Liver transplant outcomes in primary biliary cholangitis and metabolic dysfunction-associated steatotic liver disease overlap

Primary biliary cholangitis (PBC) frequently overlaps with metabolic dysfunction-associated steatotic liver disease (MASLD). The impact of concurrent MASLD on liver transplant (LT) in PBC remains unclear. This study compared pre- and post-LT outcomes between PBC with and without MASLD. We conducted a retrospective study using the UNOS/OPTN database to compare adult LT candidates with PBC or concomitant PBC/MASLD from 2002 to 2024. Nearest neighbor 1:1 propensity matching by multiple variables ensured cohort comparability. Outcomes included transplant probability, waitlist dropout, and post-LT patient and graft survival, analyzed with Kaplan-Meier and adjusted Cox regression. Before matching, PBC/MASLD had higher BMI (pre-transplant: 31.9 vs 26.8; post-transplant: 32.0 vs 26.6) and more diabetes (pre-transplant: 45% vs 15%; post-transplant: 42% vs 14%) compared to PBC-only. After matching (215 pre- and 151 post-transplant), PBC-only showed higher waitlist dropout (p=0.005). Post-transplant patient and graft survival rates were similar between groups. Among PBC/MASLD, diabetes was associated with significantly lower long-term patient survival (10-year survival: 46% vs 76% in PBC/MASLD without diabetes, p=0.01). On multivariate analysis, PBC/MASLD with diabetes remained the strongest independent predictor of post-transplant mortality (aHR 2.31, p=0.003), followed by MELD score (aHR 1.03 per point, p=0.02). PBC is associated with increased waitlist dropout compared to PBC/MASLD. Post-LT survival is comparable between groups unless diabetes is present, which significantly impairs long-term outcomes in PBC/MASLD. Prioritized diabetes screening and metabolic management post-LT is essential in this group. Future research should investigate factors affecting waitlist dropout and optimal glycemic control strategies in PBC patients.