Recurrent hepatitis C after liver transplantation

Abstract

Cirrhosis due to hepatitis C is now the commonest indication for liver transplantation in Western Europe and in the United States. Graft reinfection is almost universal. The natural history of recurrent hepatitis C ranges from minimal damage to cirrhosis in a few months or years. Different virus and host immune factors are involved in the pathogenesis of hepatitis and are determinants of the outcome. The association between immunosuppression and severity of HCV recurrence is conflicting and remains to be evaluated fully. The treatment of recurrent HCV disease with IFN or ribavirin, as monotherapy, is ineffective. Preliminary results from combination therapy, however, are encouraging. Currently, a reasonable approach would be to treat patients with histological and clinical disease progression. New approaches for the prophylaxis of recurrent hepatitis C are under evaluation but whether this treatment will influence the severity of liver disease or the outcome of recurrence is still unknown.

Management of recurrent viral hepatitis B and C after liver transplantation

“…A tendency toward increase in serum HCV RNA levels seems to be associated with the early phase after transplantation when the use of immunosuppression is greatest and the use of a steroid bolus more frequent. In fact, Berenguer et al showed in an analysis based on the historic timing of transplantation more aggressive HCV recurrence in those patients who were given a shorter course of steroids [18][19][20]. Several factors within this analysis, including treatment variations among transplant teams and the increased use of marginal donors, may have affected their outcomes.…”

Posttransplantation prevention and treatment of recurrent hepatitis C

“…Approximately 20% of the patients develop cirrhosis at 5 years post-OLT 2,3 compared with a similar percentage or less who develop cirrhosis at 20 years in the pre-OLT setting. 4 Because not all patients post-OLT progress to fibrotic liver disease, at least in the medium term, many studies have evaluated such viral and host factors as donor and recipient age and sex, pre-OLT HCV concentration, HCV genotype, HCV quasispecies, donor and recipient histocompatibility, presence of coexisting liver disease (hepatitis B virus and hepatocellular carcinoma), type and dose of maintenance immunosuppression, and number of pulses of high-dose steroid therapy for treating rejection 5 that might predict progressive liver disease. A small group of patients develop a severe form of cholestatic hepatitis associated with a very high intracellular load and perhaps more quasispecies homogeneity.…”

Induction immunosuppression for patients who underwent transplantation for cirrhosis caused by hepatitis C? The answer is no!

“…5 Once cirrhosis occurs, decompensation is rapid. 6 Graft reinfection is manifested by acute lobular hepatitis, usually asymptomatic 7 and diagnosed in more than 50% of patients between 2 and 6 months.…”

“…Many studies have examined viral factors that might predict the course and outcome of recurrent HCV, 5 but apart from an association with viral load, 14 it is difficult to be sure whether the development of fibrosis, the key factor in recurrence, is related to viral factors. 5 Coinfection with cytomegalovirus (CMV) is disputed as a cofactor, [15][16][17] but obviously even despite prophylaxis, CMV infection would be more likely with a more powerful induction immunosuppression.…”

“…5 Coinfection with cytomegalovirus (CMV) is disputed as a cofactor, [15][16][17] but obviously even despite prophylaxis, CMV infection would be more likely with a more powerful induction immunosuppression.…”