Recurrent primary sclerosing cholangitis after liver transplantation: Impact of inflammatory bowel disease on graft outcomes in a Southern European multicenter cohort

Primary sclerosing cholangitis (PSC) is an established indication for liver transplantation (LT), but disease recurrence (rPSC) and the course of associated inflammatory bowel disease (IBD) may influence post-transplant outcomes. This study aimed to determine the prevalence of rPSC and evaluate associated risk factors in a Mediterranean population. We conducted a multicenter retrospective study including PSC patients who underwent LT across 14 transplant centers in Southern Europe. Clinical characteristics, IBD phenotype and activity, immunosuppressive therapy, colectomy status, and post-LT outcomes were analyzed. rPSC was defined according to established diagnostic criteria based on imaging and/or histology after exclusion of secondary causes of biliary injury. A total of 143 patients were included. rPSC occurred in 19.6% of recipients, a prevalence comparable to Northern European cohorts. The presence of IBD was independently associated with increased risk of rPSC in multivariable analysis (HR 4.26; 95% CI: 1.27–14.23; p =0.02), whereas recurrence was more frequently observed among patients with ulcerative colitis. De novo IBD developed in 6.9% of patients and was more frequent among those with rPSC. Post-LT IBD activity worsened in 25% of cases, requiring therapeutic escalation, although it was not significantly associated with recurrence. Neither pre- nor post-transplant colectomy significantly influenced recurrence risk. rPSC was not associated with overall patient survival but was linked to impaired graft survival and a higher need for retransplantation. In this large Mediterranean cohort, IBD was independently associated with increased recurrence risk, whereas ulcerative colitis and de novo IBD were more frequently observed among patients with rPSC. Recurrent PSC was associated with impaired graft outcomes, including reduced graft survival and increased retransplantation. These findings highlight the importance of careful IBD monitoring after LT and support structured long-term surveillance strategies.