Good afternoon, everyone. My name's Josh Levitsky. I'm at Northwestern, and I'm joined by Pratima Sharma at the University of Michigan. This is part two of the cholestatic and autoimmune liver disease SIG and liver transplant and surgery program on optimizing pre- and post-transplant management of immune-mediated liver disease. And we'll have three talks today, and we'll have a panel discussion at the end. Pratima, do you want to? Yeah. Sorry. So our first speaker today is Dr. Josh Levitsky. He's a professor of medicine at Northwestern. He is going to talk about optimizing immunosuppression in patients with autoimmune-related liver diseases. It's working. Thank you, everybody, and welcome to this session. So I was given the challenge of presenting on how to manage patients with autoimmune liver disease after liver transplant. And the first thing I'll say is there's very little data out there really kind of guiding us here. So some of this is going to be extrapolating from data, but also some of my own personal thoughts about managing these patients and try to focus on some areas that really need to be studied. I think this is an understudied area. This is a patient population that usually is not enrolled in clinical trials, in biomarker studies, in tolerance studies, and immunosuppression studies. So part of this is to really identify unmet needs so that we can focus on this patient population and come up with better strategies. These are my disclosures. This is the outline. I'm just going to provide a little overview of the topic of immunosuppression and autoimmune liver disease. And just when we include autoimmune liver disease, I'm mainly speaking about autoimmune hepatitis, PBC, and PSC. We'll talk about the rejection and recurrent disease risk for each of these and how does immunosuppression potentially modulate or increase or decrease risk based on different therapies. And then I'd like to talk a little bit about monitoring strategies in this population. I think this, again, is more so of just clinical pearls and experience than real data. And then just end with some unmet needs to set things forward. And we can talk more about that in the panel. So one thing that I think has really sort of changed over the last decade or two is this matter of rejection in liver transplant. This used to be, many, many years ago, thought to be kind of more of a benign process. You treat it. They don't have worse outcomes. But I think that the patient population has gotten older, more comorbidities. And when we looked at the two databases of A2L and SRTR a number of years ago, we found that rejection, any rejection, even if it's in the first six months after transplant, increases your risk of death and graft failure. And actually, the patients who do the best are those who don't have rejection. That's the gray line on the bottom. And the reasons for this are not entirely clear. There's a small percentage that have graft failures. And I think the majority of those are the ones that we are going to be talking about today, which are autoimmune liver disease. Whereas most of the rest of the population, it's the treatment of rejection, the comorbidities of the therapy that is leading to immunosuppression complications as a downstream effect. Nevertheless, it does matter in liver transplant. And it's something that we should try to monitor for and avoid if possible, particularly late rejection. And this was an older study a couple of years ago, 10 years ago, that looked at patients who had transitioned to chronic rejection. And those who had acute rejection without features of chronic rejection did well. But those who had early chronic rejection had very poor survival. And on the last, on the previous slide, the top line that looks the worst are patients who had late rejection. And this is a population that we're talking about today, the autoimmune liver disease, that is probably at highest risk for these late rejection events. I've seen patients many, many years out, even into their older age, who've had autoimmune liver disease that can develop rejection late. We looked at, we did a follow-up study looking at the last 10 years of SRTR. And mainly this was to address the issue of hepatitis C and whether the rejection matters in the era of antiviral therapy. And it also does have a similar impact. Even with hepatitis C being essentially eliminated, there's still an impact of acute rejection. Again, it goes back to the comorbidities of this population, but also the autoimmune patients are mixed in here too. So just some epidemiology of the percentage of patients that are transplanted who have autoimmune liver disease in the US. And I was looking at the recent UNOS data, and it's a little bit hard to tease out who is actually in autoimmune liver disease within the category. So I thought this was a little bit easier to look at. This was from a few years ago, but it's upwards of about 15% or so have either autoimmune, PBC, or PSC being transplanted in the United States. So within that study, we looked at risk factors for biopsy-proven acute rejection. And there are multiple risk factors when you look at it, some of them more significant than others. But when we looked at the different diagnoses, autoimmune, PSC, and PBC, there's actually surprisingly, you would think that these would be very significant risk factors. And in fact, what only came out is that PBC was clearly a risk factor for acute rejection. Autoimmune hepatitis did not seem to come out as being a risk factor for biopsy-proven acute rejection. In these very large databases, again, I think this is probably more so, these patients have more so of late rejection, which is a smaller percentage. So the numbers might have not been statistical. And PSC and SRTR was clearly a related risk factor. So I'm gonna go into each of these diseases because immunosuppression and the way that they're managed, it can be different between autoimmune hepatitis, PBC, and PSC. We sort of grouped them together, but certainly there's different ages, different comorbidities. We know that, of course, autoimmune hepatitis is a disease that is responsive pre-transplant to immunosuppression, which PBC and PSC are not known to be at this point. So there are some differences here that are important and that have been studied in terms of immunosuppressive therapy and the correlation with the risk of rejection and recurrent disease in these populations. So autoimmune hepatitis, there's definitely a significant risk of recurrence with this disease, up to 70% within five years. That kind of depends if you do a lot of protocol biopsies, you're gonna see a lot of signs of recurrence that may be more subclinical. But nevertheless, we do see a fair percentage of recurrent autoimmune hepatitis. And the median recurrence is about two and a half years. And any recurrence, no matter at any time, worsens patient and graft survival. And again, it's a little difficult to say if it's the immune suppression or they progress to chronic rejection. Certainly there's a mixture in this population more so than in the NASH or alcohol population. Diagnosed by, to really diagnose recurrent autoimmune, you really need to have the histology and autoantibodies and hypergamma globulinemia. I think that's important because some of these can look also like late rejection and have some overlapped features. Some of the risk factors that have been panned out from different studies include high titers of autoantibodies. If you see an X plant that has a lot of inflammation on the X plant, I think it's a good idea to go look at X plants. There's a lot of necroinflammatory activity then that increases the risk of recurrent disease after. Certainly certain genetics, but the main point that we're discussing here is immunosuppression. And there definitely is an association with early corticosteroid withdrawal. And actually, some of more recent literature, MMF seems to increase the risk of recurrent autoimmune hepatitis. Although this is not robustly studied or very clear, just some associations. The good news is that the recent guidelines on autoimmune hepatitis did their own meta-analysis of continuation versus discontinuation of corticosteroids after liver transfer autoimmune hepatitis. This is extremely well done analysis. And actually, when you do a meta-analysis, which again, has some of its issues, but nevertheless, it's not too convincing that long-term corticosteroid use protects patients from recurrent autoimmune hepatitis. That was something that I always was trained to believe to just keep a bitty piece of, if I have a prednisone long-term and kind of still do that often. But the ASLD has, based on the data, the recommendation was that to consider gradual withdrawal of steroids after liver transplant, but this was a conditional recommendation with low certainty. From the ILTS, when we did the immunosuppression guidelines, just reviewing the data, this was not a meta-analysis, but our recommendation was consider steroid weaning, but supplant that with an additional agent, azathioprine and mycophenolate. I think we probably all agree that these patients need some type of dual immunosuppression, but do they need triple, meaning CNI therapy, an antimetabolite, and a low-dose prednisone? That's where it doesn't seem to be absolutely necessary, but certainly there's case-by-case for sure. How do we manage the immunosuppression when patients have recurrent disease? It's really kind of similar to pre-transplant. It's steroids. With a mild presentation, you can just increase immunosuppression, emphasizing compliance, which can happen in this population, younger population often. Certainly there's some data on switching from cyclosporine if they were on it in the past to crolimus, but more moderate to severe cases are the ones we worry about, and these can progress to needing re-transplantation. And so we tend to aggressively treat these almost like this is rejection with high-dose steroids, and just looking at their baseline immunosuppression and augmenting it and seeing where the gaps are. If it's a compliance issue, for sure, that's a little bit different, but if they need more, a lot of times they just need more immunosuppression or you tweaked them down a little bit and they had this recurrence or kind of a rejection, and we need to keep them at a bit higher level. And so there are some data, although not great long-term data on the use of additional agents after the recurrent disease. And re-transplantation in patients who have severe recurrent autoimmune hepatitis, my experience is this has been more non-adherent patients that present this way with severe recurrence and are too far gone to recover with steroids. There is this, just wanted to clarify the difference some differences between recurrent autoimmune hepatitis and this de novo autoimmune hepatitis, which can look very similar. And de novo is certainly patients who are transplanted for other reasons and develop in autoimmune hepatitis-like picture. We can sort of say this looks like a plasma cell-rich rejection. And some of the differences are this is more common in children, de novo autoimmune hepatitis. It seems to be better in children than in adults, but the chance of developing a remission and needing re-transplant is a lot lower than patients who have recurrent autoimmune hepatitis. It seems to be more easily treatable if you catch it early. But by and large, the management is quite similar. And then Dr. O'Leary is gonna be talking about some biomarkers and antibodies, but clearly there's an association between donor-specific antibodies and autoimmune hepatitis and de novo autoimmune hepatitis. In fact, the BAMF guidelines for chronic antibody-mediated rejection describes features that look like autoimmune hepatitis, plasma cell interface hepatitis, chronic hepatitis. So there's definitely an association here. What do we do about that? We don't exactly know yet whether monitoring for that or treating that would help this problem. I think that's certainly, I'll mention at the end, an unmet need area. So moving to PBC and recurrent disease, the data here also has been really looked at in several studies over years, the impact of immune suppression therapy and the risk of recurrent disease. And we know that PBC recurs in up to 50% of patients. It takes a little bit longer to develop it. There is an increased risk of re-transplantation and death, although it does take a longer time period for this to progress to needing re-transplant. There was a nice meta-analysis done of a number of studies. There's been 15 to 20 good-sized studies, and this boiled down to, I think, six studies that met the criteria for a meta-analysis to look at the risk factors for recurrent PBC and kind of describe this population. And what they found is just looking at everything these are the different hazard ratios. On the top, A is age. So there is sort of a tendency towards younger age and recurrent disease, but it was not significant. But the B is actually tachrolimus therapy. So many of the studies have shown that tachrolimus has been associated with an increased risk for recurrence. We don't know exactly why this may be, but it is definitely a strong signal. And then the bottom one is use of erso-deoxycholic acid as a protective agent against recurrence. And so it seems like potentially cyclosporine and erso might lead to the lowest rates of recurrent disease. Whether that improves patient and graft survival long-term is not known. And then finally, PSC, which has really the least amount of data in relation to immunosuppression, sort of not surprisingly, it's a fibrotic kind of non-inflammatory type disease. Although of all of those, it probably has the highest risk of progression to needing retransplant due to debilitary cirrhosis from strictures. And similar recurrence rate than PBC. But if you look at the risk factors for recurrent disease in PBC, they're well-known ones that active inflammatory bowel disease having actually a colon increases the risk where colectomy has been associated with a reduced risk. But if we look at the immune compartment here that actually rejection, severe rejection, or more than one episode increases the risk of recurrent PSC and there must be some biliary type process that is going on that may be involving the donor bile ducts that increases this risk. But on the other hand, there's no association with any type of immunosuppressive therapy with the risk of recurrent disease in PSC. So there really isn't sort of a different management other than trying to avoid rejection in this population. So a little bit on monitoring. This is an evolving field of how to monitor patients and Dr. O'Leary will be talking about this and some of the biomarkers that can be tested. They need to be tested in serial fashion in this population to see if they're effective in detecting early rejection or recurrence. Because right now we just have aminotransferases and trough drug levels. We know that the autoantibodies and IgG levels, even though they are diagnostic of recurrent, let's say autoimmune hepatitis, they don't appear to correlate with a risk of it or at least it hasn't been studied that way to look at that. We've been developing a number of biomarkers in the population, in the general liver transplant population, including DSA, but also mRNA, cell-free DNA, et cetera, to detect early signs of rejection but most of the studies we've done, in fact all of them, have excluded patients with autoimmune liver disease. So these types of things need to be studied in that specific population. What about surveillance biopsy? This comes up quite a bit and I think in pediatrics this is done more often than in adults but we spent almost a week at Banff in September talking about this issue of bringing back some patients to surveillance biopsy and this would be a population that would be most ideal to put through a research protocol of surveillance biopsy because of their risks. They're younger, they're higher risk for rejection, recurrence, but the issue of course is that a lot of patients have some abnormalities on histology when you do biopsies and whether they're meaningful or not is difficult. There really hasn't been, in the autoimmune liver disease population, a robust surveillance liver biopsy program in adults that have shown a benefit or how to guide immunosuppression. I will point out one recent study that is getting to the point of doing surveillance biopsies. This is published from the Hanover Group where they intentionally, several years ago, came up with a protocol to do surveillance biopsies in their entire liver transplant population and use the biopsy in combination with DSA to determine if you're lower, intermediate, or high risk for rejection and so they grouped these patients together and when I looked at the paper, a quarter of them actually were autoimmune liver disease. I was under the impression this was just in the non-immune. Unfortunately, they don't really report in the paper the specific outcomes of that small subset but nevertheless, the study was able to get to the point of having the biopsy maybe being beneficial in reducing immunosuppression whereas there are some patients who had it increased but really no long-term follow-up so we need to do more studies. So just ending up with some pearls of management, I think this is kind of some more personal thoughts here. I think this patient population is at higher risk for rejection and recurrence. Certainly, we try to advise patients if they have a viral infection or different meds that can affect absorption of immunosuppressive therapy. Vaccinations, we've seen these flare-ups after COVID vaccination that can be very severe so I think these patients really need just more attention, more immune monitoring than the general liver population. So to conclude here, then I'm gonna conclude with unmet needs. So there is some evidence, pretty good evidence, that patients transplanted for autoimmune liver disease have higher rejection rates and there's graft loss that is related to recurrent disease or chronic rejection in this population. It's unclear if immunosuppression can modulate this but it does seem that you should at least have dual therapy for autoimmune hepatitis and it doesn't seem that long-term prednisone is absolutely necessary but at least a dual therapy and considering a switch to cyclosporine for PBC at some point, maybe not up front but maybe down the road when there's a period of quiescence might help. These patients really need to be monitored more closely. And I've just listed here, there's a lot of unmet needs. There's a real gap here in data in this population and of course part of it is that it's a smaller subset of the whole liver transplant population and they also get excluded from immunosuppression studies but we need to be thinking about immunosuppression protocols and studies in this population and utilizing novel agents that can modulate the immune system and also apply these serial monitoring approaches that are now coming into clinical practice, specifically in this population that are at highest risk for rejection and graft failure. And of course, tolerance induction, this has been completely ignored in this population, but I do think that there can be tolerance-type approaches to help maybe minimize and get people off of dual therapy or maybe single therapy, because this is something that has not been, these patients have not been included in studies. So thank you. I think we'll take questions at the end. Thank you. Okay, so I'm going to introduce Dr. Jackie O'Leary, who's at Dallas VA and is a professor of medicine, good friend, and has been a real leader in this field of immunosuppression and donor-specific antibodies and immune monitoring. Jackie's going to be talking about defining the role of invasive-slash-noninvasive biomarkers of tolerance and antibody-mediated rejection. Welcome. Thank you. Great. Thank you so much. It's certainly a pleasure and an honor to be here today to talk to you about biomarkers, and certainly Josh did a great job sort of piquing your interest in this as we sort of move forward. These are my disclosures, but none of them have any relevance to today's talk. So remember that all lab tests that we order are actually a biomarker of something, and so I think we're going to start with the ones that we use most commonly, and that's LFTs. Certainly in liver transplant medicine, we rely heavily on them. The only little pesky problem is that they don't actually monitor liver function. And then over the years, the normal range continues to increase in value. How they define the normal range is they take a very large group of outpatients together and say, what is the median and then the two standard deviations? And so if you live in Texas, where everybody's waistline is larger than their hat size, then it really continues to go up. And so there are areas of Texas where ALT of 74 is considered the upper limit of normal, and that's not normal. So the absolute value over time of this, quote, normal range has become less predictive because we all used to have a liver biopsy that looked like this. And then as we're getting our NASH on, then all of our baseline liver biopsies are really potentially moving to a different normal. But change over time will likely always be helpful. We're going to spend quite a lot of time today talking about the pediatric liver transplant study by Sandy Fang. And I want to highlight, though, that in weaning studies, and in particular in this one, they started with over 2,900 pediatric liver transplant patients in 12 centers. 12% met their inclusion criteria. About half of them were recruited. Then 50% further of those were excluded for an abnormal liver biopsy, so that 3% actually completed the trial. And about a third of them were tolerant, so that would be a total of 1% of patients that you started with were tolerant of those 2,900. And so although we have so much to learn from this, it's a beautiful study. I applaud her and the other centers for completing it. We do have to understand that weaning to true tolerance, defined as normal liver function tests, the absence of immunosuppression, and a normal liver biopsy afterwards, is really applicable to a very, very, very small cohort, although incredibly educational. So in this study, when they did the cross-sectional biopsies of 157 patients that were referred, they did sort of parcel out into three different clusters. We're going to spend a lot of time talking about one of the groups that flunked out, which was Cluster 1 that had this interphase hepatitis and the mRNA signature of T-cell mediated rejection. So the Cluster 1, one of the risk factors for being there was, of course, having an ALT. At every point that you increased, there was a 7% increase in the probability that you were in that Cluster 1 group and flunked out, the other major risk factor being DSA. But even though that, quote, normal range is incredibly broad, we do have to think that it still is a very useful biomarker, because if you have incredibly low ALT, defined here by less than or equal to 13, that that actually may indicate that you have an absence of abnormal histologic findings. Now I did say to Sandy at Banff that I'm not sure I have any patients with an ALT less than 13 because of the waist size. But I actually do, and I think you all probably do as well. But most of us have a lot of patients that sort of fall in this intermediary range of an ALT of 13 to 19. And then are there other things that we can use in order to look at whether or not they have subclinical alloimmune reactivity? And the answer is yes, and certainly looking for DSA can be helpful. If you were DSA at very, very low levels here, this is an aggregate of the sum of all the DSAs, then it was low likelihood at 15% versus 43% if you had higher level DSA. But once again, these are very small numbers, so we can't necessarily rely on this completely being a DSA less than 10,000 as the absolute marker. So turning to a different cohort, which was our Baylor cohort, we looked at sort of a different slice of the pie. These were patients who were getting liver biopsies per protocol. They thought anything was wrong. They did have aminotransferases that were stable for them. And they all had DSA in serum, which is why they were chosen for this study. But the patients that had no injury despite DSA in serum did have the lowest ALT, usually below 20. And once again, indicating that these very low levels can be helpful. Certainly immunosuppression levels are a biomarker. In one study looking retrospectively at 123 pediatric liver transplant patients, immunosuppression was the biggest risk factor for having a positive DSA. Most of them were taking cyclosporine. But they looked at the trough level of TAC, and certainly those patients being run with lower trough levels of TAC were at higher aggregate risk for being positive for DSA. And that, of course, is not on an individual basis, but as an aggregate of total patient population. So Josh has been a leader in donor-derived cell-free DNA. And this is also an interesting type of biomarker. It's best studied, and there's a very large literature in kidney transplant. But he's recently published a study in liver transplant looking at patients, the TX is transplant patients who have normal liver function. And the donor-derived cell-free DNA is incredibly low in those patients. The acute dysfunction, no rejection, is that in-between group there, which has a lower percentage of donor-derived cell-free DNA. And those patients having acute rejection on your right do have the highest percentage. When combined at the time of the event with ALT, this does modestly increase the area under the curve. But what it's most useful for would be to look as an anticipatory study before the ALT goes up in serial measurements. And you can see in this graph on your far right that the patients who have acute rejection are having the donor-derived cell-free DNA percentage start to go up as soon as 75 days from when they underwent biopsy. So certainly something to look into as far as a monitoring technique for the future. I think elastography is something we all use quite regularly at large transplant centers. It's not as widely available as, of course, something as cheap as LFTs. But it is available in most large transplant centers in Europe and in the US. And elastography, however, we wish that it was specific for fibrosis. It does measure liver stiffness. So we have to take into consideration what that may mean. In transplant, remember, we're not just getting the metavir-type viral-based fibrosis pattern. There may be different types of fibrosis patterns, such as pericentral or pericellular. And does that elevate the liver stiffness as much or more than virally-based fibrosis patterns? Remember, the blood flow may be altered in a graft because of vascular anastomosis mismatches, as well as injury-causing capitalization of the sinusoids may alter blood flow and change the stiffness. Infiltration of fat elevates the stiffness. Any kind of inflammation, whether it be from COVID or from virus or from alloimmune. And then fluid accumulation. So it's, of course, going to go up in AKI. And then so many more of our patients have CKD. This does potentially affect liver stiffness, diastolic and systolic cardiac problems, and pulmonary hypertension. So although the absolute value in a liver transplant may be less reliable to predict the absolute value of fibrosis, change over time is probably going to be incredibly useful, especially if you do this serially. And the utility of the KPA has been shown to be associated with histology as well. In the weaning trial that was discussed before, in this intermediary group, patients who had a low KPA, here they happen to define that as 8.4. I happen to use a little bit lower cutoff of 7. But once again, it does also depend on your renal function and other variables. The patients who had a lower KPA had a low likelihood of having any kind of inflammation on liver biopsy and being in that bad group with interface hepatitis versus those with a higher KPA with these normal-ish values of ALT were much more likely, specifically two-thirds, to have alloimmune potentially reactivity. Another study looking at KPA, you'll see that one of the biggest risk factors, specifically an odds ratio of 4.5, was the risk for having an elevated KPA above 7.5 here was their cutoff was having DSA in serum. And once again, when we're looking at these elastography values, there's a very new and I think is interesting hypothesis of fibrosis progression, whether this is applicable in liver transplant is unclear, and the cutoff for it is definitely unclear. But what they're hypothesizing is really that liver disease, either by inflammation, congestion, or cholestasis, then leads to elevated sinusoidal pressure, which then results in fibrosis. So you're having this double-edged sword that maybe your inflammation elevates the pressure and the pressure causes the fibrosis, as opposed to a direct mechanism of the inflammation stimulating the Kupfer cells to produce fibrosis. I'm not sure that anything is that simple, but it's certainly something to take into consideration as we move forward with elastography, because elastography, although not a perfect test, and we certainly don't have any perfect tests, it's probably not ever good to have elevated intrahepatic pressures. How high is bad? I don't think we know. But should we follow this? I think the answer is yes. Should we treat an elevated KPA? We have no idea. But when it goes up, that's probably never good. However, how much it goes up to trigger a liver biopsy, we also don't know. But those are sort of unmet needs that I think we need to study further. Delving into epilate mismatch and DSA, certainly antibodies don't ever form to a protein. They form to an epilate, which is a bit of a protein. So when you look at epilate mismatching, and once again, this has been popularized mostly in kidney transplantation, the risk factors for development of de novo DSA in liver transplant are a higher burden of epilate mismatches. And with both, there's two different types of determining how many HLA epilate mismatches you have. And there's programs for this. One is called the HLA matchmaker. This is not matching you with a date of an organ. But it's the HLA matchmaker. And the second one is the PERTCHE2 score for this DRB1 and DQ. But you can see that the more epilate mismatches you have, the more likely you are to develop de novo DSA. And then if you look at by the other method, PERTCHE2, similarly, the more epilate mismatches you have by that score, the more likely you are to develop de novo DSA. In a small transplant trial of 45 living donor liver transplants, the more epilate mismatches you had, the lower your TCMR-free survival was post-transplant, fairly soon afterwards. So what happens if you develop de novo DSA? Well, DiBello and colleagues looked at this in a group of 232 DSA negative patients six months post-transplant, found that 10% of them developed de novo DSA over time. And a quarter of those had overt antibody-mediated rejection. And even if you didn't, you were likely to develop more accelerated fibrosis after transplant. And some new data from Cousin et al. looking in pediatric patients by protocol biopsy and DSA testing, that only 11% of patients had normal histology. This was, of course, a cross-sectional study. And the more DSAs you had, the more likely you were to have inflammation and fibrosis, which is why we developed this chronic antibody-mediated rejection score. And the higher your score, the more likely you were to have graft loss, which happens very slowly over a long period of time. But if you have a low score, less than 13, then even with DSA and serum, you were likely to do well in the long term. Fortunately, the patients who had a biopsy with a low score in that no allograft loss were likely on the follow-up biopsy one to four years later to have a similar score. Fortunately, in the patients who had a high score and then went on to allograft loss, sadly, they also were likely to have a stable elevated score, which then resulted in graft loss. So DSAs as a biomarker are certainly very strongly associated with inflammation and fibrosis. More details about the exact type of inflammation and fibrosis patterns are found in these myriad of articles. But certainly, it's fortunate that not all patients with DSAs have this inflammation and fibrosis clinically apparent. If you just test simple DSA, the hazard ratio for de novo DSA and graft loss is 1.8, which is a bit better, more sensitive if you use C1q. And de novo IgG3 was a bit better than that, indicating that maybe this subtype might be more deleterious. And then looking on the flip side of the patients who were tolerant in Sandy Fang's study, those tolerant patients, although some of them did develop DSA, none of them actually had IgG3, which was certainly reassuring. Annette Jackson looked at the 129 IWF patients that flunked out and didn't go on to withdrawal of immunosuppression. And she found that actually IgG4 was the biggest risk factor for being in Cluster 1, that group with interphase hepatitis. And if you think about it, what happens over time is you get IgG switching. So when you initiate an alloimmune response or an antibody response, you have an IgG1 that then can subsequently switch to IgG2. Over time, it will switch to IgG3 and 4. But the patients who do have IgG4 subclass have had the alloimmune response the longest. So whether or not this is something actually specific to IgG4 or whether it is a measurement of the length of time that you have had the alloimmune response is yet to be determined. And because of the myriad of data looking at DSAs in liver transplantation, the Comet group has recommended screening for DSAs in those patients before you undertake significant minimization in patients in the clinic. So although the presence of DSA is very strongly advocated for as a risk factor for fibrosis and having subtle subclinical inflammation on protocol biopsy, the absence of DSA actually may be incredibly useful. And the probability of tolerance increases in patients who are devoid of DSA. In the Grenada trial, none of the tolerant patients there had DSA to start with. In the Wozniak pediatric study, it was 29% versus 61% were devoid of DSA that were tolerant. In patients who attempted weaning, more patients with subsequent fibrosis had DRB1 DSA. In the O study and in Sandy Feng's trial, a lower C4D score was predictive of the ability to wean. And in the Shaked weaning study, de novo DSA development was the strongest risk factor for rejection during immunosuppression minimization. So certainly in those patients that you want to minimize or wean actually off immunosuppression, the absence of DSA may be incredibly helpful. But what if we're only looking at the surface? And so if you just focus here on this hepatocyte, then if you had only looked at the surface, then you would not necessarily have seen the incoming alloimmune response that was going to eat it. So if we want to really look deep down to see if patients can be truly weaned off immunosuppression, unfortunately we still need a liver biopsy. And the BAMF group has come up already with the BAMF minimization criteria for portal inflammation. It is, of course, ideally absent everything, right? So ideally absent portal inflammation, although this is the one thing that can be tolerated at minimal to focal mild portal inflammation. Obviously no interface activity, no central zonal inflammation, and no bile duct damage. Although depending on why the fibrosis was there, that can be tolerated in certain types of patients, such as those with hep C who may have been cured. But if you want to take an even deeper dive into the biopsy, this next generation pathology that Jake Demetrius has spearheaded, he has looked at the immune synapse formation that can predict weaning failure, or the absence of this can predict success. And this is where you look at the close intranuclear lymphocyte APC distance, as well as lymphocyte nuclear flattening. And in the patients who had a higher density of this, then they had 100% sensitivity and 75% specificity for weaning failure. So this is where basically you have an interaction of the lymphocyte with the APC. And you can see that the tolerant patients in the gray boxes have fewer infiltrating macrophages that are the APCs, fewer infiltrating CD8 T cells, and then the fewer lobular IA synapses. So what happens to patients who have flunked out of the weaning studies, meaning that they did not meet the criteria for weaning? Well, fortunately, after five years, they had repeat biopsy in 73 of them. And there was not considerable progression. So although there may be this small amount of inflammation found in these patients, there was no overall long-term significant progression. What about an mRNA signature as a biomarker? Once again, this is in the biopsies, and Sanchez-Foyo and colleagues developed this 11 mRNA signature of TCMR, which was elevated in the cluster 1, as well as, of course, in patients with acute TCMR, and those patients who had moderate to severe damage on protocol liver biopsy, as well as much higher in the patients with acute TCMR, where it was developed. There are many other biomarkers of tolerance, and I would highlight this lovely scoping review in AJT that went through a very large quantity of them, most of which have been looked at in usually one patient population, and certainly we need more studies to confirm or deny whether or not these are helpful in either selecting patients for weaning or trials from the serum or liver biopsies. So if you're thinking about selecting patients for weaning, do remember that a lot of the data really only looks at patients more than five years out, and whether or not this applies to patients sooner after transplant, although Abhishek Head, of course, did his trial one to two years out after transplant, but had a much lower success rate at weaning. But most of the data is more than five years out. Having a very low ALT, less than or equal to 13, is predictive of having a very good clean biopsy devoid of alloimmune reactivity. In those patients with an intermediary ALT of 13 to 50, being DSA negative with a low KPA, how exactly to define that I think we're still working on, but in order to wean patients off immunosuppression, we still do need a liver biopsy, and ideally they would, of course, meet the BAMF mini-criteria, and if you had access to analyzing the AI isins, then that would certainly be the best way to select the patient. So in conclusion, LFTs are an imperfect biomarker, but ALT less than or equal to 13 may indicate the absence of inflammation. Elastography also remains an imperfect test that measures fibrosis, inflammation, and fluid. In combination with ALT, this may be useful. Change over time for both of these is probably the most useful. DSA generally is never good, but DSA positive patients have a decreased probability of successful weaning and an increased probability of fibrosis and interface hepatitis on biopsy, and I'm still a strong proponent of limited protocol biopsy in order to predict what to do with immunosuppression and how to optimize that. We're still working on. Thank you so much. That was a great presentation, very comprehensive. Thank you. Our third and last speaker is Dr. Pallak Trivedi. He is an associate professor from University Hospitals Birmingham, United Kingdom. Thank you very much for inviting me to give this talk. I'm going to talk about inflammatory bowel disease, predominantly in patients with PSC, how to optimize care for patients with IBD before and after transplantation, and why this should be the remit of the hepatologist, not the IBD-ologist. Why should we care about it? I've ended it already. As you can probably tell, I'm from the UK. I'm not from North America. This is a snapshot of liver transplant activity in the UK. Now, whilst fatty liver disease, alcohol-related liver disease are by far the dominant causes of chronic liver injury in the Western population, autoimmune liver diseases, PSE, PBC, AIH, collectively are the leading indication for transplantation where we work in the United Kingdom. Secondly, as we've already sort of come to hear throughout the day, autoimmune-related liver diseases are the leading indication for regraft, and I'll come on to the reasons why that is and how inflammatory bowel disease may fit into that paradigm. And it's not just the United Kingdom. I am not a Brexiteer. I wish we were still in Europe. So going to my European neighbours, I want to show you some of these slides. The Nordic Liver Transplant Program many years ago showed that the leading indication for transplantation in their nations was indeed primary sclerosing cholangitis. And a little bit across the pond from where I am, if you look at projections from the French Liver Transplant Registry, PSE in the sky blue is likely to be the leading indication for transplantation there as well. Now, when it comes to recurrence, we've talked about recurrence. Cynthia gave an excellent tour de force about recurrent PSE. Undoubtedly, recurrent PSE is a big problem and leads to graft loss. What you can see here is a study from 2015 conducted across the United Kingdom showed the impact of recurrent PSE and graft loss. But even when you look at people who've had recurrence or not, taking everybody who has PSE and a transplant, the risks of graft loss in that group, i.e. all PSE transplant recipients, is greater than all other liver diseases combined. Now, PSE is part of a syndrome, okay? We recognize that 70, probably up to 80% of people develop inflammatory bowel disease at some point in their lifetime. Now, the group in Oxford, led by a colleague of mine called Dr. Culver, have shown that in people with inflammatory bowel disease, even those who have normal liver tests, about 20% of them have some radiological features of sclerosing cholangitis. That is not going to be the same in every single center across time. Some of this will be improvement in MRI-based technology, but it raises the question, are we missing PSE? But that's a title for a different talk. IBD, of course, does not have to occur at the same time as PSE. When we conducted a population-based study across the United Kingdom, what we found is that about 40% of individuals do develop inflammatory bowel disease either after PSE is diagnosed or very close to the time, and the remaining 60% with IBD were diagnosed with IBD many years prior. So that reinforces a point that we should always be looking for inflammatory bowel disease. And of course, the phenotype is unique, which is why we offer colonoscopy to everybody at the point of PSE diagnosis who doesn't have an underlying IBD. But what does IBD mean to us as hepatologists? Well, my colleagues in King's about 10 years ago published this very nice study, and what it showed is that in individuals who have active inflammatory bowel disease before the point they're transplanted, the risks of graft loss are truly devastating. It is empirical that we drive home the message to attain remission from IBD in all our patients with PSE. And yes, I do manage IBD as a hepatologist, and we have a much lower threshold for attaining mucosal healing in this patient population because there's no medical treatment for the liver disease. But the last thing any of us want is a patient who's got active severe colitis who we now have to assess for a liver transplant. So that's why we have a much lower bar of introducing biologics and indeed some surgical interventions. Another study published from Australia, sort of two-center study, shows the impact and validates in some ways the King's data wherein people who have moderate to severe IBD have a much greater risk of developing recurrence of PSE after transplantation. This very nice study from the Nordic program shows that about 40% of people do develop deterioration in IBD after transplantation. And when we're trying to find out what the risks of IBD flaring or developing IBD after transplantation are, younger age was a predictor. Younger age we now recognize is a very aggressive phenotype in our patients with PSE and IBD. But also the immunosuppressive regimen. Now here they dichotomize this to cyclosporine and azathioprine versus tacrolimus and mycophenolate. This may pose a little bit of an era effect wherein people who are using cyclosporine may represent a slightly older or historic cohort. But azathioprine is something that we still use in practice, much more so than mycophenolate in this particular patient population. And there is data emerging showing that actually azathioprine and tacrolimus-based combinations may be effective at maintaining remission in this group rather than tacrolimus and mycophenolate combinations. Now this is some very old data from my institute from Birmingham, and it was one of the first studies to ask the question, does the timing of colectomy in people who need a colectomy impact the risk of recurrent disease? And as you can see here, those individuals which are in red, very few of them who had a colectomy prior to or very close to the time they were transplanted developed recurrent PSE. But in the individuals who did not undergo colectomy or who had a colectomy some time after they were transplanted, there was a very high risk of recurrence. And for many years, this study was not validated. However, there are now at least three, but now perhaps even more studies that in some way, shape or form, slightly different statistical methodology have validated the observation. And we recently conducted a systematic review and meta-analysis, again finding that colectomy prior to transplantation is associated with a lower risk of recurrent disease, but the persistence of IBD afterwards is a risk factor for it developing. Now, I'm not by any means saying that you should offer colectomy to absolutely everybody. But in individuals who you can see have progressive liver disease over the course of time, whose colitis isn't quite getting under control, and you failed a biologic, you failed a second biologic, that is the time where you would have to counsel these individuals as to the long-term benefits of having a colectomy early on, rather than waiting for things to get out of control, both in the liver and the bowel. And in a similar way, it's not going to be the be-all and end-all risk factor. We recognize that even people with cardiovascular disease, not all of them are going to be smokers, but stopping smoking is one of the things that we advise very early on. So there will be other risks for recurrent disease, but this is one of the most consistently validated observations. The problem we have is that when do we ask them to have a colectomy? There are some people who sadly present with advanced liver disease and bad colitis. And which one of these two things is going to trip over the individual? You have colitis that's refractory to medical intervention with a high risk, 30% lifetime risk in some studies, of cancer or dysplasia. And you've got an incurable, progressive liver disease with a high risk of recurrence. I've already given my view about the timing for colectomy, and of course that is not going to be for absolutely everybody. In somebody who's got decompensated disease, we would of course try to say to them, very soon after you're transplanted, that's probably the safest time to have your operation. But the type of colectomy is also starting to matter. Not all types of colectomy are the same. In individuals who elect to retain an ileostomy, at least what our data has shown, is that the risks of graft loss are very low. In individuals who don't have a colectomy at all, they fall somewhere in the middle. But in people who have a restorative procedure with a pouch, they have a much greater risk of graft loss, both with regards to hepatic artery thrombosis, which actually is probably one of the leading indications for graft loss in this group, as well as recurrent PSE. So again, it is the patient and the surgeon's joint decision as to whether somebody should have a pouch. Our job is at least to counsel them, saying, look, this is what the data shows if you elect to have a restorative procedure. We recognize that people with PSE and pouches have worse pouch function. They have fertility problems and have a higher risk of chronic pouchitis compared to those with IBD alone who have colectomy. And we should be the people to help them make an informed decision if they need surgery. Why do people need surgery in PSE-IBD? Many people, and certainly my teachings were, PSE was a quiescent colitis. It rarely causes problems. But when we look at our national data, and there is data published from other countries which validate this observation, the main reason people undergo colectomy with PSE and IBD is actually not for cancer. It's for persistent active colitis. And we do not have any randomized control trial data specifically for the treatment of colitis associated with PSE. There is no RCT in this patient group, despite us as a community recognizing it's a different phenotype, a different disease distribution, with a different disease behavior. So what is the evidence of biologics in people with PSE-IBD? There have been several multicenter observational cohort studies in addition to several case series. Usually these are performed in non-transplant populations. Let's look at the evidence for anti-TNF therapy. So I've provided some very high-level overview statistics here. These are very noble efforts, so please do go and read the studies. Don't take my word for it. But when we look at anti-TNF data, yes, we are able to induce remission. We are able to induce clinical response. But there is a greater than seven-fold increased risk of acute cholangitis. So when we've got our patients with difficult-to-treat IBD and PSE, if they've had a history of recurrent cholangitis, anti-TNFs are not my first option in this patient population. The International PSE Study Group conducted this study, led by Cynthia and Kate Lynch from Australia. And what it showed, using vedelizumab, was that, yes, we are able to improve the mean mayoendoscopic subscore in this group of individuals. But these are not in individuals having liver transplantation. I'll come to show you a few slides in a moment. When we look at anti-TNF therapy for inflammatory bowel disease after liver transplantation, there is very little data. And this is a recently published study in the Digestive and Liver Disease Journal from Italy. And you can see that, yes, we are able to induce some form of response or clinical remission using anti-TNF. But, again, the incidence of infections is very high with anti-TNF use. And when I use anti-TNF use in my practice, we do withdraw the azathioprine or the mycophenolate first and maintain the calcineurin inhibitor in an attempt to minimize the immunosuppressive burden and adverse consequences. That is not an evidence-based strategy. That is just a personal practice. There is evidence of vedelizumab in liver transplant recipients, and I've just provided a screenshot from this systematic review. Now, in this particular study, they looked at all case reports and case series, and they report very high clinical response rates, perhaps more so than we've ever seen in any other IBD population treated with vedelizumab. So, certainly, this is something that will be an emerging area that we need to study thereafter. And thank you to Christoph Schramm for providing this data at the 11th hour for me. The International PSC Study Group have just submitted their experience looking at tofacitinib in patients with PSC, again, non-transplant recipients. And what we do see is a reduction in the Mayo score. Some of these individuals were followed up at three, others followed up at 12 months. One of the concerns I have with tofacitinib in liver transplant practice is the thrombosis risk. In this particular study, there wasn't a heightened thrombosis risk pre-transplant, but after liver transplantation, when you've got the risks of hepatic artery thrombosis, you've got the risks of graft loss associated with that, tofacitinib and other jacanibs need to be used very carefully. So this is still an emerging area. Let's talk a little bit about microbiome manipulation. So we recognize from many studies across the world now that the gut microbiome, either in stool or mucosal adherence samples, is different to those individuals with IBD alone and healthy control subjects. And this very nice study from a few years ago showed that if you take the stool from a patient with PSC and you inoculate this into germ-free mice, I mean, this is a horrible experiment, you really want to do trans-species FMT, but you give stool from people with PSC to these mice, they develop periductal fibrosis and biliary injury. And it was predominantly driven by specific organisms, as I've indicated on screen. And this feeds into other data, initially from the pediatric literature and later in adult medicine, showing that if you give oral vancomycin to deplete entrococcus predominantly and heighten colonic regulatory T-cell activity, you improve colitis activity in individuals. Now this appears to be a PSC colitis-specific observation. When you use oral vancomycin in people with colitis alone, it doesn't do anything. But for some reason in people with PSC colitis, be it the entrococcus, be it some other biological mechanism we don't understand, there seems to be in, again, open-label, off-label, sort of single-arm studies, an improvement in colitis activity. We recently finished recruiting to an open-label pilot study of oral vancomycin in people with PSC and active colitis. And this is just a snapshot of the transplant recipients from that cohort. So giving people a four-week course of oral vancomycin led to a massive drop in fecal calprotectin. We're still analyzing the endoscopic data from those, as well as the non-transplant recipients. But certainly, this appears to be an emerging area of interest. But we do need randomized controlled trials. But it is sort of an interesting observation that oral vancomycin attenuates colonic inflammation in this group. The story is slightly convoluted when it comes to oral vancomycin. Because on the one hand, you improve colitis activity. There were some studies showing a reduction in alkaline phosphatase. But in animal models, when we look at giving oral vancomycin or other antibiotics, you exacerbate biliary injury. So I don't think it's going to be a very simple answer as to how this drug works. In the same studies, however, when you give fecal microbiota transplantation rather than giving oral vancomycin, you attenuate biliary injury. It's a question as to whether we should replace, rather than deplete, gut microbiota in people with PSC-associated colitis. And we're just about to open a randomized controlled trial of colonically-divided FMT specifically for this patient group with PSC-related IBD. I'll say my summary, because my slides have gone. In summary, active inflammatory bowel disease does appear to be associated with adverse consequences in our liver transplant recipients, both in terms of the risks of recurrent PSC as well as the risks of overall graft loss. What we recognize is that in individuals who have ongoing inflammatory bowel disease, there is no randomized control trial evidence to support any of the biologics. But we have to gather that information moving forward. Some of it is going to be informed from data using observational studies. Microbiome manipulation is an area of ongoing investigation. There are several gut microbiome posters, oral sessions, and parallel sessions in this conference alone. But I certainly think that the oral vancomycin story in PSC is very interesting, particularly with regards to the colitis component more so than the liver disease. Thank you for your time. So, thank you for that, both of you, and I think we'll open it up for questions. So, when you come to the microphone, just state your name and then the question. In the meantime, when people are getting ready to come to the microphone, I have a question for Dr. Trivedi. So, do you, in your practice, in the liver transplant recipients for PSC who have UC or IBD, do you change their immunosuppression to cyclosporine and azathioprine, or how do you do that? We don't change them to cyclosporine, but we do use and favor azathioprine over mycophenolate. Now, clearly, if they have recurrent acute rejection, we may modify that. It really depends on the need of the hour, but certainly, we favor tecralimus and azathioprine-based regimens over tecralimus and MMF-based regimens as a broad rule, but other things may dictate what we use. All right. Go ahead. Can I ask a follow-up to that, just real quick? Sure, yes. So, that's mainly, the cyclosporine, though, would be more beneficial for the IBD, though, not the actual recurrent PSC. Oh, sorry, sorry. Yeah. So, we use taquinoneza. We don't tend to switch to cyclosporine anymore, so, yeah, yeah. Sorry. So it really depends on what is our treatment targets and should it be... Mind repeating that? Yeah. Oh, yeah. Sorry. Yeah. So the question was in people who don't have very active IBD but bad recurrence, what do you do in those individuals? I suppose it's what is the treatment targets and should we have the same treatment target in PSE-IBD as opposed to IBD alone? And I think the answer is yes, we should have different targets. Getting mucosal healing or as close as you can is the way forward in inflammatory bowel disease practice. And it's not just if the IBD is severe, but if you're not able to get on top of the inflammation despite currently available agents, that is deemed a treatment failure. So in that particular group of individuals, we're not saying you have to have one, but we talk to them about what the data shows. We talk to them about the fact that we cannot get their disease under control, and that's why we would say, please meet my surgical friend. Seriously think about colectomy, not just because of your liver, but because the long-term risks with inflammation and bowel cancer. The long-term risks, the fact that their disease may be control or steroid dependent now, but it's not gonna stay like that forever. So we have a joint PSE-IBD clinic specifically for these sorts of difficult individuals. But if they've got ongoing inflammation, even without symptoms, yes, we do offer colectomy. So, I think from what I heard, you're asking about protocol colonoscopies after transplantation. I mean, we continue to offer annual colonoscopy to everybody, irrespective of what their symptoms are. If they've got very, very active symptoms, sometimes it's a bit risky to do that, but as a general rule, everybody gets offered an annual colonoscopy. Our surveillance and practice is exactly the same as if it is pre-transplant. I think fecal cow protecting is slightly difficult to interpret because it's released by the biliary epithelium, and there's a paper published by the King's Group last month showing that even in people with very high fecal cow protectins, they can have normal colonoscopy because it's all from the bile ducts, and they've had recent cholangitis, and there is a counter-argument that even in people with fecal cow protectins of, say, 200, 300 relative, which are not that high, they can have MAO3 colitis. So I think it's unclear yet, but we do use it, I just don't know what it means in totality yet. Josh, maybe I can ask you a question about autoimmune hepatitis and your preferred agents after transplant. I certainly have heard and seen the data on MMF with increased risk, but I've always wondered whether or not the patients who had more severe autoimmune hepatitis were the ones that got MMF, and whether or not you favor MMF as the dual agent versus steroids versus azathioprine for compliance. So we don't generally change our protocol, we are very TAC and MMF based, and in general though what happens is if patients develop recurrence of autoimmune hepatitis on that regimen, we'll often look at their, you know, we're basically saying their immunosuppression is insufficient, and so often we'll switch them to azathioprine, and then I've been getting into the practice of monitoring their metabolite levels, and when I have enough data to present, I don't think anybody has really, you know, presented on that before, but it's actually a good biomarker in non-transplant patients, but we don't start off with TAC and azathioprine in general, because I think MMF is a little bit better and more targeted immunosuppression early after the transplant, but certainly later if they have a recurrence in the autoimmune. I think that's maybe better for anti-rejection early on, but later on I think recurrence rates can be higher with MMF, and we will usually switch them there. In terms of this prednisone, I'm sort of getting a little more impressed with the potential to wean patients off prednisone. The problem is, is a lot of times they're on it a long time before transplant, and then you keep them on it a long time afterwards, and it just isn't worth it to try to take them off a bitty amount of it, but certainly if you have someone who hasn't been long on prednisone that you could potentially wean to dual therapy, I think that could be a reasonable approach instead of keeping them on triple long-term. I just had a question about the pouch. Certainly that was very small numbers, that the pouch increased the risk after transplant, and I was wondering, do you think that that's the inflammation that's driving the recurrence of PSC secondary to that, or are you even offering that to patients now that you have this data? It is small numbers. It was, I think, about 240 liver transplants of which 20-something had a pouch, so it is small numbers. When somebody needs to have a colectomy or undergoes one, we don't say absolutely don't have it. That's completely their choice, but what we do say is at least our data from Birmingham shows that there is a slightly higher risk of graft loss after transplantation. It's about 30% compared to less than 10, and the reason that may be important for somebody who is not even a transplant recipient is if I say and I show them that, look, your fibro scores year on year and your native liver are going up, your liver biochemistry has never settled down, the chances or your predicted probability that you're going to come to transplant is X percent, it's trying to contextualize and making sure that they're fully aware of what happens, and we also show them the quality of life data regarding pouches. Some of them may perceive it as fear-mongering. Some of them value that counseling, and some of them say, I accept the risk, but I really don't want a stoma, and that's completely their choice, and we have to support them in that decision. I have a question for you that's kind of a burning question about the immune liver disease in Europe, percentages getting transplanted compared to like in North America, which is dramatic. I was just thinking about this in my head and why that may be. Is it less obesity? Is it genetics because of more homogeneous population having more immune disease? Is it something in the water, in the microbiota, or what do you think the reason for it? It's double what we have in the U.S. Yeah, I mean, it's a very good question. I didn't answer the second part of your question regarding microbiome, but I think it's microbiome driven, the pouch thing, more than, but the, I generally don't know, I mean, I don't think it's just the obesity thing. I mean, the, I'm not in the U.K., so I can say it, but the U.K. is a pretty obese population as well, so I don't think it's that, but certainly the incidence is rising for PSC and AAH, and PBC is relatively flat, but the prevalence of all three diseases is rising in Europe. That has been, that is very well published, but I think even the rate of prevalence is not enough to account for that data. So I don't know why we're transplanting more. It may be that some of the people with alcohol-related liver disease, fatty liver disease, are not being offered transplant because they're too high risk, perhaps? Selection bias. Yeah, yes, so maybe because of that, but it's not just the U.K., it is all of Europe, really. I have another question for Dr. Tavaiti, and it's about vancomycin use in patients who have PSC and IBD. You have shown data, which is very compelling, especially in the mouse model, that even though it is working, but it increases the periductal fibrosis. Do you think, because I have a few patients, and they are young patients with recurrent PSC, and they have asked me about vancomycin, and I was just like, I don't know, there's no data, it's not ready for prime time. What is your opinion on that? Yeah, so it's a very good, I mean, we don't have any RCT data. It's off-license, it's off-label. So in non-transplant patients, for PSC, everybody in my mind is eligible for a clinical trial, but for those who don't want to do a trial, we do discuss off-license medicines, and post-liver transplant recipients fall into that group. They're not going to be eligible for any trial medication. So I offer it, but particularly for those with difficult-to-treat colitis, and those individuals who are not able to commit, or not able to receive, or who have failed biologics. And I'm not saying it's going to be the silver bullet, but it is something that we are using to induce remission for colitis, and that's perhaps the only confidence I have in it personally, and we will be submitting and publishing our data from our full trial very soon. But again, it's an open-label study, it's more mechanistic to try and understand what it does. We, you know, we will need to move to a proper RCT, and I think that should be a colitis-related RCT, rather than a liver-endpoint one, because we know what endpoints in colitis look like, we have no idea what endpoints in PSE should look like. So how long do you treat them, for four to six weeks, based on your data, or you will just keep them? We do, yeah, so we offer four to six weeks, then we withdraw, because it's an induction, we use it as an induction agent, but, I mean, if people who flare up soon after and there's nothing else, we have started using it as maintenance. I think the longest patient I've got on it has had it for about six months. There are theoretical concerns around VRE and other pathologies, which we do counsel them about, and we are trying to collect safety data on it, but these are really small numbers, so I think we need to pull our resources together, and I'm not saying it is the silver bullet, but it is something else in our armory that we are learning about. Do you check for C. diff before you? Yes, yeah, everybody, yeah. Do you ever, do you pick that up? Sometimes, I mean, we've picked it up in one or two people, none of those were in that particular data, but we always check for C. diff, campylobacter, Shigella, E. coli, as routine in all patients before we start vancomycin, yeah. So, Josh, I just was going to ask about your approach to immunosuppression post-transplant in patients who have overlap with autoimmune and PBC with the cyclosporine data, but then the autoimmune recurrence, where do you fall on those? That's difficult. I think, honestly, these patients are really case-by-case and looking at their course over time and trying to figure out from a clinical perspective, sort of trial and error, what the best regimen is, but I do think that, I think it would be risky to, if someone had an overlap, to switch them from TAC to cyclosporine, and this just goes back to, if you remember, the old data on chronic rejection and also steroid refractory rejection from the 90s was significantly higher with cyclosporine versus tacrolimus, but a pure PBC that's never had rejection, and they typically are older patients than the autoimmune, I think it's a reasonable approach, given the data, but, again, these are meta-analyses, there haven't been randomized controlled trials, I think it would be difficult. What's your approach? We don't use cyclosporine at all, hardly ever, actually, so we do favor tacrolimus-based regimens, and when they get very difficult recurrence, we are starting to use, obviously erso we give now prophylactically, but we are starting to use abetacolic acid and fibric acid derivatives in that group, and there's some data being put together by the global group on that, but we don't tend to use cyclosporine, and one question for Jackie, actually, is about antibody-mediated rejection, because that's a really difficult group of patients to treat, and for some reason, our young people with PSE tend to be the group that cause the most problems with antibody-mediated rejection, and I was just going to ask if you have any particular tricks or tips as to how you sort of treat them beyond optimizing the tacrolimus, and for some of them, we offer plasma exchange, but long-term, it's a really difficult group, and I just wanted to know what your thoughts and practice is. Sure, well, I think that the, so I'm assuming you're talking about acute antibody-mediated? Well, chronic, actually, chronic, yeah. Yeah, so chronic antibody-mediated rejection, so I'm, certainly, I think it has to be a tac-based regimen, but I think everybody these days is, with rare exceptions, is using a tac-based regimen. You know, I think there, we have a real underappreciation for the non-compliance that's going on out there, and so that's why I think I was highlighting, you know, I think we've sort of underappreciated how important, maybe, Nvarsis, XRs, you know, or Avograft as far as once-daily dosing, and certainly, although I'm a bigger fan of MMF, if you really can't get the patient to, you know, and you think that non-compliance is a big deal, then I think, you know, I am a fan of putting them on azathioprine just because if you can't make sure that they're going to take the MMF twice daily. You know, once we do acute antibody-mediated rejection therapy, I'm also a big fan of a tail of IVIG, usually once monthly for about six months, so that, because so many of the patients with acute antibody-mediated rejection are the ones at highest risk to go on to chronic antibody-mediated rejection, so that's been my practice as far as trying to help stave that off. And then following them sort of more closely, I tend to want to do also a biopsy, even if the LFTs are looking quite good, in order to see what the underlying pathology is, and then fiber scanning more often because a lot of the things that I talked about earlier with, you know, the capillarization of the liver from chronic antibody injury does increase the fiber scan numbers, and so you can see this occult progression of injury over time that you may catch with fiber scans, so to look at whether or not you're sort of achieving stability versus progression. So just closer follow-up with a protocol biopsy with repeated elastography, and then, you know, I mean, we don't have a lot of data. The one thing that I do like also is putting them on a statin, so statins decrease class II expression, and so you can't bind to a motif that you aren't expressing, so I don't do high-dose statin in patients, of course, who have elevated bilirubins because of the liver hope safety trial, but I'm a fan of atorvastatin because it has a better safety profile than simvastatin as far as the myositis that can go along with it. It's lipophilic, and it will decrease class II expression, and it has the best effects on the native kidney for decreasing proteinuria and increasing GFR, and so many of these patients are on higher-dose TAC that I think that may be helpful. So those are some of my thoughts. Thank you. Jackie, I wanted to ask you a question, a little bit of an intersection of the end of my talk with unmet needs and tolerance and thinking about the immune liver disease population and tolerogenic strategies. You know, I think full immunological tolerance of withdrawal would be a major hurdle in this population, but what do you think? Do you think it's crazy to consider them for minimization studies and carefully done, and how would you maybe think about designing that with the surveillance biopsies and DSA, or do you think this is just a population we should avoid doing immunosuppression reduction studies in? Yeah, no, I think that's a great question, and it gets into immunosuppression personalization, right? So once again, you know, there's finally a nice paper that came out in AJT that looked at the area under the curve of TAC levels and predicting the risk for cancer, and so we've all known sort of for a long time but without actual data that shows that the longer you're exposed to higher levels of TAC, the greater your risk for cancer. So if you can even notch it down a little bit, you're going to have better renal outcomes, you're going to have better cancer outcomes. So I think it's very reasonable to think about this, but it's going to have to be in combination with, to me, you know, ideally it's, your risk is going to be based on whether you're DSA positive or negative. Your risk is going to be based on your elastography values going up or down. I think that's a great way also to kind of serially monitor things. You know, I think we have to test some of these other biomarkers like cell-free DNA because it does have the ability to tell us earlier, potentially, that we're getting into problems. So combining these, and the only thing is that the cost of all of this may play a role. You know, once you invest in the elastography machine, then, you know, it's all up front, but when you're doing serial cell-free DNA tests, that does go up on the cost, but certainly if we could prove that we could run people at lower dose immunosuppression with testing it every, you know, six weeks or something along those lines, and you could run them on lower dose immunosuppression, I think that would be beneficial. Plus, I think we need to optimize the non-CNI-based immunosuppression that's not renally toxic in order to see, you know, what we can do. So I think that that patient population is a unique patient population, but that is going to benefit so much more from it because they tend to be younger. Absolutely, yeah. One last question to all of you. So Arsodiol reduces the risk of recurrence in patients with PBC and also, you know, improve the LFTs in PSC patients. So when do you start these patients on Arsodiol, or do you continue them on Arsodiol after transplant? Yeah, PBC, they're on it now prophylactically. We changed that from the seminal publication about six, seven years ago, so we just put them on prophylaxis. PSC, we generally don't, and I think there's really no data there, and I get, again, it just goes back to it not being effective in pre-transplant PSC in, you know, preventing progression. I think though sometimes what happens, if patients have strictures or they need dilations, sometimes we throw a little bit of Urso on, but I can't tell you that it's more treating us than them, to be honest. But for PBC, we're absolutely putting it on as a preventive measure. Yeah, so for PBC, we 100% right through and continue. PSC, I mean, we're just like Josh, so it's, if you get recurrent PSC, we'll start it, but it's the 13 to 15 mg per kg, not the high dose. Very similar, I mean, for PBC, Urso's for life, not just for Christmas, and for PSC, we don't start it on anybody. If they have very strong feelings about not wanting to stop it after they're transplanted, we don't fight with them, but yeah, very similar approach. Thank you. We have one last question from the audience. Please state your name and the question. Might not be working. We have to yell. I don't think it's working. Oh, there. Yeah, it is. Okay. Thank you for your talk. I was just wondering, given that when patients are responsive to oral vancomycin, we'll learn very quickly within one to two months if they have a response, assuming the correct dose and brand, or bioavailability, why is it that we don't use that as a first line of therapy as opposed to biologics? That's a very good question. I mean, I think that the story is not complete yet. It's just that we discovered the effects of vancomycin after biologics, and there are some people who really hate corticosteroids, and those individuals who have lots of reasons to not give steroids to induce remission from their IBD, we have been using oral vancomycin. In the UK, to start biologics is a bit of a process, and it's not just a decision made by one individual. We have to sit around a room and argue about which one to start. So often, I've given them oral vancomycin whilst the decision about biologics is made, and once vancomycin has started to work, we don't need the biologic. So I think the strategy will change, probably. This concludes our session. Thank you so much to all the speakers, and thank you for listening to our talks. That's a great talk.

autoimmune liver disease

liver transplant

autoimmune hepatitis

primary biliary cholangitis

primary sclerosing cholangitis

rejection

immunosuppression

monitoring strategies

tacrolimus therapy

bile duct damage

elastography

limited protocol biopsy

inflammatory bowel disease