Hepatitis C therapy before and after liver transplantation

Authors

  • Norah A. Terrault

    Corresponding author
    1. Division of Gastroenterology, Department of Medicine, University of California–San Francisco, San Francisco, CA
    • Division of Gastroenterology, Department of Medicine, University of California–San Francisco, S357, 513 Parnassus Avenue, San Francisco, CA 94143
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    • Telephone: 415-476-2227; FAX: 415-476-0659


Abstract

Key Points

  • 1Pretransplant therapy, using a low-accelerating-dose regimen, is an option for patients with mildly decompensated liver disease and low laboratory Model for End-Stage Liver Disease scores. Achievement of an on-treatment virologic response is the goal of therapy. Preliminary data suggest that up to two-thirds of patients who become hepatitis C virus RNA–negative on treatment will be hepatitis C virus infection–free post-transplantation.
  • 2Effective prophylactic therapies are not available. Hepatitis C antibody therapy has been ineffective in preventing hepatitis C virus infection in studies to date.
  • 3Preemptive antiviral therapy started within weeks of transplantation is limited by tolerability, particularly in patients with high Model for End-Stage Liver Disease scores pre-transplantation. Rates of sustained virologic response vary from 8% to 39%. Histological benefits in virologic nonresponders have been demonstrated.
  • 4Posttransplant antiviral therapy in those with evidence of recurrent disease is the mainstay of management. A combination of pegylated interferon and ribavirin is the treatment of choice, and sustained virologic response is achieved with 48 weeks of treatment in approximately 30% of treated patients. Attainment of early loss of hepatitis C virus RNA is highly predictive of sustained virologic response. Histologic improvements are seen in responders. Survival is prolonged among those achieving a sustained virologic response.
  • 5Posttransplant antiviral therapy is limited by poor tolerability and the frequent need for dose reductions and/or discontinuation. Immunologic complications, including acute rejection, chronic rejection, and autoimmune-like hepatitis, occur in association with therapy, albeit at low rates.
  • 6Hepatitis C virus–infected liver transplant recipients represent an important patient population in need of new therapeutics options to prevent patient and graft losses due to recurrent hepatitis C virus disease.

Liver Transpl 14:S58–S66, 2008. © 2008 AASLD.

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