Protocols for Recurrent Hepatitis C After Transplantation
Recurrent Hepatitis C infection occurs in nearly all transplanted livers. Progression of recurrent HCV is known to occur more rapidly and can be more aggressive compared to the course in one’s own liver. The time to cirrhosis in the transplant graft is often shorter in duration.
Laboratory tests do not readily assess the severity of liver disease in the transplanted liver. Currently we recommend “protocol” liver biopsies in patients transplanted with HCV at 4 months after transplantation and yearly thereafter to assess disease severity and need for HCV therapy. We will also obtain liver biopsies for significant changes in liver tests.
HCV therapy with pegylated interferon and ribavirin in the post transplant liver patient is used to attempt to stop progression of liver disease and prevent cirrhosis in the transplanted graft. Treatment following transplantation is considered on an individual basis. Not all patients are appropriate candidates for treatment after transplantation, and treatment can be associated with certain risk.
Re-transplantation for recurrent HCV is controversial and may not be of benefit without the ability to control or eradicate virus, as HCV could recur even more rapidly in the newly transplanted liver.
To help better understand the nature of recurrent HCV infection and its consequences thereafter, physicians and researchers in the transplant program are pursuing state-of-the-art research in both the treatment of HCV and in controlling the immune system in patients transplanted with HCV. Patients are encouraged to participate in these efforts.
To address the challenges of controlling HCV infection following liver transplantation, the PENN program is pursuing new forms of therapy. Patients are encouraged to participate in ongoing trials for possible benefit.
Transplant options and timing of transplantation in patients with HCV Because of the likelihood of recurrent HCV, transplantation should not be performed too early in the course of the disease. If there is relatively good function as demonstrated by a low MELD score, and no life-threatening complications, it may be best to keep your own liver as long as possible, since the operative risk of the transplant itself, or significant recurrent disease, may be higher than the risk of waiting. If symptoms progress and liver function deteriorates, then transplantation is indicated.
Potential options for transplant include obtaining a liver from a “standard-criteria” deceased donor, an “extended-criteria” deceased donor, or a living donor. Each donor offer is carefully evaluated by our transplant surgeons, and will not be used if they do not feel it appropriate for transplant. Sometimes we will be offered a donor liver that is positive for HCV, but does not have any significant liver injury. These donors can be used in patients who have HCV with results equal to what is achieved with HCV-negative donors. All transplant options can yield excellent results, but not all options are appropriate for all patients, and not all outcomes are predictable.
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