Background: Some patients with ulcerative colitis (UC) develop advanced liver disease due to conditions such as primary sclerosing cholangitis (PSC) and may require liver transplantation (LT). However, data on the long-term course of UC and the use of advanced therapies in LT recipients are limited. We aimed to evaluate UC activity before and after LT, as well as the role of advanced therapies over extended follow-up in this population. Methods: This was a retrospective, multicenter cohort study including 213 patients with UC who underwent LT between 2000 and 2022. Clinical disease activity (partial Mayo score), endoscopic disease activity (Mayo endoscopic subscore), and the use of advanced therapies were evaluated before and after transplantation. Results: Among the 213 patients, the clinical remission rate was 84.7% before and 81.2% after LT, showing no significant change (P = .416). Despite stable clinical remission, 27.9% of patients exhibited moderate-to-severe endoscopic inflammation during long-term follow-up (mean: 110 months). The use of advanced therapies increased significantly after LT (from 3.7% to 12.7%, P = .005) and was not associated with an increase in infectious complications (P = .591). Conclusions: In most patients, clinical disease activity remains stable after LT. However, persistent moderate-to-severe mucosal inflammation is observed in a substantial subset during long-term follow-up. Advanced therapies, particularly vedolizumab, are being used more frequently in this setting and may offer disease control without a corresponding increase in infection risk. These findings underscore the need for individualized, interdisciplinary management and further prospective evaluation of treatment strategies in this population.

Patients with Crohn’s disease (CD) may require liver transplantation (LT) due to advanced liver diseases, including primary sclerosing cholangitis (PSC), autoimmune hepatitis, or other etiologies. However, data on CD activity and the use of advanced therapies following LT are limited. This study aimed to assess CD activity before and after LT and to evaluate the use of advanced therapies in this setting. Methods: In this multicenter retrospective cohort study, we analyzed 40 patients with CD who underwent LT between 2000 and 2022 at four university hospitals in Germany. Clinical and endoscopic disease activity, as well as the use of advanced therapies, were evaluated before and after transplantation. Results: Before LT, 89.7% of patients were in clinical remission, which remained stable after LT (85.7%; p = 0.650). Nevertheless, 22.6% of these patients demonstrated moderate to severe mucosal inflammation on endoscopy during long-term follow-up. The use of advanced therapies remained low after transplantation (pre-LT: 11.7%, post-LT: 7.5%; p = 0.532) even among those with endoscopic disease activity. Conclusions: Although clinical remission of CD is usually maintained following LT, endoscopic evidence of persistent mucosal inflammation is common and may be underrecognized. Despite this, advanced therapies are not frequently used in the post-transplant setting. These findings suggest that individualized treatment strategies are needed to address subclinical disease activity while balancing therapeutic effectiveness with transplant-specific risks.