Switching from Tacrolimus to Cyclosporine for Cholestatic Hepatitis due to Hepatitis C Virus Reinfection after Liver Transplantation

Abstract

Recurrence of hepatitis C virus (HCV) infection after liver transplantation has been shown to negatively affect graft and patient survival. Combination therapy with pegylated interferon (PEG-IFN) and ribavirin is efficacious, but poorly tolerated. A 57-year-old man with HCV infection and cirrhosis underwent cadaveric liver transplantation in the United States. The HCV genotype was 1b. The immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, and prednisolone. Liver function was stable until 4 months after transplantation, but then deteriorated, accompanied by a rapid rise in the serum HCV-RNA level. Liver biopsy revealed the recurrence of HCV infection, and treatment with PEG-IFN alpha-2b plus ribavirin was initiated. The patient responded well to therapy, and liver function improved, but high HCV-RNA levels persisted. On postoperative day 260, the patient had a relapse of hepatitis and received β-interferon 3 MU/day for 2 consecutive weeks. The patient responded well, but only transiently to therapy. Liver function fluctuated in association with high HCV-RNA levels, despite subsequent treatment with PEG-IFN alpha-2b plus ribavirin. Eleven months after transplantation, tacrolimus was switched to cyclosporine. Three months later, liver function became normal, and the HCV-RNA level decreased dramatically. Because a combination of cyclosporine and interferon synergistically suppresses HCV replication in vitro , early switching of tacrolimus to cyclosporine may be a safe and worthwhile option in patients who have recurrent HCV infection after liver transplantation.