Optimal therapy in hepatitis C virus liver transplant patients with direct acting antivirals

Hepatitis C virus (HCV) end stage liver disease is a main indication for liver transplantation (LT). Recurrent HCV always occurs when patients are transplanted with a detectable viral load, leading to cirrhosis in 20-30% of patients within 5 years. Achieving a sustained virological response (SVR) with antiviral treatment is the only way to improve patient and graft survival. Dual therapy based on pegylated interferon and ribavirin (PEG-IFN/RBV) was the standard of care for many years with limited efficacy and a poor safety profile. The addition of first generation NS3/4 protease inhibitors (PI) improved SVR rates from 30 to 50-60%. But the occurrence of serious adverse events and drug-drug interactions with calcineurin inhibitors have both been limiting factors for their use during LT. The preliminary results of the use of second generation direct acting antivirals (DAA) in transplant patients showed better efficacy with an SVR rate >70%. The pre- and post-transplantation safety profile is good. Although fewer drug-drug interactions are expected, some new DAA still interact with immunosuppressive drugs. Certain questions such as the use of RBV or the optimal duration of therapy have still not been resolved but should be answered by the many ongoing studies in the coming year.