April 01, 2010

HCV-associated liver disease after liver transplantation

By Professor Sandeep Mukherjee, MBBCh, MPH, FRCPC

Associate Professor in Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, Corresponding Author: smukherj AT unmc.eduSandeep Mukherjee


Hepatitis C virus (HCV)-associated liver disease continues to be the most common indication for liver transplantation (LT) in the United States accounting for nearly 50% of all liver transplants. Recurrence is universal in patients viremic at the time of transplantation with histological hepatitis developing in the majority of patients. Although the natural history of recurrent HCV is difficult to predict, it is widely accepted that cirrhosis from recurrent HCV occurs in up to 30% of patients within five years of transplantation. Once cirrhosis is established, the annual risk of hepatic decompensation defined as the development of ascites, hepatic encephalopathy or variceal bleeding, is 42% [1]. These statistics highlight the importance of recurrent HCV after LT, which in turn has stimulated the controversy surrounding retransplantation of recurrent HCV, particularly in the first post-operative year when retransplantation for severe recurrence is not recommended due to poor outcomes [2]. It would seem insightful that eradicating HCV either before LT or treating recurrent HCV shortly after LT would have a major impact on decreasing the incidence of recurrent HCV and its expected complications. Unfortunately, most patients referred for LT evaluation have decompensated disease and are often unable to tolerate pegylated interferon and ribavirin therapy [3]. The treatment of recurrent HCV is complicated further by poor sustained viral response (SVR) rates and reports of progressive fibrosis with hepatic decompensation despite SVR. The most successful approach to the treatment of recurrent HCV remains eradicating HCV before hepatic decompensation in which reported SVR rates with pegylated interferon and ribavirin vary from 50% to 70%. The natural history of recurrent HCV, risk factors associated with severe recurrence and the treatment of recurrent HCV will be discussed in this article.