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- Patients and Methods
Chronic hepatitis C is a principal indication for liver transplantation. Recurrent viral infection is inevitable and graft disease is common. We report tolerability, safety and efficacy of pegylated interferon alpha 2b (PEG-IFN) monotherapy for patients with hepatitis C virus (HCV) recurrence and fibrosis after liver transplantation. Repeated measurements of serum HCV titer permitted assessment of the kinetics of the antiviral response for all patients.
We screened 63 patients transplanted for HCV at our center for antiviral treatment, 14 were eligible and treated, but only 6 completed the proposed 52 weeks of therapy. Eight were withdrawn because of severe/life-threatening side effects/events, including liver dysfunction (4 patients). None of those 8 achieved a sustained virological response (SVR). Five of 6 who completed treatment were HCV RNA negative at the end of treatment, and 2 achieved an SVR. Viral kinetics were similar to published observations for treatment of non-transplanted HCV patients. Patients with genotype non-1 infection displayed a more rapid decline of viral titer than was observed for genotype 1 infection.
Post-transplant HCV patients are frequently unsuitable for, or intolerant of PEG-IFN. Liver dysfunction was a major concern.
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- Patients and Methods
Chronic hepatitis C affects more than 170 million people worldwide and may lead to cirrhosis and liver cancer (1). In most liver transplant programs, hepatitis C is the most frequent indication for liver transplantation (2). Recurrence of viral infection and disease after transplantation is virtually universal (3,4). In this clinical setting the disease is frequently more rapidly progressive in comparison with non-transplanted patients, and may lead to graft cirrhosis in 8–30% of patients within 5–7 years of transplantation (5–7).
Antiviral treatment of non-immunosuppressed non-transplant patients with combination pegylated IFN (PEG-IFN) and ribavirin (RIBA) leads to sustained virological response (SVR) in a substantial proportion (8,9). Treatment of the hepatitis C virus (HCV) patient after liver transplantation is more challenging. Combination therapy is efficacious, but patient selection is difficult, and tolerability and timing of therapy remain a challenge (10–12). With respect to the preferred timing of treatment, two strategies have been proposed (5,13). Proponents of pre-emptive or early post-transplant treatment argue that HCV recurrence should/can be treated before significant graft damage has occurred, and that efficacy may be enhanced by treatment at an early stage (14). However, opponents of early treatment express concern that the risk for development of graft rejection may be increased (15), and that early treatment does not permit segregation of patients into those with mild (for whom the risk/benefit balance might be to defer consideration of treatment) vs those with more aggressive graft reinfection (who might benefit from treatment to prevent precocious graft damage). Thus, many physicians argue in favor of deferred antiviral treatment, targeted at those with clinically significant graft reinfection.
Standard treatment for chronic hepatitis C is the combination of PEG-IFN and RIBA, which has been used in the post-transplant setting (5,11,12,14,16,17), reviewed in Ref. . However, monotherapy with PEG-IFN may result in an SVR in a significant percentage of patients, notably patients infected with genotypes 2 or 3 (19–21). The main side effect of RIBA is anemia, which may be severe if dose adjustment is not made for treatment of patients with renal dysfunction (22,23), including transplant recipients. Thus, PEG-IFN monotherapy may be an effective and a safer treatment for patients post liver transplant.
Here, we report the results of an investigator-initiated study that evaluated the safety, tolerability and efficacy of PEG-IFN given to liver transplant patients with HCV recurrence and evidence of fibrosis on pre-treatment liver biopsy. In addition, the protocol included detailed viral kinetic studies during the first week of treatment.
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- Patients and Methods
A total of 139 patients were transplanted for chronic HCV in our Liver Unit between the years 1988 and 2002. Of these patients, 42 died prior to initiation of this study, and 34 patients were followed up abroad or were lost to follow-up. The remaining 63 patients were reviewed regarding the suitability for antiviral treatment, and 49 patients were excluded for the reasons outlined in Table 1 (more than one reason in some).
Table 1. Reasons for exclusion of patients for treatment
|Reason of exclusion||Number of patients1|
| Alcohol dependency||3|
|Social issues and preference||7|
| Recent change in immunosuppression||2|
| Liver failure and other liver disease||9|
|Absence of fibrosis or HCV PCR negativity||12|
|Other organ disease|
|Difficult to control diabetes||3|
Finally, 14 patients were suitable for the study and consented to treatment. Twelve of 14 patients were male, the median age was 50 years and the median pre-treatment body weight was 84 kg (see Table 2). Five patients were infected with HCV genotype 1, 3 with genotype 2 and 6 with genotype 3. Two patients were of Asian origin (#8 and #13) and were infected by genotype 3. The other 12 patients were Caucasians. Immunosuppression comprised cyclosporine for 6 patients (4 with azathioprine), tacrolimus for 8 patients (1 with azathioprine, 2 with mycophenolate).
Table 2. Demographics of PEG-IFN-treated patients
|Patient number||Sex||Ethnicity||Age||HCV genotype||Weight (kg)||Pre-treatment fibrosis score1||Pre-treatment viral load||Treatment begin (in years post OLT)|
|1||M||C||59||2a/2c||104||3||5.3 × 105||3.8|
|2||M||C||50||3c||94||3||1.2 × 106||3.2|
|3||M||C||52||2b||99.7||NA||1.4 × 107||2.3|
|4||M||C||56||2b||82.7||6||3.58 × 106||5.5|
|5||M||C||37||1||69||3||3.8 × 106||1.9|
|6||M||C||42||1||98||2||9.59 × 105||3.0|
|7||F||C||48||3a||51.3||2||1.3 × 105||3.4|
|8||M||A||51||3a||75.5||NA||2.7 × 106||2.0|
|9||M||C||49||1b||99||3||2.2 × 106||4.3|
|10||M||C||50||3||85||3||1.8 × 105||0.9|
|11||F||C||53||1||77.5||3||1.2 × 106||3.1|
|12||M||C||57||1b||82||3||1.1 × 105||2.4|
|13||M||A||46||3b||98||1||4.88 × 106||1.1|
|14||M||C||48||3a||74.9||1||1.3 × 106||1.8|
The median pre-treatment fibrosis stage was 3 and the inflammatory grade 6. Commencement of PEG-IFN was at an average of 2 years and 9 months after liver transplantation. The mean initial dose of PEG-IFN was 109 μg (1.3 μg/kg), median 100 μg.
All 14 patients treated with PEG-IFN experienced side effects. The most common side effects were flu-like symptoms (12 patients), infections (5 patients) including three infections at injection sites, and depression (3 patients). Of the 14 patients, only 6 completed 52 weeks of treatment. Five of these 6 did not require any PEG-IFN dose reduction, and 1 patient required a dose reduction (from 1.3 μg/kg at commencement to 1.2 μg/kg) in response to neutropenia at treatment week 18 (Table 3).
Table 3. Treatment tolerability and follow-up of the 14 treated patients
|Patient number||Tolerability and follow-up|
|1||Retinal vein thrombosis leading to blindness|
|2||Intolerable flu-like symptoms|
|3||Pruritus, deterioration of liver biochemistry. Biopsy: recurrent HCV infection, prominent bile duct damage and loss (in 40% of the portal fields). Liver biochemistry improved after discontinuation of PEG-IFN|
|5||Acute renal failure and fungal sepsis|
|6||Abnormal liver biochemistry, positive ANA and SMA, IgG and IgA raised. Biopsy: cellular rejection and recurrent hepatitis C|
|7||Neutropenia and infection, abnormal liver biochemistry. Liver histology: HCV infection and ductopenia + ductular reaction in keeping with low-grade chronic rejection, nodular regenerative hyperplasia. Reassessed for liver transplant, died of liver failure|
|8||Shoulder pain, chest infection and leg weakness during treatment|
|9||Septic episode after sigmoidoscopy, psychological side effects, hair loss and injection site infection during treatment|
|10||Abnormal liver biochemistry week 44. Biopsy: moderate inflammation and fibrosis, bile duct damage. Increase in tacrolimus dose and continuation of antiviral treatment|
|11||Weight loss, tiredness and abnormal liver biochemistry positive SMA and elevated IgG week 32. Biopsy: recurrent hepatitis C, features compatible with autoimmune hepatitis, features suggestive of fibrosing cholestatic hepatitis. Patient died with liver failure shortly after treatment discontinuation|
|12||Flu-like symptoms only|
|13||Diarrhea, flu-like symptoms, injection site infection times 2|
|14||Lethargy, facial swelling, neutropenia, injection site infection|
Of the 8 patients who failed to complete treatment, PEG-IFN was stopped after a median treatment duration of 10 weeks. PEG-IFN was discontinued in 4 patients because of abnormal liver biochemistry.
Patient 3 developed pruritus and deterioration of biochemical liver function tests at treatment week 8. Liver biopsy showed changes in keeping with recurrent HCV infection but also prominent bile duct damage and loss (in 40% of the portal fields). PEG-IFN treatment was stopped, and the biochemistry improved. Clinically, the patient remains well with stable biochemistry more than 6 years after transplantation and more than 3 years after PEG-IFN treatment.
Patient 7 experienced neutropenia and infection with Streptococcus pneumoniae. That was followed by abnormal liver biochemistry at treatment week 13, which led to discontinuation of PEG-IFN. Liver histology at that time showed mild inflammatory activity and fibrosis consistent with HCV infection, but also ductopenia and ductular reaction in keeping with low-grade chronic rejection. In addition, nodular regenerative hyperplasia was diagnosed.
Patient 11 presented at treatment week 32 with weight loss, tiredness and abnormal liver function tests. The biopsy at that time was compatible with recurrent hepatitis C and treatment was withdrawn because of increasing intolerance to the IFN. Immunological investigations revealed a positive smooth muscle antibody (SMA) with an elevated serum IgG of 21.9 g%. In response to persistently abnormal liver function tests, liver biopsy was repeated and showed features of recurrent hepatitis C, but with very prominent inflammation (raising the possibility of an additional pathological process such as autoimmune hepatitis). In addition, biliary features were present as seen in aggressive HCV infection (fibrosing cholestatic hepatitis). The patient died shortly thereafter of liver failure.
Patient 6 developed abnormal liver biochemistry at treatment week 26. Liver biopsy showed features of both cellular rejection and recurrent hepatitis C. The immunological investigations showed positive anti-nuclear antibody (ANA 1:40), weakly positive SMA, IgG 18.16 g% and IgA 3.35 g%. Treatment was discontinued.
In addition to these patients who stopped treatment because of abnormal liver function, patient 10 experienced abnormal liver biochemistry at treatment week 44. Liver histology at that time showed mild to moderate inflammatory activity and fibrosis, and also prominent bile duct damage consistent with either rejection or HCV infection. The immunosuppression (tacrolimus) was increased and antiviral treatment was continued until treatment week 52.
There were two very early treatment withdrawals. One patient stopped treatment because of intolerable flu-like side effects. The other patient suffered severe early depression. Sudden loss of vision associated with retinal vein thrombosis (treatment week 19, patient 1), and presumed fungal sepsis with acute renal failure (treatment week 2, patient 5) were the indications for premature treatment cessation for an additional 2 patients.
Virological outcome and viral kinetics
Median viral titer of the 14 patients prior to treatment was 2 × 106 copies/mL (1.2 × 106 for genotype 1, and 2.7 × 106 for genotypes 2/3). The median viral half-life was 4.77 h for all patients as calculated using the steepest drop in viral titer observed during the first 48 h after initiation of antiviral treatment (5.89 for genotype 1 patients and 2.79 for genotype 2/3 patients, p-value for difference between genotypes >0.2).
The median viral titer 1 week after the first dose was 4.9 × 105 for the whole patient group, 1.5 × 106 for genotype 1 and 1.1 × 105 for genotypes 2/3 (p > 0.2).
A reduction in viral titer in the first week (for examples of viral kinetics see Figure 1) was found with a median of 0.7 log10 reduction (0.2 log10 in patients with genotype 1 and 1.1 log10 for patients with genotypes 2/3, p > 0.2). Of the 10 patients who had at least 12 weeks of treatment 7 had undetectable HCV RNA at week 12, 2 had a drop in viral titer of 0.5 and 0.6 log10 and 1 patient had an increase in viral titer of 0.3 log10. At week 24, 8 patients continued on treatment and 6 of these had undetectable HCV RNA. Six patients were treated for 52 weeks, and 5/6 were RNA-negative at the end of treatment. Ultimately, 2 patients (of all 63 patients screened for antiviral treatment) achieved SVR. The patient who failed to achieve RNA-negativity despite 52 weeks of treatment had a drop in viral titer of 0.4 log10 during 1-year treatment. Overall, an end of treatment response was observed for 8 of the 14 patients. For 3 patients this was at the time of premature treatment withdrawal, and none of those 3 patients had an SVR.
Figure 1. Viral kinetics of 4 patients at initiation of treatment. Viral load was measured using the Roche Amplicor® assay before as well as 1/2 h, 3 h, 6 h, 12 h, 24 h and 7 days after the first injection of PEG-IFN. The kinetics of 4 representative patients are displayed. For correlation with viral outcome of these patients see Table 4.
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The 2 patients who experienced SVR had the greatest reductions in viral titer at day 7 after treatment initiation (at least 3.0 log10, Table 4).
Table 4. Viral kinetics and virological outcome of the 14 patients treated with PEG-IFN
|Patient number||HCV genotype||Viral titer pre-treatment||Virus half-life (h)||Drop in viral titer at 1 week (log10)||Treatment duration (weeks)||End of treatment PCR||SVR|
|1||2a/2c||5.3 × 105||10.58||0.8||19||Negative||No|
|2||3c||1.2 × 106||1.13||2.5||1||Positive||No|
|3||2b||1.4 × 107||2.79||1.5||7||Negative||No|
|4||2b||3.58 × 106||2.48||0||2||Positive||No|
|5||1||3.8 × 106||5.89||0.4||2||Positive||No|
|6||1||9.59 × 105||19.00||0||25||Negative||No|
|7||3a||1.3 × 105||9.64||0||13||Negative||No|
|8||3a||2.7 × 106||1.41||3.1||52||Negative||Yes|
|9||1b||2.2 × 106||3.89||0.2||52||Negative||No|
|10||3||1.8 × 105||3.61||2.3||52||Negative||No|
|11||1||1.2 × 106||>20||0||32||Positive||No|
|12||1b||1.1 × 105||5.65||3.0||52||Negative||Yes|
|13||3b||4.88 × 106||5.68||0.6||52||1.6 × 106||No|
|14||3a||1.3 × 106||1.89||1.1||52||Negative||No|
Study protocol scheduled biopsies pre-treatment, post-treatment and 1 year after treatment (Table 5). Of the 9 patients who had pre- and post-treatment biopsies, 4 had an unchanged fibrosis score during treatment, 1 patient had an improved fibrosis score (patient 7) and 4 had fibrosis progression during treatment (Ishak scores, Table 5). All but 1 patient had a slowing of fibrosis progression rate as calculated using the pre- and post-treatment biopsy Ishak scores. Inflammatory grade was stable or improved in all but patient 14, who also experienced a deterioration of fibrosis score during treatment (Table 5). One-year follow-up biopsies were available for 7 patients, 4 of which showed fibrosis progression and 3 had a stable fibrosis score. Of the 6 patients who completed 52 weeks of treatment, the non-responder (#13) had progression of fibrosis during and after treatment (Ishak stage 1 2 3) and an increase in inflammatory grade after treatment (grade 6 6 7). Of the 3 patients with the end of treatment HCV RNA negativity but without SVR, 2 had fibrosis progression during treatment (#10 and #14) and 1 (#9) had a stable fibrosis score. Of these patients, 2 regressed in inflammatory grade (#9 and #10) and 1 progressed (#14, Table 5).
Table 5. Changes in fibrosis stage and inflammatory grade with PEG-IFN treatment and during 1-year follow-up
|Patient number||Pre-treatment||Post-treatment||1-year follow-up|
|Fibrosis stage||Fibrosis progression||Inflammatory grade||Fibrosis stage||Fibrosis progression||Inflammatory grade||Fibrosis stage||Fibrosis progression||Inflammatory grade|
|2||3 (2)||0.96 (0.64)||7||3 (2)||0.0 (0.0)||7||NA||NA||NA|
|5||3 (2)||1.39 (0.92)||6||5 (3)||1.11 (0.56)||5||NA||NA||NA|
|6||2 (1)||0.53 (0.26)||9||2 (1)1||NA||51||3 (2)||NA||5|
|7||2 (1)||0.99 (0.50)||6||1 (1)||−0.58 (0)||4||1 (1)||0.0 (0.0)||3|
|82||NA||NA||NA||1 (1)||NA||3||1 (1)||0.0 (0.0)||2|
|92||3 (2)||0.73 (0.49)||7||3 (2)||0.0 (0.0)||5||NA||NA||NA|
|102||3 (2)||4.64 (3.09)||6||4 (3)||0.46 (0.46)||5||NA||NA||NA|
|11||3 (2)||0.98 (0.65)||7||3 (2)||0.0 (0.0)||4||5 (3)||1.86 (0.93)||8|
|122||3 (2)||1.49 (0.99)||6||3 (2)||0.0 (0.0)||6||3 (2)||0.0 (0.0)||3|
|132||1 (1)||1.01 (1.01)||6||2 (1)||0.77 (0.0)||6||3 (2)||0.80 (0.80)||7|
|142||1 (1)||0.59 (0.59)||2||2 (1)||0.68 (0.0)||3||3 (2)||1.16 (1.16)||3|
|Median||3 (2)||0.99 (0.65)||6||3 (2)||0.0 (0.0)||5||3 (2)||0.0 (0.0)||3|
Both patients with SVR (#8 and #12) had a stable fibrosis stage during the period investigated (stages 1 and 3, respectively) and improved in their inflammatory grade post-treatment (grade 3 2 and grade 6 3, respectively, Table 5).
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This study makes a number of important observations. Firstly, in our experience the proportion of patients who could benefit from antiviral treatment was very small: of 63 patients screened for antiviral treatment, a minority appeared suitable for treatment, and only 2 treated patients achieved sustained virological clearance. Contraindications to antiviral therapy are frequently observed in the post-transplant state. Secondly, in this select treated group, complications of treatment were frequently experienced. Thirdly, the viral kinetics in this patient group are similar to those observed during the treatment of non-immunosuppressed patients, and sustained virological response may be possible. Thus, PEG-IFN has antiviral efficacy, but application is limited by contraindications and poor tolerance. Our finding that a small proportion of our patients were ultimately treated with PEG-IFN is consistent with the relatively low rates of patient recruitment observed in other post-transplant HCV treatment studies. For example, in a recently published study, only 67 patients were enrolled from more than 20 Liver Units (27).
The patients selected for treatment in our study were clinically stable at treatment initiation with no evidence of hepatic decompensation and no significant comorbidity. None had experienced recent rejection. Nevertheless, a number of patients experienced serious side effects, frequently necessitating withdrawal of antiviral therapy. The serious side effects, which were probably caused by PEG-IFN treatment, included depression, graft rejection, probable de novo autoimmune hepatitis and retinal vein thrombosis. In addition, one patient developed a severe infection complicated by renal failure shortly after commencement of antiviral treatment. Causation is unclear. It appears that, compared with treatment of non-transplant immunocompetent patients, antiviral treatment of transplanted patients is a greater challenge. Complications can be expected more frequently and are potentially more serious. Consistent with our observations, a recent study of pre-emptive treatment for HCV transplant patients also found that a small percentage of screened patients were suitable for treatment, and the authors reported a high percentage of dose reductions, treatment withdrawals and complications (28). In our study, we found that severe complications could occur at any stage of treatment, and we therefore recommend very regular follow-up during the entire duration of the treatment. Because of the potential risks, the treatment should be given in centers experienced with transplant follow-up and with antiviral treatment for chronic hepatitis C.
As part of the viral kinetic study, serum viral titer was measured immediately before administration of PEG-IFN. Titers were similar to those found in non-immunosuppressed patients (25,29–32) and were no different from those measured by other investigators in patients during the chronic stable phase of reinfection with HCV (33,34). First phase decline of viral titer during treatment is an index of antiviral efficacy. The rate of decline permits calculation of serum virus half-life. The half-lives we measured for patients with HCV genotypes 2 and 3 were similar to the values described in the literature for non-immunosuppressed patients (32,35). The measured half-lives for patients with genotype 1 infection appear longer than those described in published literature for non-immunosuppressed patitents (2.86–3.0 h, (32,35)). However, the number of patients examined in our study is small. Also, calculation of first phase decline and serum half-life depend on the number of measurements made during the steep phase of viral decline. Thus, calculated values will overestimate the true half-lives. Differences observed between cohorts in different studies may reflect differences in sampling frequency rather than true differences in the rate of viral clearance during suppression of replication.
Although the numbers are small, the treatment results in this population reflect previous findings that the end of treatment responses and SVR are dependent on adherence to treatment (36) and are predicted by a rapid drop in serum titer at the initiation of treatment (30). In our cohort, 5 of 6 patients who tolerated the planned duration of treatment achieved an end of treatment response. In our cohort, in only 2 patients (1 patient with genotype 1 and 1 with genotype 3 infection) treated for 52 weeks, virological clearance (SVR) was seen. This confirms the finding that SVR can be achieved in this patient population, and it seems likely that the addition of RIBA to the treatment regimen (if tolerated) will decrease the rate of viral recurrence after the end of treatment. However, tolerability of combination therapy may be inferior to that of IFN monotherapy and compliance with treatment might be affected (5). Thus, it is important that all forms of treatment are evaluated on an intention-to-treat basis.
Published studies with combination antiviral therapy of IFN and RIBA for HCV recurrence thus report an SVR of around 20% for non-PEG-IFN (27,37–46), reviewed in Ref.  and 25% for PEG-IFN (5,12,14,16,17), reviewed in Ref. . The numbers in these studies are small, and there is a wide variation of reported SVRs. However, it is believed that an SVR after antiviral treatment in this population is sustained and associated with improvement in liver fibrosis (47).
The interpretation of the histological analysis in our study is very limited because of the small numbers. However, of the 7 patients treated for more than 12 weeks, and in whom paired histology was available, 4 did not progress in their fibrosis stage and only 1 (#14) had a more rapid fibrosis progression during treatment compared to pre-treatment. This finding suggests that control of viral replication, even without the achievement of viral clearance, may be beneficial in terms of disease progression. Given the potential morbidity and mortality associated with post-transplant HCV cirrhosis, a treatment strategy aiming at viral suppression might be beneficial and cost effective.
Treatment had to be discontinued in 4 patients because of abnormal liver biochemistry, including 2 patients who developed histological evidence of rejection. Chronic as well as acute rejection has been reported in patients with recurrent hepatitis C treated with IFN, especially in the (early) trials of IFN monotherapy (5). Rejection appears to be less frequent in studies of combination antiviral therapy. Therefore, it is possible that there is a protective effect of RIBA. One study found histological evidence of graft rejection in 8 of 23 patients treated with IFN for recurrent hepatitis C (48). In this study as in ours, none of the patients had evidence of rejection pre-treatment, but 7patients experienced acute rejection and 1 chronic rejection with therapy. Antiviral treatment was continued in some of the patients, but 2 patients had to be retransplanted for graft loss attributed to the treatment (48).
We conclude that many patients transplanted for HCV and who develop recurrent disease will not be suitable for treatment with IFN, and that many will not tolerate prolonged treatment despite careful monitoring. Liver dysfunction, including severe rejection, was observed during our study and has been observed by other investigators. PEG-IFN-suppressed viral replication and a high proportion of treatment-tolerant patients achieved HCV RNA PCR-negativity by the end of treatment. Histological response in terms of slower fibrosis progression or improvement of fibrosis score may be possible and, therefore, prolonged antiviral treatment may be beneficial even in the absence of viral clearance.