Retransplantation for recurrent hepatitis C

Abstract

Recurrence of hepatitis C virus (HCV) after orthotopic liver transplant (OLT) may be mild or may lead to progressive liver disease requiring retransplantation (re-OLT). Results of re-OLT for hepatitis C are not well known. We analyzed outcomes in 14 patients retransplanted for recurrent hepatitis C. All had evidence of recurrent hepatitis on multiple biopsies. Polymerase chain reaction (PCR) was performed in blood or tissue samples from 12 patients when recurrence was suspected; all 12 were positive for HCV-RNA. Explants showed chronic hepatitis with bridging necrosis in 3 patients, hepatitis with transition to cirrhosis in 2, hepatitis and cirrhosis in 3, and cirrhosis alone in 2. In 2 patients, in whom immunosuppression had been withheld for 4 to 6 weeks, there was also evidence of chronic rejection. Four died of sepsis perioperatively (median, 32.5 days; range, 9-59); pre-OLT, 3 of 4 had renal failure, and 1 had fever with no obvious source of infection. Ten patients did well early after OLT and were discharged. One patient was readmitted 6 weeks after discharge and died of cytomegalovirus (CMV) infection 127 days after re-OLT. One patient with concomitant vanishing bile duct syndrome, probably due to chronic rejection, developed recurrent hepatitis and died of progressive liver failure 161 days after re-OLT. Eight patients are well at a median of 926 days (range, 315-1930) after re-OLT. Three have evidence of mild recurrent hepatitis on liver biopsy, one is overweight with severe steatosis on biopsy, and four have no evidence of recurrent hepatitis. Retransplantation for hepatitis C should be considered a viable option for patients who develop end-stage hepatic dysfunction secondary to recurrent disease and should be performed before development of infectious complications and renal insufficiency.

Retransplantation for hepatitis C: Results of a U.S. multicenter retransplant study

“…As expected, MELD score increased at each interval of evaluation from initial transplantation to reTX. At the time of the first listing and transplantation the MELD scores were higher in group 2 and 3 compared to group 1 (first listing, mean MELD score, 13 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] vs. 18 vs. 15 ; first transplant, mean MELD score, 15 vs. 20 vs. 18 ). MELD scores at second listing and reTX were distinctly higher than initial listing and transplantation (second listing, mean MELD score, 21 vs. 21 vs. 25 ; reTX, mean MELD score, 26 vs. 25 ).…”

“…Several single-center studies have noted slightly higher survival than reported by our group. 18,[21][22][23] The reported ability of MELD scores to predict post-reTX survival has been variable. 9,[24][25][26][27] In our study, although MELD scores were not predictive of post-reTX survival, higher MELD scores (particularly Ͼ25) at the time of reTX were associated with high post-reTX mortality.…”

“…9,19,24,25,28 In our study it was not predictive of survival in HCV patients partially due to low (3 yr) survival even in the moderate MELD score range. [20][21][22][23][24][25] Given the mean MELD score Ͼ25 at the time of evaluation for reTX, it is not surprising that these patients were often not offered a retransplant or could not survive long enough to get the organ they needed.…”

The efficacy of prophylactic interferon alfa-2b in preventing recurrent hepatitis C after liver transplantation

“…16 We reported severe fibrosing cholestatic hepatitis in 7.4% of patients who underwent liver transplantation for hepatitis C. 5 With longer follow-up, we and others have observed that liver failure and complications of cirrhosis develop as well. 3,17 Once hepatitis C recurs, treatment is largely ineffective. This may be partly because of the extremely high viral levels observed after transplantation.…”

Hepatitis C viral infection in the immunosuppressed patient

“…Out of a cohort of 12 subjects retransplanted for HCV re-infection, 8 patients have now survived longer than after their first transplant with only mild disease recurrence. 39 This is probably a reflection of the use of less immunosuppression following retransplantation for recurrent hepatitis C.…”