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Hepatitis C virus and liver transplantation
1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Liver Transplant Program, Stanford University Medical Center, Stanford, California, USA.
Insights
Liver transplantation survival is improving, but recurrent hepatitis C (HCV) remains a challenge. Combination antiviral therapy shows promise for treating post-transplant HCV, improving patient outcomes and quality of life.
Area of Science:
- Hepatology
- Transplantation Immunology
- Virology
Background:
- Liver transplantation offers improved survival for chronic viral hepatitis.
- Hepatitis C virus (HCV) recurrence is common post-transplant, unlike hepatitis B.
- No definitive prevention for recurrent HCV exists, impacting long-term outcomes.
Purpose of the Study:
- To review outcomes of liver transplantation for chronic HCV.
- To evaluate treatment strategies for recurrent HCV post-transplantation.
- To assess the impact of recurrent HCV on patient quality of life.
Main Methods:
- Review of current literature on liver transplantation for HCV.
- Analysis of factors influencing HCV recurrence and allograft injury.
- Evaluation of antiviral therapies for post-transplant HCV.
Main Results:
- Long-term survival after liver transplantation for HCV is uncertain.
- Recurrent HCV can range from mild to severe allograft injury.
- Combination therapy (interferon/ribavirin) shows promise for recurrent HCV.
- Recurrent HCV negatively impacts quality of life and mental health.
Conclusions:
- Pegylated interferon plus ribavirin is a promising treatment for recurrent HCV.
- Antiviral therapy is recommended for moderate to severe allograft hepatitis.
- Improved antiviral therapies may reduce the need for liver transplantation.
- Donor pool expansion strategies can benefit HCV patients awaiting transplant.
Abstract:
Advances in immunosuppressive therapy, operative techniques, and perioperative management have resulted in long-term patient survival rates approaching 90% following liver transplantation for chronic viral hepatitis. The increasing number of referrals for liver transplantation reflects the impact of chronic HCV infection as a cause of end-stage liver disease. Unlike hepatitis B, there is still no effective treatment in preventing recurrent hepatitis C after liver transplantation. The spectrum of allograft injury related to universal HCV infection recurrence ranges from no evidence of histologic injury to mild inflammation to severe disease with allograft failure in small proportion of patients. Various factors may explain these differing outcomes, including degree of pretransplantation viremia, HLA compatibility, presence of more pathogenic HCV genotypes, integrity of cellular immune response, and type of immunosuppression. Fortunately, patient survival does not seem to be affected short-term; the long-term outcome of liver transplantation for chronic hepatitis C is unclear but is likely to be decreased. Combination therapy with interferon plus ribavirin seems to be a promising treatment strategy for posttransplantation recurrent hepatitis C, and the use of pegylated interferon plus ribavirin may improve these results. Patients with moderate to severe allograft hepatitis are appropriate candidates for combination antiviral therapy. Histopathologically documented recurrent hepatitis C in liver transplant recipients is associated with impaired quality of life, inferior physical condition, and a higher incidence of depression compared with patients who did not have HCV and in those without HCV recurrence. In conclusion, it is possible that the continued improvements in antiviral therapy against HCV infection may ultimately decrease the number of patients needing liver transplantation. Suitable candidates with chronic HCV infection thus warrant treatment with pegylated interferon plus ribavirin combination therapy in the hope of decreasing disease progression. Recent studies, which require confirmation, suggest that nonresponders to standard antiviral therapy may benefit from maintenance therapy. The donor pool for patients with chronic hepatitis C and decompensated cirrhosis can be improved by using HCV-positive donors and by increasing utilization of newer surgical techniques, including adult-to-adult living-donor liver transplantation and split-liver transplantation.