Direct acting antiviral therapy after liver transplantation

Historically, postliver transplant patients with chronic hepatitis C have had worse outcomes than nonhepatitis C-related causes because of accelerated fibrosis posttransplantation and the lack of effective well tolerated therapies for hepatitis C, and posttransplant hepatitis C patients have been considered a special population. Since 2013, we have entered the era of all oral direct acting antiviral agents for hepatitis C with sustained response rates that are consistently above 90% in nontransplant patients.

The introduction of direct acting antiviral agents to posttransplant patients has demonstrated that sustained virologic response rates that are comparable with nontransplant patients can be achieved with excellent tolerability. The combinations of sofosbuvir/ribavirin, ledipasvir/sofosbuvir/ribavirin, daclatasvir/sofosbuvir/ribavirin, sofosbuvir/simeprevir ± ribavirin, and paritaprevir/ombitasvir/dasabuvir/ribavirin have all achieved high sustained response rates posttransplants. The previously dreaded complication of fibrosing cholestatic hepatitis C can now be effectively treated.

In the era of all oral therapies, no patient who undergoes transplant for hepatitis C-related cirrhosis should have their graft fail because of recurrent hepatitis C. It is expected that long-term survival of those who undergo orthotopic liver transplant for HCV-related cirrhosis will be comparable to those without hepatitis C.