Hepatitis C virus: Up to the minute

Abstract

Key Points 1. Hepatitis C virus reinfection is almost universal in patients who are polymerase chain reaction–positive at the time of transplantation, and it significantly impairs patient and graft survival. 2. The virus infects the graft a few hours after transplantation and leads within weeks to a viral load higher than the pretransplant levels; this is associated with an accelerated progression to cirrhosis, graft loss, and death. 3. Multiple host, donor, and viral factors are associated with rapid fibrosis progression: high pretransplant and posttransplant viral loads, severe early histological recurrence, more potent immunosuppression and treatment of rejection episodes, cytomegalovirus or human immunodeficiency virus coinfections, and increasing donor age. 4. Annual protocol biopsy, noninvasive fibrosis evaluation, or both are recommended to evaluate fibrosis progression and determine the time for antiviral therapy. 5. Pretransplant antiviral therapy may reduce or eliminate the risk of recurrent infection. However, this approach is limited because of side effects and a risk of complications in decompensated patients. 6. Preemptive therapy early after transplantation is less effective because of the high level of immunosuppression and is limited by low applicability and poor tolerance. 7. The treatment of established graft lesions with a therapy combining pegylated interferon and ribavirin yielded promising results, and a sustained virological response was achieved in approximately 30% of the patients. Sustained virological responders experienced long-term beneficial effects with respect to fibrosis progression and graft and patient survival. Variables associated with a sustained virological response include the following: non-1 genotype, absence of previous antiviral therapy, early virological response, adherence to therapy, and low pretreatment viral load. However, antiviral therapy is limited by the frequent need for dose reductions or discontinuation and a low risk of acute or chronic rejection and autoimmune-like hepatitis. 8. Patients infected with hepatitis C virus before and after transplantation are those who will benefit the most from new classes of direct antiviral agents. Liver Transpl 16:S26-S35, 2010. © 2010 AASLD.