Treatment of Hepatitis C After Liver Transplantation

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The goal of hepatitis C virus (HCV) treatment in liver transplant (LT) recipients is to prevent graft loss and liver-related complications. Currently, the primary approach to the management of transplant recipients with HCV has been to treat after transplantation (Table 4.1). Antiviral therapy can be undertaken early, within the first 6 months post-LT, when recurrent viremia is documented, but prior to the presence of histologic criteria for treatment. This is often termed preemptive therapy. More commonly, treatment with antiviral therapy is reserved for those with recurrent and progressive histologic disease. Experts recommend treatment for patients with moderate to severe necroinflammatory activity or mild to moderate fibrosis (F2 or greater). Peginterferon and ribavirin has been the mainstay of posttransplant therapy for the past 15 years. With the recent approval of the first direct-acting antiviral (DAA) drugs—NS3/4A protease inhibitors—the standard of care for patients with genotype 1 HCV infection has changed to a triple drug regimen of peg-IFN, RBV, and either telaprevir or boceprevir. Since the majority of transplant recipients with HCV are infected with HCV genotype 1, this offers a significant opportunity to improve outcomes in these patients. Although, triple therapy is not approved for use in transplant recipients, off-label use is occurring due to significant need for more efficacious therapies in patients with progressive or severe recurrent disease. However, significant challenges including a higher risk of adverse events and more drug–drug interactions have been identified in early reports. In the future, DAA drugs with improved tolerability and less drug–drug interactions may allow greater ease of use, better tolerability, and higher rates of viral clearance.