Liver transplantation in viral hepatitis. New insights

Liver transplantation is the only therapeutic option for end-stage liver disease. When disease is due to hepatitis B, C or D viruses, transplantation is aggravated by important morbidity related to the recurrence of viral infections. The risk of reinfection has led to the identification of prognostic criteria and measures for preventing or diminishing the reinfection hazard. HBV recurrences can be diminished with the use after transplantation of immunoglobulins against the HBsAg (HBIg). With this prophylaxis the risk of reinfection is proportional to the viremic load before transplantation; it is high (> 90%) in patients with elevated viremia, low in non-viremic HBsAg carriers (such as those with fulminant hepatitis or HDV coinfection), intermediate in the remaining cases. The recent availability of potent antivirals against the HBV has provided a tool to further reduce the reinfection risk. Antiviral therapy or immunoprophylaxis, however, may lead to the emergence of resistant mutants; combination therapies appear in order to prevent this event. There is at present no valid prognostic indicator to identify HCV transplants at risk of recurrent disease or prophylactic measure to prevent reinfection. Reinfection is virtually universal and the course of infection is apparently benign over the short term in the majority of cases; the disease is rapidly progressive with cholestatic features mimicking chronic rejection in 10-20% of HCV reinfected transplants. Neither the HCV genotype nor coinfection with HGV appear to influence the clinical outcome. The long-term prognosis appears at present less favourable than previously perceived; several studies indicate a progressive reduction of the survival curve due to insidious HCV cirrhosis developing over 5 to 7 years. Interferon or Ribavirin monotherapy are not effective for prevention or therapy of recurrences while their combined use yields promising results.