Transplant recipients exchange one health state for another. Pre-transplant preparation should encourage realistic expectations of life after transplantation. Before transplantation, potential recipients should be given an opportunity to discuss the donation process. This may reduce the burden of emotional debt experienced by some recipients. Feelings of stigma and future uncertainty may be worse for transplant recipients with HCV. A qualitative approach can provide deeper insight into issues affecting quality of life after transplantation for HCV, and explain some of the ambiguous and contradictory findings of previous quantitative studies.

Our observations imply that the selection of resistant virus may be essential, but is not sufficient to cause overt failure of prophylaxis with development of clinical disease. It seems likely that the patients' immune response contributes, at least partially, to the long-term control of infection in these patients.

Chronic hepatitis C is a principal indication for liver transplantation. Recurrent viral infection is inevitable and graft disease is common. We report tolerability, safety and efficacy of pegylated interferon alpha 2b (PEG-IFN) monotherapy for patients with hepatitis C virus (HCV) recurrence and fibrosis after liver transplantation. Repeated measurements of serum HCV titer permitted assessment of the kinetics of the antiviral response for all patients.We screened 63 patients transplanted for HCV at our center for antiviral treatment, 14 were eligible and treated, but only 6 completed the proposed 52 weeks of therapy. Eight were withdrawn because of severe/life-threatening side effects/events, including liver dysfunction (4 patients). None of those 8 achieved a sustained virological response (SVR). Five of 6 who completed treatment were HCV RNA negative at the end of treatment, and 2 achieved an SVR. Viral kinetics were similar to published observations for treatment of non-transplanted HCV patients. Patients with genotype non-1 infection displayed a more rapid decline of viral titer than was observed for genotype 1 infection.Post-transplant HCV patients are frequently unsuitable for, or intolerant of PEG-IFN. Liver dysfunction was a major concern.

Hepatitis C virus (HCV)-induced cirrhosis is the most common indication for liver transplantation (LT). However, graft reinfection is nearly universal. The choice of immunosuppression, including the calcineurin inhibitor (CNI), may have some effect on severity of recurrence and graft survival. In addition, HCV recurrence may have some impact on metabolism of immunosuppressive drugs. In this retrospective study, we examined the dose and blood levels of tacrolimus (TAC) and cyclosporin A (CYA) in HCV patients consecutively undergoing transplantation (TAC, n ϭ 44; CYA, n ϭ 60) and surviving 12 months post-LT. In addition, we examined the CNI dose and blood levels in an age-and gender-matched comparison group of patients who were transplanted for alcoholic liver disease (ALD) (TAC, n ϭ 44; CYA, n ϭ 47). During the 12-month period of observation, TAC levels were significantly higher for HCV than for ALD patients (P ϭ 0.002). The dose of TAC decreased over time for both HCV and ALD patients (P Ͻ 0.001), but the reduction was greater for HCV patients (P ϭ 0.03). CYA dose decreased over time for both groups (P Ͻ 0.001) but a greater reduction was observed for the HCV group (P ϭ 0.007). For both HCV and ALD patients, CYA levels decreased over time (P Ͻ 0.001) but there was no significant difference between HCV and ALD patients. Thus, to maintain comparable blood levels, a greater reduction of dose was required for HCV than for ALD patients. In conclusion, our observations demonstrate a likely effect of HCV infection on CNI metabolism, an effect that is not clearly due to graft damage. Physicians need to be alert to this interaction and to the need to respond quickly to changes in CNI levels that may be associated with HCV infection and with HCV clearance during antiviral therapy. Liver Transpl 14: 81-87, 2008.

The treatment of patients with advanced HCV is challenging, although many treated patients achieve SVR. Significant toxicity is experienced and there is treatment-related mortality. This balance of efficacy and toxicity needs to be considered before commencing treatment.