New Insights in Recurrent HCV Infection after Liver Transplantation

Hsu, Shih-Hsien; Yeh, Ming-Lun; Wang, Shen-Nien

Owing to relatively poor efficacy and high adverse effect, most experts now delay antiviral therapy till a histological evidence of recurrent HCV infection is established after LT. However, for patients diagnosed with fibrosing cholestatic hepatitis, antiviral therapy must be given as early as possible after LT because of the poor short-term prognosis and rapid fibrosis progression. Initially, conventional IFN-based therapy was used to treat recurrent HCV infection after LT. A systematic review, consisted of 27 studies with a total of 689 patients, demonstrated a mean SVR rate of 24% with conventional IFN-based therapy [70] . Compared to conventional IFN-based therapy, pegylated IFNbased therapy showed a significant improvement of SVR rate. Three recent systematic reviews demonstrated 20-40% of SVR rate in genotype 1 and 50-100% in genotype 2/3 subjects using Pegylated IFN-based therapy for recurrent hepatitis C after LT [71] [72] [73] . The same result is also found in the histological improvement, regardless of necroinflammation or fibrosis. The factors to predict a better SVR are also the same as in nontransplant patients. Genotype non-1, low pretreatment HCV RNA, rapid virological response, and adherence to therapy have been identified as the positive predictors [70] [71] [72] . The association between response and recipient/donor liver IL-28B genotype is also reported recently [26, 74] . Charlton [26] . Fibrosing cholestatic hepatitis is another poor predictor, and it is almost incurable with IFN treatment when fibrosing cholestatic hepatitis develops [75] . Safety and tolerance for therapy are also among the major concern in LT recipients with HCV recurrence. Dose reduction, discontinuation, and acute rejection were noted in 44% (38-50%), 24% (21-27%), and 2% (1-3%) of patients treated with conventional IFNbased therapy [70] . For the patients treated with Pegylated IFN therapy, a better SVR rate was noted in comparison to the IFN-based group. Meanwhile, the rejection rate was also found to be elevated with a mean rate of 5-10% (highest 25%). In addition, dose reduction was noted in over 50% of patients, and treatment discontinuation was found in around 30% of patients [70] [71] [72] .