Antiviral therapy in patients with HCV-cirrhosis

The main cause of liver cirrhosis and liver cancer in the western world is Hepatitis C virus (HCV) infection. Liver transplantation is the only effective treatment once the disease is decompensated. In viremic patients who undergo transplantation, disease recurrence is universal resulting in the development of a new cirrhosis in about one third of the patients after 5 to 10 years of follow-up. Initiation of the antiviral treatment with Peg-IFN and ribavirin prior to transplantation may prevent HCV recurrence if a sustained viral response (SVR) is achieved. Moreover, it might even be possible to achieve an improvement of the liver function degree so that transplantation may be differed. There are few studies that assess the efficacy and safety of the antiviral treatment in the cirrhotic setting. Available information shows SVR rates between 20 and 40%, lower with decompensated disease. The need for treatment withdrawal and dose reductions is significant in this setting. Cytopenias are one of the most frequent adverse effects; hematopoietic growth factors have shown to increase patient compliance, but it is still unclear whether they result in greater SVR. In addition, an increased risk of bacterial infections has been recently described, with a recommendation to use prophylactic therapy during antiviral treatment. In conclusion, antiviral therapy is an option for cirrhotic patients who have a good liver function but should not be recommended in patients with Child-Pugh-Turcotte class C, due to a high risk of severe complications.