Early MRCP surveillance for recurrent primary sclerosing cholangitis after liver transplantation: a prospective imaging study

The true incidence and early course of recurrent primary sclerosing cholangitis (rPSC) after liver transplantation (LT) remain uncertain, largely because most studies rely on clinical/biochemical features which trigger imaging. We prospectively evaluated rPSC incidence, risk factors, and outcomes in all adult PSC transplant recipients (January 2017 - September 2024) using a predefined magnetic resonance cholangiopancreatography (MRCP) surveillance protocol at 1 and 3 years. rPSC was diagnosed by Mayo criteria, and advanced rPSC was defined by therapeutic endoscopic intervention, retransplantation, or death. Among 119 recipients, 105 were eligible for follow-up and 102 completed at least the first scheduled MRCP. Recurrent disease occurred in 50 of 102 recipients (49.0%), including 31 (30.4%) already detected at the first imaging. During a median follow-up of 56 months, advanced rPSC developed in 15/102 patients (14.7%). Ulcerative colitis, de novo post-transplant inflammatory bowel disease (IBD), and post-transplant IBD flare were associated with recurrence. Independent predictors of advanced recurrence were male sex, cytomegalovirus viremia, and lower donor body mass index, whereas cytomegalovirus donor-recipient mismatch was protective. Cytomegalovirus viremia was observed in 9 of 102 patients. Kaplan–Meier analyses showed faster progression to advanced recurrence in patients with cytomegalovirus viremia than in cytomegalovirus-negative recipients. Protocol-driven MRCP surveillance demonstrates that rPSC is frequent and often detectable early after liver transplantation, identifying a potential therapeutic window before clinical manifestations occur. Distinct risk profiles may suggest two phenotypes: an IBD-driven and a cytomegalovirus-associated form.