced therapies over extended follow-up in this population. Methods This was a retrospective, multicenter cohort study including 213 patients with UC who underwent LT between 2000 and 2022. Clinical disease activity (partial Mayo score), endoscopic disease activity (Mayo endoscopic subscore), and the use of advanced therapies were evaluated before and after transplantation. Results Among the 213 patients, the clinical remission rate was 84.7% before and 81.2% after LT, showing no significant change (P = .416). Despite stable clinical remission, 27.9% of patients exhibited moderate-to-severe endoscopic inflammation during long-term follow-up (mean: 110 months). The use of advanced therapies increased significantly after LT (from 3.7% to 12.7%, P = .005) and was not associated with an increase in infectious complications (P = .591). Conclusions In most patients, clinical disease activity remains stable after LT. However, persistent moderate-to-severe mucosal inflammation is observed in a substantial subset during long-term follow-up. Advanced therapies, particularly vedolizumab, are being used more frequently in this setting and may offer disease control without a corresponding increase in infection risk. These findings underscore the need for individualized, interdisciplinary management and further prospective evaluation of treatment strategies in this population.