Hepatitis C and liver transplantation

Abstract

Cirrhosis secondary to hepatitis C virus (HCV) infection, alone or in combination with alcohol, is the principal indication for liver transplantation among adults, and is responsible for about half the transplants performed in many centres.1 2 This may mean that a subset of the approximately 300 million people worldwide infected with HCV will progress to cirrhosis, liver failure, and would need a transplant in the future.3 As there is no universally effective antiviral treatment, it is expected that demand will soon outstrip the already limited donor organ supply. Some facts about HCV infection and liver transplantation have been substantiated since the end of 1998. ( a ) HCV infection (as defined by detectable viraemia) will occur universally after liver transplantation among patients who are viraemic before transplantation4; ( b ) de novo HCV infection is rare but may still occur even though blood products are screened5; ( c ) HCV related graft disease develops in the majority of patients followed for at least five years after transplantation6 7; ( d ) the natural history of hepatitis C, measured histologically, is variable and ranges from minimal damage to fibrosing cholestatic hepatitis6-8; ( e ) there is a lack of effective prophylactic treatments aimed at the prevention of recurrent disease; ( f ) current antivirals in the treatment of post-transplant HCV disease are of limited efficacy.9-14 A number of important issues still need to be investigated, including: ( a ) study of the causes of the decreasing mortality rate seen in HCV infected patients awaiting liver transplantation, particularly with the use of HCV infected organ donors and/or antiviral drugs before transplantation; ( b ) better understanding of the long term outcome of transplant recipients with HCV, and the factors associated with disease progression; ( c ) improvement of the management of recurrent HCV disease, with emphasis on immunosuppression; ( d …