Recurrent hepatitis C virus disease after liver transplantation and concurrent biliary tract complications: poor outcome

Abstract

Recurrent hepatitis C virus (HCV) infection is particularly aggressive in the post-liver transplantation setting, with rapid progression of liver fibrosis. Biliary complications remain a significant cause of morbidity following liver transplantation. Post-cholecystectomy biliary strictures are associated with advanced hepatic fibrosis. The aim of this retrospective study was to determine whether the presence of biliary complications affects survival in liver transplant recipients with recurrent HCV disease. The files of liver transplant recipients (53.7% male; mean age 52.7+/-10.3 yr) were reviewed for incidence, type and treatment of biliary complications, and findings were compared between those who developed recurrent HCV disease (n=47, 83.9%) and those who did not (n=9). Twenty-one biliary complications developed in 12 patients with recurrent HCV (25.5%). Treatment with endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography with balloon dilatation and stent placement or surgical revision was successful in nine (75%). Three biliary complications developed in three patients with no recurrence (p=NS). There was no statistically significant association between recurrent HCV disease and biliary complications. However, among those with recurrent disease, the recurrence was severe in nine of 12 recipients with biliary complications (75%) but in only nine of 35 without biliary complications (26%) (p=0.001). Death was documented in eight patients with severe recurrence (44.4%), including three (37.5%) with biliary complications and two (7%) with non-severe recurrence, neither of whom had biliary complications (p=0.003). Antiviral treatment was successful in nine of 25 patients (36%) who received it. On multivariate analysis, biliary complications were a significant predictor of severe recurrence (OR 27.0, 95% confidence interval 2.07-351.4) (p=0.012). Fibrosis stage in the second biopsy was significantly correlated with serum alanine aminotransferase (p=0.01) and with duration of biliary obstruction (p=0.07). In conclusion, biliary complications of liver transplantation strongly affect outcome in patients with recurrent HCV disease despite attempts to relieve the biliary obstruction and to treat the recurrent HCV disease.

Clinical characterization of patients developing histologically‐proven fibrosing cholestatic hepatitis C post‐liver transplantation

“…We analyzed these patients separately so as to eliminate the confounding effect of biliary problems on the clinical course and outcome of the patients. Biliary problems are, however, a risk factor for worse outcome in patients with recurrent HCV 26,27 …”

Spanish society of liver transplantation (SETH) consensus recommendations on hepatitis C virus and liver transplantation

“…Recently, a higher proportion of biliary stenosis has been observed in some studies in HCV-infected recipients, both late (> 1 month after transplantation) (73), and diffuse non-anastomotic stenosis (74). Likewise, a higher rate of severe fibrosis associated with the presence of biliary complications (23,74) has been found, with a rate of severe fibrosis (fibrosis 3-4) in 75% of those who developed biliary complications compared with 26% in those who did not (74). In another study, however, there was no association between the presence of biliary complications and HCV-related disease severity (23).…”

Hepatitis C in liver transplant patients

“…Although outcomes related to HCV recurrence after transplantation from DCD donors have not been published, it is apparent that the requirement for retransplantation is significantly higher following DCD, mainly because of a higher incidence of nonanastomotic biliary strictures [33]. As biliary strictures have been reported to be associated with worse outcomes related to HCV recurrence [34], it can be postulated that the natural history of HCV infection may be affected in transplant recipients if they receive a graft from a DCD donor.…”