Cirrhosis can recur in a transplanted liver or develop from a different cause, posing a long-term challenge for transplant recipients. Although liver transplantation is the primary treatment for patients with advanced cirrhosis, fibrosis and cirrhosis can still develop in the transplanted liver. A study found that 11.4% of patients who received a liver transplant for cirrhosis later developed cirrhosis in the transplanted liver, highlighting the need for long-term monitoring of fibrosis progression after transplantation.
Addressing this challenge, Dr. Abhinav K. Rao and Dr. Don C. Rockey from the Digestive Disease Research Center, Medical University of South Carolina, USA, examined consecutive adult patients who underwent liver transplantation for cirrhosis and were followed from January 1, 1987, through December 31, 2023. The analysis included 937 patients after excluding those transplanted for non-cirrhotic conditions and those with active hepatitis C virus infection at transplantation. Cirrhosis after transplantation was identified using liver histology and/or clinical evidence of portal hypertension, with supportive imaging findings used in patients without liver biopsy results. The study was published online on September 3, 2026, in the journal Portal Hypertension & Cirrhosis .
Among 937 patients, 107 developed cirrhosis after transplantation, with a median time to diagnosis of 7.8 years. Of these, 89 patients (83.2%) represented recurrence of the liver disease that had originally led to transplantation. Recurrence was most common among patients whose original diagnosis was autoimmune hepatitis, affecting 16 of 55 patients, followed by primary biliary cholangitis, affecting 11 of 52 patients. De novo cirrhosis, caused by a different disease, developed in 18 patients, representing 16.8% of post-transplant cirrhosis cases and 1.9% of the overall cohort. Chronic rejection accounted for nine cases, while metabolic dysfunction-associated steatohepatitis accounted for four.
“Our findings show that cirrhosis after transplantation is uncommon, but when it develops, recurrence of the original liver disease is the most frequent explanation, ” said Dr. Rao. “ The particularly high recurrence rates observed among patients transplanted for autoimmune hepatitis and primary biliary cholangitis emphasize the need for continued surveillance of liver health after transplantation. ” The study also found that patients who developed cirrhosis after transplantation had lower long-term survival than those who did not. Twenty years after transplantation, survival was 50.6% among patients with post-transplant cirrhosis compared with 70.7% among those without it.
The findings could help clinicians identify transplant recipients who may need closer monitoring for progressive liver injury. The study also highlights the importance of controlling disease-specific risks after transplantation. In patients transplanted for hepatitis C, recurrent hepatitis C cirrhosis was much less common in the post-direct-acting antiviral era. The researchers also noted that metabolic risk factors may contribute to recurrent metabolic dysfunction-associated steatohepatitis, while chronic rejection was the leading cause of de novo cirrhosis.
“Our results support lifelong surveillance for fibrosis progression in transplant recipients and point to opportunities for improving prevention and follow-up, ” said Dr. Rockey. “ Understanding why cirrhosis returns or develops anew may help guide future studies aimed at preventing graft injury and improving long-term outcomes.”
Overall, the study shows that cirrhosis can develop years after transplantation and is associated with reduced survival, supporting lifelong surveillance for fibrosis progression and further multicenter research to validate these findings and identify strategies to prevent recurrent and de novo cirrhosis.
Reference
Title of original paper: Recurrent and De Novo Cirrhosis After Liver Transplantation
Journal: Portal Hypertension & Cirrhosis
DOI: https://doi.org/10.1002/poh2.70068
About Medical University of South Carolina, USA
The Medical University of South Carolina (MUSC), based in Charleston, South Carolina, is an academic health system focused on education, health care, research, and innovation. MUSC aims to pioneer a healthier future for all by transforming lives through breakthrough research, educating the next generation of medical leaders, and delivering world-class care. Its work emphasizes expanding access to education, research, and patient care to improve outcomes and eliminate health disparities. Through its research programs, clinical services, educational institutions, and partnerships, MUSC seeks to advance health and benefit communities locally and worldwide for patients and communities.
Website: https://www.musc.edu/
About Dr. Abhinav K. Rao
Dr. Abhinav K. Rao is a physician and clinical researcher affiliated with the Digestive Disease Research Center and the Division of Gastroenterology and Hepatology at the Medical University of South Carolina, USA. He graduated from Sidney Kimmel Medical College at Thomas Jefferson University in 2022. His research interests include colon cancer, colorectal cancer, colonoscopy, cirrhosis, and hepatic encephalopathy. His research and publications focus on clinical questions in gastroenterology and hepatology, including liver disease and gastrointestinal disorders.
Funding Information
This project was supported, in part, by the National Institutes of Health – the National Institute of Diabetes and Digestive and Kidney Disease (grant number P30 DK123704) and the National Institute of General Medical Sciences (grant number P20 GM130457), which supported Don C. Rockey. This study was also supported by Veterans Administration Medical Center, Yale School of Medicine (grant number Merit I01BX006016).
Portal Hypertension & Cirrhosis
Observational study
People
Recurrent and De Novo Cirrhosis After Liver Transplantation
3-Sep-2026
Don C. Rockey is the Co-Editor-in-Chief of Portal Hypertension & Cirrhosis. He is therefore excluded from the peer-review process and all editorial decisions related to the publication of this manuscript. The other author declares no conflicts of interest.