Post LT Immunosuppressive Strategies for PSC: Journal of Hepatology | March 2026
Introduction
Primary sclerosing cholangitis is a unique indication for liver transplantation because long-term outcomes are influenced not only by graft survival, but also by the risks of acute cellular rejection, recurrent PSC, and complications related to associated inflammatory bowel disease. Although survival after transplantation is generally favorable, the ideal post-transplant immunosuppressive strategy remains uncertain. This international survey from the IPSCSG is important because it highlights how little standardization currently exists in the care of PSC patients after liver transplantation.
Summary
This survey of 31 transplant centers across Europe, the United States, and other regions showed marked heterogeneity in immunosuppressive practice after liver transplantation for PSC. Nearly half of centers reported using a more intensive immunosuppressive approach in PSC than in other transplant recipients, and basiliximab induction was routinely used by a similar proportion. Triple immunosuppression was common early after transplantation, but long-term practice varied substantially. Some centers tapered to tacrolimus monotherapy, most used dual therapy, and about one-quarter maintained triple therapy long term. Corticosteroid use also differed greatly, with most centers stopping prednisolone within the first year, while nearly one-third continued lifelong prednisolone. Importantly, these differences were seen even among high-volume transplant centers, suggesting that experience alone has not led to convergence in practice. Follow-up strategies also varied, including inconsistent use of imaging and protocol liver biopsies. The major message is that post-transplant care in PSC remains highly individualized and not evidence-based. This variation creates an important opportunity for comparative outcome studies to determine whether certain immunosuppressive strategies are associated with lower recurrence, better graft survival, or fewer long-term complications.
