Cyclosporine after liver transplant for PSC
In patients undergoing liver transplantation for PSC, should cyclosporine be avoided in the post‑transplant immunosuppressive regimen to reduce recurrence
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No. The evidence does not support switching to or preferring cyclosporine over tacrolimus to reduce PSC recurrence, and guidelines advise against empirical protocol switching from a tacrolimus- to a cyclosporine-based regimen 1. Cyclosporine has shown at most a marginal or mixed benefit on recurrent PSC, and this apparent benefit has been attributed to an "era" effect rather than a true pharmacological one 1,2; a propensity-score-matched analysis found tacrolimus gave significantly better long-term patient and graft survival than cyclosporine 3. 1–3
What is known:
- The ESOT consensus recommends against empirical protocol switching from a tacrolimus- to a cyclosporine-based regimen, balancing rejection and kidney injury risks. 1
- Cyclosporine showed only a marginal benefit on recurrent PSC versus tacrolimus, attributed to an era effect rather than a pharmacological one; the priority is avoiding acute rejection with a tacrolimus-based regimen. 1
- The association of cyclosporine with recurrent PSC has been mixed across studies. 2
- A propensity-score-matched analysis found tacrolimus gave better 10-year patient and graft survival than cyclosporine, making it the preferred calcineurin inhibitor. 3
What is unknown / caveats:
- Earlier studies suggested cyclosporine might give a lower recurrence rate, but recent large analyses favor tacrolimus for long-term outcomes 3
- No accepted evidence-based immunosuppressive strategy exists for PSC recipients; few trials are randomized, prospective, or long-term 1,2
- Studies rarely account for dose, cumulative drug levels, or regimen changes over time 1
- The excerpts do not establish that any specific agent choice reliably prevents recurrent PSC.
References
- Carbone M, Della Penna A, Mazzarelli C, De Martin E, Villard C, Bergquist A, Line PD, Neuberger JM, Al-Shakhshir S, Trivedi PJ, Baumann U, Cristoferi L, Hov J, Fischler B, Hadzic NH, Debray D, D'Antiga L, Selzner N, Belli LS, Nadalin S. Liver Transplantation for Primary Sclerosing Cholangitis (PSC) With or Without Inflammatory Bowel Disease (IBD)-A European Society of Organ Transplantation (ESOT) Consensus Statement. Transpl Int. 2023. PMID: 37841645.
- Henson JB, King LY. Post-Transplant Management and Complications of Autoimmune Hepatitis, Primary Biliary Cholangitis, and Primary Sclerosing Cholangitis including Disease Recurrence. Clin Liver Dis. 2024. PMID: 37945160.
- Becchetti C, Viganò R, Aprile F, Scaravaglio M, Vitale G, Perricone G, Mazzarelli C, Vangeli M, Belli LS, Carbone M, Morelli MC. Beyond the Graft: Optimizing Post-Transplant Care in Primary Sclerosing Cholangitis. J Clin Med. 2026. PMID: 42123212.
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Reviewer notes