Liver transplantation for hepatitis C: the hidden truth

Hepatitis C related chronic liver disease is an important cause of decompensated cirrhosis in patients who need liver transplantation in south-east asia, europe, africa and north america. Although anti-viral treatment for hepatitis C in the form of Pegylated interferon and ribavarin are fairly effective in achieving virological response in those who do not have genotype 1 of the virus, patients who already have liver dysfunction at the time of diagnosis or those that have ascites or severe hypersplenism are unable to complete the course of therapy or need dose reductions. Even those who attain virological response may relapse.
Patients with HCV related cirrhosis who undergo liver transplantation usually have significant viral loads at the time of transplant and treating them with interferons to reduce this level is often impractical and can be poorly tolerated. Unlike for hepatitis B there is no effective vaccination or immunoglobulin to protect against recurrence of HCV infection in the transplanted liver. As of now patients with HCV should clearly understand that HCV infection will recur in all the transplanted livers. In fact, HCV virus can be identified in the liver within hours of transplantation. The timing and outcome of HCV related damage to the liver after transplantation is different and is related to factors in the following cartoon.

Patients with concurrent obesity and significant alcohol intake or HIV infection are at a higher risk of accelerated HCV recurrence and damage. 

Active surveillance and protocol liver biopsy to detect early HCV related inflammation in the transplanted liver cells followed by supervised therapy is the only way to mitigate the progression to fibrosis in the transplanted liver. The transplanted liver cells are more susceptible to viral damage due to the immune-suppressive state. While some studies have suggested that cyclosporine has anti HCV action as compared to tacrolimus among the immune-suppressive agents, this has not been proven conclusively. Undetected and inappropriately treated, HCV recurrence can lead to cirrhosis and end stage liver disease within months to a few years. Despite adequate treatment, sustained virological response may not be achieved in all patients and these may develop recurrent cirrhosis and become candidates for a re-transplant after a variable period of 5-20 years. In fact ,most re-transplantations across the western world are performed for this indication.

Patients with HCV therefore should bear in mind the following before undergoing liver transplants

1. Unless there is concurrent liver tumor within the liver, kidney dysfunction or other life-threatening complication, liver transplant should be delayed as far as possible.
2. HCV patients should abstain from alcohol and keep their weight in check
3. Immunosuppression should be tightly monitored as excessive or pulse therapies can accelerate recurrence and hepatocyte damage
4. They should discuss with their transplant centres and preferably not accept deceased organs from older donors (>65 years) that are fatty or have cold ischemia of more than 6 hours 
5. After transplantation, they have to be extremely compliant with follow-up for early detection of recurrence
6. Re-transplantation may be required in a significant proportion of patients after 5-20 years