Post-liver transplant hepatitis C therapy

Pharmacologic therapies to treat chronic hepatitis C virus (HCV) have rapidly evolved over the past few years and resulted in short courses of all oral multidrug cocktails of direct-acting antivirals (DAAs) that achieve sustained virologic response (SVR) rates consistently >90 % in low-risk patient populations. Of note, these same cocktails are now being used off-label with unprecedented success in patients post-liver transplantation (LT) revolutionizing how we think about treating HCV in patients who need and have a liver transplant. For patients who are already post-LT, the tolerability of therapy has improved affording most patients the opportunity to be treated and cured. In patients not on cyclosporine, sofosbuvir (SOF) and simeprevir with or without ribavirin (RBV) showed in a pooled analysis an SVR12 rate of 87-90 %. Paritaprevir, ritonavir, ombitasvir, dasabuvir, and ribavirin treatment has also been studied post-LT and demonstrated a 97 % SVR12 rate with 24 weeks of therapy in patients with early-stage fibrosis. Ledipasvir + SOF + RBV for 12 or 24 weeks achieved SVR12 rates of >96 % in post-LT patients including those with compensated cirrhosis. We are fortunate to have truly entered a new era of HCV therapy, where non-decompensated post-LT patients are no longer disadvantaged and can enjoy SVR rates similar to non-transplant patients. These well-tolerated medications call into question the ideal time to cure HCV. Specifically, short courses of interferon-free medication may be able to be administered peri-transplant in order to spare the new graft all the potential complications of viral infection. At this time, the best-tolerated and most cost-effective approach to this important new strategy is under active investigation.