© 2014, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(14)60260-5

Published online May 29, 2014.

 

 

Acknowledgements: We thank the professors of Key Laboratory of Transplant Engineering and Immunology, Ministry of Health at West China Hospital for guidance.

Contributors: DYL, XXZ and CNS designed the study and collected data. DYL and XXZ analyzed the data. DYL wrote the main body of the article. All authors helped with the manuscript revision. CNS is the guarantor.

Funding: This study was supported in part by a grant from the National Nature Science Foundation of China (30972923).

Ethical approval: Not needed

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

 

(Hepatobiliary Pancreat Dis Int 2014;13:464-473)

 

KEY WORDS: ursodeoxycholic acid; acute cellular rejection; liver transplantation; meta-analysis

Administration of ursodeoxycholic acid (UDCA) has been well recognized as a simple and cost-effective option to treat various chronic liver diseases, such as primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), cystic fibrosis and intrahepatic cholestasis in pregnancy.^{[1, 2]} UDCA exhibits a cytoprotective activity which may be involved in reducing bile toxicity, anti-oxidation, anti-apoptosis and stabilizing membrane.^[1-4] Additionally, in PBC patients, UDCA significantly reverses aberrant HLA class I molecules expression on hepatocytes, thereby suppressing T lymphocytes antigen recognition and cytotoxicity.^{[5, 6]} With the cytoprotective activities together with immunomodulatory effects, UDCA can act as an attractive adjuvant therapy in acute cellular rejection (ACR) after liver transplantation (LT).^[7-9]

 

In 1990 Persson et al^[10] reported that prophylactic use of UDCA after LT reduced the incidence of ACR significantly. Subsequently, several clinical trials validated this effect but others demonstrated contradictory results.^[10-17] Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of UDCA in reducing the incidence of ACR in liver transplant recipients.

 

 

All relevant studies regarding effects of UDCA in liver transplantation were searched independently by two researchers (DYL and XXZ) in electronic database, PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ScienceDirect databases and Web of Science, from January 1981 to March 2012. Relevant abstracts of international meetings were also searched. Finally, references of each included-study were searched manually. The following MeSH terms and key words were searched: "ursodeoxycholic acid" or "bile acids" combined with "liver transplantation" or "orthotopic liver transplantation". Any discrepancies were resolved by consensus.

 

RCTs that evaluated the efficacy of UDCA as an adjuvant treatment to prevent ACR after LT were included without language limitation. Exclusion criteria were: (1) trials with non-parallel design; (2) trials with significant difference in baseline characteristics between treatment and control groups; (3) abstracts which were unable to obtain complete data; (4) multiple publications of the same database.

 

Data were extracted as: first author, publication year, number of participants, baseline characteristics of treatment and control groups (age, gender, original liver disease and immunosuppressive protocol), inventions (doses, starting and during), follow-up time, primary end-points (ACR, steroid-resistant rejection and multiple episodes of ACR) and the diagnosis of ACR and steroid-resistant rejection.

 

The quality of each study was also assessed independently according to the Jadad scoring system by two reviewers (XXZ and CNS) and, a Jadad score of 3 to 5 points indicated high-quality research.^[18] Additionally, allocation concealment and intention-to-treat (ITT) analysis were also considered, but did not contribute to the overall quality score. Any disagreements were resolved by discussion and consensus.

 

Meta-analyses were made using RevMan 5.1.6 (The Cochrane Collaboration, Oxford, UK) software. Statistical heterogeneity between RCTs was assessed using the Chi-square test. A P value less than 0.1 was considered statistically significant, and the Higgins I² statistical method was quantitatively used to measure sources of heterogeneity. The I² value less than 25% indicated low heterogeneity, between 25% and 50% indicated moderate heterogeneity. Subsequently, the fixed effects model was applied to calculate the summary risk ratios (RRs) and the Mantel-Haenszel method was used to detect the 95% confidence intervals (CIs). When heterogeneity was high (I² value >50%), a random effects model was used and tried to explore the sources of heterogeneity by the subgroup or sensitivity analyses.^[19] Funnel plots were constructed to screen potential publication bias.^[20] Differences in proportions between two groups were examined by the Chi-square analysis, and P<0.05 was considered statistically significant.

 

 

The selection process flowchart of our study is shown in Fig. 1. A total of 2350 records were identified by our initial literature search. After the primary screening of abstracts, 2196 were rejected because of duplicity (n= 857) and irrelevant (n=1339) records. Of the remaining 154 articles, 137 records were excluded for the following reasons: review articles (n=14), irrelevant (n=98), nonhuman (n=23) and editorials (n=2). Subsequently, 17 studies were selected for further analysis. Four records were excluded because of duplicate publications: three meeting abstracts and one letter^[10] used the same data sources with other four trials. Two records were excluded because one was historical control trial (HCT)^[11] and another did not have a control group.^[13] Two records were excluded without our end-points of interest.^{[21, 22]} Three records were excluded for different intervention modalities. As one study evaluated the effect of pre-transplantation UDCA therapy on the outcome of LT,^[23] and the other two trials evaluated the role of UDCA in liver transplantation recipients with total immunosuppression withdrawal (TIW).^{[24, 25]} One editorial was excluded as it has no experimental data.^[26] One study was excluded as tauroursodeoxycholic acid was used instead of UDCA.^[12]

 

Four prospective, randomized, double-blind and placebo-controlled trials with 234 patients were finally selected for the analysis. All included patients had orthotopic liver transplantation (OLT) with the same surgical procedures divided into treatment (UDCA-treated) and control (placebo-treated) groups. Many factors like age, gender and especially primary liver disease can influence the incidence of ACR.^[27-31] Autoimmune hepatitis (AIH), PBC^{[29, 30]} and hepatitis C^[31] have been reported to be associated with higher incidence of ACR. Although all four studies claimed that there was no basic imbalance in baseline characteristics between the two groups included age, gender, and primary liver disease (Table 1), we still made comparative analysis of the proportion of patients with high ACR-risk diseases (AIH, PBC and hepatitis C) between the two groups in each trial to further clarify the homogeneity of underlying disease. However, no statistically significant difference was noted (Table 2).

 

The summary of four included trials is described in Table 3. In all the trials, the UDCA and the placebo had identical appearance and taste. In addition, the effects of different doses and duration of UDCA were also evaluated in these trials, 10 to 15 mg/kg per day for 3 to 6 months in three RCTs^[15-17] and 600 mg/d for 2 months in one RCT.^[14] In Keiding et al's study, administration of UDCA was started on the first post-operative day whereas, in other three trials,^{[14, 16, 17]} UDCA was started on postoperative days 3 to 5. The primary end-points in all trials contained the incidence of ACR and steroid-resistant rejection and the multiple episodes of ACR according to the similar diagnostic criteria.

 

The quality assessment of four RCTs is summarized in Table 4. Each trial was randomized and double-blind (identical placebo), but only Barnes et al^[16] provided the method to generate the sequence of randomization. There was a description of withdrawals and dropouts in reports on four trials. Two trials performed an ITT analysis. One trial had adequate allocation concealment with a statement on the use of sealed serial envelope. Therefore, we confirmed that all four trials were high-quality without the source of heterogeneity.

 

The four trials reported the number of patients who experienced one or more episodes of ACR and steroid-resistant rejection in the UDCA and placebo groups, but only three trials reported the number of patients with the multiple episodes of ACR (Table 5). Prophylactic use of UDCA did not decrease the number of patients with ACR (RR: 0.94, 95% CI: 0.77 to 1.16, P>0.05) with nil heterogeneity (P=0.95, I²=0%). Use of UDCA also did not decrease the incidence of steroid-resistant rejection (RR: 0.77, 95% CI: 0.47 to 1.27, P>0.05) with nil heterogeneity (P=0.52, I²=0%). In addition, UDCA use did not decrease the number of patients with the multiple episodes of ACR (RR: 0.60, 95% CI: 0.28 to 1.30, P>0.05) with moderate heterogeneity (P=0.14, I²=49%) (Fig. 2).

 

According to the time of administration of UDCA, the four trials were divided into two main groups: early (the first postoperative day) and delayed (between postoperative days 3 and 5) intervention groups. The subgroup analysis showed that the early or delayed intervention of UDCA did not decrease the number of patients with ACR and steroid-resistant rejection (Fig. 3). Thus, a subgroup analysis was based on the dose of UDCA, which indicated that high-dose UDCA (average 1000 mg/d) or low-dose UDCA (average 600 mg/d) also did not affect these results (Fig. 4). In addition, comparison between the triple-drug immunosuppressive regimen and the double-drug regimen showed that UDCA used as an adjuvant in LT patients treated with the triple-drug or double-drug regimen did not decrease the number of patients with ACR and steroid-resistant rejection. In addition, the triple-drug regimen did not reduce the multiple episodes of ACR but the double-drug regimen tended to decrease this event (Fig. 5).

 

After excluding the Pageaux et al^[14] study, there was still no difference in the incidence of ACR between the two groups (RR: 0.95, 95% CI: 0.77 to 1.17, P>0.05) with nil heterogeneity (P=0.83, I²=0%). In addition, this also did not alter the incidence of steroid-resistant rejection (RR: 0.73, 95% CI: 0.44 to 1.21, P>0.05) with nil heterogeneity (P=0.42, I²=0%) (Fig. 6).

 

 

ACR is regarded as one of the most common problems faced by liver transplant recipients in spite of advances in immunosuppressive therapy.^{[8, 9]} In addition, when high-dose steroid fails to treat the episode of ACR, steroid-resistant rejection occurs. OKT3, although helpful to further suppress the immune system, may cause infections.^[32] The aberrant expression of HLA class I molecules on hepatocytes plays an important role in the process of ACR, thus providing a therapeutic window. Such abnormal expression could significantly be reversed by administration of UDCA in PBC patients. This immunomodulatory effect together with cytoprotective activities of UDCA made many clinical trials determine the efficacy of UDCA in the prevention of ACR after LT, but led to a contradictory conclusion. In view of limited reliability of retrospective studies and HCTs, we only included four high-quality RCTs (Jadad score 4 to 5) in our study. A sensitivity analysis showed no significant difference in the result which further confirmed the reliability and stability of our analysis.

 

This meta-analysis of RCTs showed that UDCA was beneficial as an adjuvant treatment for ACR in liver transplant recipients, including the incidence of ACR and steroid-resistant rejection. Moreover, no difference between different intervention programs (high vs low-dose UDCA, early vs delayed UDCA treatment, the triple-vs double-drug immunosuppressive regimen with UDCA) was found. Three of the four RCTs explored the effect of prophylactic UDCA on the multiple episodes of ACR, and showed no benefits with moderate heterogeneity. The subgroup analysis found that the double-drug regimen was superior to triple-drug regimen in decreasing the multiple episodes of ACR.

 

How does UDCA as an adjuvant prevent the episode of ACR? Persson et al^[10] reported that 10 mg/kg/d of UDCA exerted this effect. But our analysis showed that two doses of UDCA (around 8 mg/kg per day and 15 mg/kg per day) did not reduce the incidence of ACR and even steroid-resistant rejection. However, perhaps 15 mg/kg of UDCA per day was still below the therapeutic range and a higher dose of UDCA might be effective. As ACR most likely occur around one week after transplantation,^{[9, 27]} it seemed that the difference in starting time of UDCA was likely to cause different results, but that was not able to be confirmed in our analysis. Whether the intervention started on the first postoperative day or between postoperative days 3 to 5 did not decrease the incidence of ACR, steroid-resistant rejection and the multiple episodes of ACR. In addition, the difference between the standard triple-drug and double-drug immunosuppressive regimen in included patients was not able to affect the conclusion that UDCA as an adjuvant did not reduce the incidence of ACR and steroid-resistant rejection, probably because both protocols contained the sufficient amount of cyclosporine. However, the double-drug immunosuppressive regimen with UDCA was able to reduce the multiple episodes of ACR. Because only three trials were included in this analysis, whether the double-drug immunosuppressive regimen with UDCA is better to prevent the multiple episodes of ACR is inconclusive and more clinical evidences are required.

 

Only four RCTs were included in this meta-analysis, the risk of publication bias cannot be assessed well irrespective of a symmetrical funnel plot (Fig. 7).^[33] There may be a selection bias in our analysis because only one trial reported the methods of randomization and allocation concealment. Besides of age, gender, primary liver disease, the race of recipient, graft preservation and immunosuppressive protocol also seems to influence the incidence of ACR.^{[27, 28, 34, 35]} These factors were not entirely uniform across the four trials, which potentially contributed to limiting factors in our study.

 

Regardless of these limitations, this analysis confirmed that UDCA does not decrease ACR occurrence after LT. This conclusion seems to be frustrating. A recent study by Wang et al^[36] indicated that UDCA administration early after LT not only significantly improved liver enzymes but also diminished the incidence of biliary sludge and casts within the first postoperative year; however, Wang et al^[36] did not found the difference in the 5-year overall outcomes. Therefore, administration of UDCA still may be a cost-effective choice for improving quality of life in patients after LT.

 

In conclusion, this meta-analysis strongly suggested that UDCA as an adjuvant treatment did not prevent the episode of ACR and steroid-resistant rejection after LT. Further trials should be conducted in order to identify whether the higher dose of UDCA will exert such benefits, and whether the prophylactic use of UDCA to the double-drug immunosuppressive regimen rather than the triple-drug regimen could decrease the multiple episodes of ACR after LT.

 

 

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