Recurrence Post Liver Transplantation Research Articles

Efficacy and safety of sofosbuvir-based therapy in hepatitis C virus recurrence post living donor liver transplant: A real life egyptian experience.

Direct acting antiviral has offered treatment of hepatitis C virus (HCV) recurrence post liver transplantation (LT) with an all-oral regimen for short duration, excellent safety profile, and high sustained virological response (SVR). The aim of this study was to evaluate the efficacy and safety of sofosbuvir (SOF)-based regimens in the real world among a cohort of Egyptian patients with recurrent HCV post living donor LT (LDLT). Patients with HCV-G4 recurrence post-LDLT were recruited from National Committee of Control of Viral Hepatitis, Egypt, from November 2014 to May 2017. They received different SOF-based regimens according to the treatment protocols available during this period. Patients' outcome and Adverse effects (AE) were evaluated. One hundred ninety patients (170 males, mean age 56.8 ± 7.9 years) were included. Calcineurin inhibitors were the main immunosuppression used (173 patients). Out of 190, 119 (62.6%) received SOF/ribavirin (RBV), 38 (20%) SOF/simeprevir (SMV), 22 (11.6%) SOF/daclatasvir (DSV)/ ± RBV, and 11 (5.8%) received SOF/LDV/ ± RBV. Overall SVR12 was 89.5%, 84.9% in SOF/RBV group, 94.7% in SOF/SMV, 100% in SOF/DCV, and 100% in SOF/LDV with no statistically significant difference ( P = 0.104). The AE reported were as follows: anemia (n = 65, 34.4%) mainly in SOF/RBV group, transient hyperbilirubinemia during SOF/SMV in 13 patients (34%), mild Acute cellular rejection in eight patients (4.2%), and hepatocellular carcinoma in two patients (1%) mainly driven by underlying liver condition. Two deaths were unlikely related to HCV therapy. Different SOF-based regimens were effective with high SVR12 rates in a difficult-to-treat population, recurrent HCV post LDLT.

HCV treatment with DAA in patients listed for liver transplant does not result in an increased risk of HCC recurrence post-liver transplant

HCV treatment with DAA in patients listed for liver transplant does not result in an increased risk of HCC recurrence post-liver transplant

Role of inflammatory markers as hepatocellular cancer selection tool in the setting of liver transplantation.

Since the advent of the Milan criteria in 1996 and its widespread adoption for selection of patients with hepatocellular carcinoma (HCC) who would benefit from transplant, there has been an extensive hunt for the ideal clinical biomarker to predict HCC recurrence. This is because Milan lack does not include tumor biology indices and recurrence rates remain in the 15-20% range worldwide. While a 'silver-bullet' biomarker has not been found, several useful inflammatory markers have been identified and used in scoring systems that supersede Milan in their ability to predict HCC recurrence post liver transplantation (LT). In this review, we aim to summarize the role of inflammatory markers paly in the selection of HCC patients awaiting LT.

Sorafenib treatment in recurrent hepatocellular carcinoma post liver transplantation.

e15613 Background: Liver transplantation (LT) is a potentially curative treatment for patients (pts) with selective hepatocellular carcinoma (HCC). HCC recurrence post LT is estimated to be 15-20%. Data on systemic therapy post-recurrence is scarce and limited case series suggest that sorafenib (SOR) may have benefit in this population. We reviewed a single center experience with SOR in recurrent HCC post LT Methods: A retrospective review was conducted on pts with recurrent HCC post LT at University Health Network (UHN) who were treated with SOR. Pt characteristics were collected including age, gender, comorbidities, background liver disease, type of LT, and time to recurrence after LT. Treatment information collected included: initial SOR dose (and adjustments), adverse events (AEs), duration of treatment and survival. Results: Between 2006 and 2016, 24 pts were identified. The average age was 60 years (range: 18-72), most pts were male (20/4), living/cadaveric transplant: 11/13. HCC etiology included hepatitis B (10), alcohol (4), NASH (3), hepatitis C (2), hemochromatosis (2), Budd-Chiari (2) and unknown (1). The average time to recurrence of HCC was 16.08 (range: 1.5-60) months post OLT. There was a bimodal time to recurrence with a median of 6 months. SOR starting doses were 200 mg BID in 18 pts, 300 mg BID in 1 and 400 mg BID in 4. 14 pts required dose adjustment due to AEs, mainly relating to fatigue and palmar-plantar syndrome. The median time on treatment was 2.5 (range: 0.25-37) months. The average time to progression on SOR and/or discontinuation due to AEs was 4.30 (+/- 7.2) months. Conclusions: SOR is reasonably tolerated in pts with recurrent HCC post LT, with expected AE profiles. In this small case series, the median time on SOR was short and estimated time to progression was shorter than that in non-transplant HCC population. Overall, SOR has limited activity in this population, but selected pts may derive extended benefit. Better understanding of responders and investigations of other therapies are needed for this population.

Pegylated interferon plus ribavirin combination therapy in postliver transplant recipients with recurrent hepatitis C virus infection

Posttransplant hepatitis C virus (HCV) recurrence is universal in chronic hepatitis C recipients. Antiviral therapy is suggested after liver transplant to halt disease progression. Pegylated interferon plus ribavirin therapy remains the standard of care in many areas where direct antiviral agents are poorly accessible. This study aimed to assess the treatment efficacy and safety of the regimen for Taiwanese patients with post-transplant HCV recurrence. Nine patients with HCV recurrence postliver transplantation were allocated. Patients received either pegylated interferon α-2a 180 μg/wk or pegylated interferon α-2b 1.5 mg/kg/wk plus ribavirin for 24–48 weeks. The primary endpoint was the achievement of sustained virological response (SVR), defined as undetectable HCV RNA throughout 6 months of follow-up after the end of treatment. The safety profiles were also documented. The rates of rapid virological response, early virological response, end-of-treatment virological response, and SVR were 33%, 63%, 75%, and 56% respectively. Of the four patients who failed antiviral treatment, the treatment responses were nonresponse (n = 1), loss of follow-up (n = 1), and relapse (n = 2). Three patients terminated therapy early due to severe adverse events, including severe anemia, intra-abdomen infection, and hepatocellular carcinoma recurrence. One of the three patients who terminated treatment early at Week 6 experienced rapid virological response followed by SVR. Pegylated interferon/ribavirin combination allowed a chance for cure with a fair SVR rate in Taiwanese chronic hepatitis C patients postliver transplantation. Early identification of side effects and careful monitoring during therapy might enhance the treatment efficacy.

Sorafenib treatment in recurrent hepatocellular carcinoma post liver transplantation.

479 Background: Liver transplantation (LT) is a potentially curative treatment for patients (pts) with selective hepatocellular carcinoma (HCC). HCC recurrence post LT is estimated to be 15-20%. Data on systemic therapy post-recurrence is scarce and limited case series suggest that sorafenib (SOR) may have benefit in this population. We reviewed a single center experience with SOR in recurrent HCC post LT. Methods: A retrospective review was conducted on patients with recurrent HCC post LT at University Health Network (UHN) who were treated with SOR. Pt characteristics were collected including age, gender, comorbidities, background liver disease, type of LT, and time to recurrence after LT. Treatment information collected included: initial SOR dose and subsequent adjustments, adverse events (AEs), duration of treatment and survival. Results: Between 2006 and 2016, 24 patients were identified. The average age was 60 years (range: 18-72), most patients were male (20/4), living/cadaveric transplant: 11/13. HCC etiology included hepatitis B (10), alcohol (4), NASH (3), hepatitis C (2), hemochromatosis (2), Budd-Chiari (2) and unknown (1). The average time to recurrence of HCC was 16.08 (range: 1.5-60) months post LT. There was a bimodal time to recurrence with a median of 6 months. SOR starting doses were 200 mg BID in 18 pts, 300 mg BID in 1 and 400 mg BID in 4. 14 pts required dose adjustment due to AEs, mainly relating to fatigue and palmar-plantar syndrome. The median time on treatment was 2.5 (range: 0.25-37) months, 4/24 patients were on treatment > 6 months. The average time to progression on SOR and/or discontinuation due to AEs was 4.30 (+/- 7.2) months. Conclusions: SOR is reasonably tolerated in patients with recurrent HCC post LT, with expected AE profiles. In this small case series, the median time on sorafenib was short and estimated time to progression was shorter than that in non-transplant HCC population. Overall, sorafenib has limited activity in this population, but selected patients may derive extended benefit. Better understanding of responders and investigations of other therapies are needed for this population.

Prior Trans-arterial chemoembolization - A protective factor against rapid HCV recurrence post liver transplant in patients with HCV with HCC? - A Retrospective Cohort Study

BackgroundHCV recurrence after liver transplant is nearly universal and results in progressive fibrosis, cirrhosis, graft loss, retransplantation and mortality. There are very few studies comparing impact of pretransplant HCC therapies either as a bridge to transplant or to downstage like TACE, hepatectomy, RFA, PEI on HCV recurrence post transplant. Primary aim of the study was studying prognostic factors associated with HCV recurrence including pre transplant HCC therapies. Material and methodsAll the patients who have undergone living donor liver transplantation at Kaohsiung Chang gung memorial hospital, Taiwan for HCV related HCC between July 2002 and June 2012 were analyzed retrospectively. Severity of HCV histological recurrence was categorized according to the ISHAK hepatitis activity index score. Rapid HCV recurrence was defined ISHAK hepatitis activity index (HAI) score greater than 4 at one year. Statistical analysis was done using SPSS version 21. (IBM). ResultsOne hundred and nine patients with HCC associated with HCV undergo living donor liver transplant from July 2002 to June 2012. Median follow up time was 31 months. Forty nine patient had significant hepatitis c recurrence at the end of one year (HAI >4) and were included in study group.60 patients without significant hepatitis c recurrence were included in control group. On univariate analysis patients who did not undergo pre-transplant trans arterial chemoembolization (0.035), primary transplant (without prior hepatectomy) (p = 0.031), high meld score (p = 0.036), high viral load pretransplant (0.007), High AFP levels (0.013) were significantly associated with rapid histological recurrence of HCV (HAI greater than 4 at one year post transplant). Total 61 patient underwent prior transarterial chemoembolization, 22 of these patients developed significant HCV recurrence while 39 patient did not developed HCV recurrence. On multivariate analysis only patient who did not undergo TACE were significantly associated with rapid histological recurrence of HCV (odds ratio 3.310, p = 0.018 95% confidence interval 1.22–8.94). ConclusionPrior TACE do not increase post transplant HCV recurrence but may be beneficial for it.

Management of telaprevir-based triple therapy for hepatitis C virus recurrence post liver transplant.

To characterize management of telaprevir (TVR)-based triple therapy of hepatitis C virus (HCV) reinfection after liver transplantation (LT). We retrospectively analyzed safety and efficacy of telaprevir - based triple therapy in a single center cohort of 19 patients with HCV genotype (GT) 1 recurrence after LT, with respect to factors possibly predicting sustained viral response (SVR) or non-SVR. All patients were treated with TVR, pegylated (PEG) and ribavirine (RBV) for 12 wk followed by a dual phase with PEG/RBV for 12 wk in 7 patients and for 36 wk in 5 patients. In total 11/19 (58%) of patients achieved a sustained response. All (11/11) SVR patients showed a rapid viral response at treatment weeks 4 and 11/14 rapid virological response (RVR) patients achieved SVR. Notably, all (7/7) patients who completed 48 wk of therapy and 80% (4/5) patients who completed 24 wk of therapy achieved SVR24. Treatment failure was significantly (P > 0.049) more frequent in GT1a infection (5/7) compared to GT1b (3/12) infection and was associated with emergence of resistance-associated mutations in the NS3 protease domain. Bilirubin level at baseline is also related to SVR (P > 0.030). None of the patients had to discontinue treatment due to side effects. RVR, GT and bilirubin are clearly related to achievement of SVR. Providing a thorough patient selection and monitoring, a full course of TVR-based triple therapy in LT patients is feasible and achieves high SVR rates.

Prophylaxis for Hepatitis B Recurrence and Renal Sparing Effects With Telbivudine in Liver Recipients Receiving Hepatitis B Core Positive Donor Grafts.

Background Living donor liver transplantation & use of HBV core positive grafts have been employed to expand the donor pool. Hepatitis B immune globulin(HBIG) & nucleos(t)ide analogues can prevent HBV recurrence post liver transplant (LT). Renal sparing effects of Telbivudine (LdT) have been shown in LT & non-LT patients. We aim to study the efficacy of LdT in liver recipients who received HBV core positive donor grafts in preventing HBV recurrence (defined as HBsAg and/or HBV DNA negativity) and maintaining renal function. Methods Adult liver recipients transplanted for indications other than HBV who received a HBV core positive graft were identified. Patients on LdT for HBV prophylaxis were included. Liver chemistries, renal function & creatinine clearance (MDRD4), creatinine kinase (CK), immunosuppressive trough levels, HBsAg & HBV DNA levels were collected at 3 monthly intervals. Results 4 liver recipients were switched from Lamivudine to LdT for HBV prophylaxis. All patients were HBsAg negative prior to LdT switch, did not receive HBIG post LTx, and were maintained on tacrolimus-based immunosuppression as per center protocol. All patients remain free from HBV recurrence 3 months after conversion. 75% had mild to moderate renal impairment prior to LdT switch; all patients showed improvement in eGFR (1.2 - 28 ml/min/1.73m2) 3 months after conversion from LAM to LdT. Serum tacrolimus trough levels (±1.5ng/ml) were similar at LdT switch and at 3 months. There were no reports of myositis or CK elevation.Table: No Caption available.Conclusions In this novel real life experience among liver recipients transplanted for reasons other than HBV receiving a HBV core positive donor graft, LdT was shown to be effective in preventing HBV recurrence and well tolerated. Improvements in eGFR were seen in all patients. Larger randomized trials with longer follow up are needed.

Su1070 Safety and Efficacy of Telaprevir-Based Triple Therapy to Treat HCV Recurrence Post-Liver Transplantation

Su1070 Safety and Efficacy of Telaprevir-Based Triple Therapy to Treat HCV Recurrence Post-Liver Transplantation

Post–Liver Transplant Leptin Results in Resolution of Severe Recurrence of Lipodystrophy-Associated Nonalcoholic Steatohepatitis

We describe the first case of a patient undergoing orthoptic liver transplantation for acquired generalized lipodystrophy-related nonalcoholic steatohepatitis who developed severe recurrence of nonalcoholic fatty liver disease in the first few months posttransplant but responded rapidly to the administration of exogenous leptin. The beneficial effects of therapy were supported by histology along with magnetic resonance spectroscopy studies, which demonstrated that leptin therapy greatly reduced fat deposition in the liver. Leptin therapy may have a role to play in preventing patients with lipodystrophy developing end-stage liver disease or in rescuing such patients who develop disease recurrence postliver transplantation.

Identifying the superior measure of rapid fibrosis for predicting premature cirrhosis after liver transplantation for hepatitis C

Hepatitis C virus (HCV) recurrence post liver transplant is universal, with a subgroup of patients developing rapid hepatic fibrosis. Various clinical definitions of rapid fibrosis (RF) have been used to identify risks for rapid progression, but their comparability and efficacy at predicting adverse outcomes has not been determined. Retrospective data analysis was conducted on 100 adult patients with HCV who underwent liver transplantation at a single center. We measured year 1 fibrosis progression (RF defined as METAVIR F score ≥ 1 at 1-year liver biopsy), time to METAVIR F2-stage fibrosis, and fibrosis rate (calculated using liver biopsies graded by METAVIR scoring F0-4; fibrosis rate = fibrosis stage/year post transplant). RF was defined as ≥ 0.5 units/year. Multivariate analysis revealed that donor age and peak HCV viral load were significant risks for RF, when fibrosis rate was used to define RF. Advanced donor age was a risk for rapid progression to F2-stage fibrosis, whereas genotype 2 or 3 HCV infection was protective. Fibrosis rate had the strongest correlation with time to cirrhosis development (P < 0.0001, r = -0.76) and was the most accurate predictor of rapid graft cirrhosis (P < 0.0001, area under the curve 0.979, sensitivity 100%, specificity 94%). Different measures of RF progression identify different risks for RF and are not directly comparable. Fibrosis rate was the most accurate predictor of rapid graft cirrhosis.

Interferon-lambda4 genetic polymorphism is associated with the therapy response for hepatitis C virus recurrence after a living donor liver transplant.

The standard therapy against hepatitis C virus (HCV) recurrence postliver transplantation includes interferon (IFN)α and ribavirin. IFNL4 ss469415590 polymorphism has been reported as a novel predictor of the response to IFN therapy for chronic HCV infection. We examined the impact of IFNL4 polymorphism on the responsiveness to IFN therapy after liver transplantation. Tissue specimens were collected from 80 HCV-infected recipients and 78 liver donors, and their IFNL4 ss469415590 genotype, hepatic IFNL4 and interferon-stimulated genes' mRNA expression levels were examined. The association of the polymorphism and expression levels in terms of the IFN therapy response to HCV recurrence was analysed. Most individuals who had rs8099917 risk alleles also had ss469415590 risk alleles (R(2) = 0.9). Sustained virological response (SVR) rates were higher in both liver graft recipients and transplants with ss469415590 TT/TT alleles than in those with the risk ΔG allele (P = 0.003 and P = 0.005, respectively). In recipients with ss469415590 TT/TT, IFNL4 TT mRNA levels showed no significant differences between livers of patients who responded to therapy and those who did not (P = 0.4). In recipients with the risk ΔG allele, IFNL4 ΔG mRNA expression levels were significantly lower in SVR patients than in non-SVR patients (P = 0.02). Hepatic interferon stimulable genes and IFNL4 mRNA expression were correlated. Our findings suggest that analysing the ss469415590 genotype and IFNL4 ΔG expression provides a novel prediction strategy for the possible response to IFN therapy after liver transplantation.

Toll-Like Receptor 3 and 7/8 Function Is Impaired in Hepatitis C Rapid Fibrosis Progression Post-Liver Transplantation

Recurrence of hepatitis C (HCV) postliver transplant is universal, with a subgroup developing rapid hepatic fibrosis. Toll-like receptors (TLRs) are critical to innate antiviral responses and HCV alters TLR function to evade immune clearance. Whether TLRs play a role in rapid HCV recurrence posttransplant is unknown. We stimulated peripheral blood mononuclear cells (PBMCs) from 70 patients with HCV postliver transplant with TLR subclass-specific ligands and measured cytokine production, TLR expression and NK cell function. Rate of fibrosis progression was calculated using posttransplant liver biopsies graded by Metavir scoring (F0-4; R=fibrosis stage/year posttransplant; rapid fibrosis defined as >0.4 units/year). Thirty of 70 (43%) patients had rapid fibrosis progression. PBMCs from HCV rapid-fibrosers produced less IFNα with TLR7/8 stimulation (p=0.039), less IL-6 at baseline (p=0.027) and with TLR3 stimulation (p=0.008) and had lower TLR3-mediated monocyte IL-6 production (p=0.028) compared with HCV slow fibrosers. TLR7/8-mediated NKCD56 dim cell secretion of IFNγ was impaired in HCV rapid fibrosis (p=0.006) independently of IFNα secretion and TLR7/8 expression, while cytotoxicity remained preserved. Impaired TLR3 and TLR7/8-mediated cytokine responses may contribute to aggressive HCV recurrence postliver transplantation through impaired immune control of HCV and subsequent activation of fibrogenesis.

Effect of Telaprevir on the Pharmacokinetics of Tacrolimus in the Treatment of Hepatitis C After Liver Transplantation Presidential Poster

Purpose: Limited data are available on using telaprevir (TVR)-based triple therapy to treat HCV recurrence post-liver transplantation (LTx). A study in healthy volunteers shows that TVR leads to major increase in tacrolimus (TAC) blood concentration. We report our preliminary experience on the effects of TVR on TAC pharmacokinetics (PK) and the safety of TVR-based therapy in the post-LTx setting. Methods: Patients with HCV genotype 1 recurrence post-LTx on stable dose of TAC for at least 6 months prior to starting the antiviral regimen were included in this study. TVR-based triple therapy was started with TVR 750 mg TID, ribavirin 600 mg daily, and peg-interferon α2a 180 mcg weekly. On day 1 of treatment, TAC at half the pre-treatment daily dose was given and levels were checked at 12 and 24 hours and every other day thereafter for 2 weeks to assess TAC PK. No additional TAC was given until the level was around 4-6 ng/mL. Once the maintenance dose of TAC was established, levels were assessed weekly. Results: Four patients (1F, 3M), mean age 56.3 years, mean time from LTx 3.25 years, and mean fibrosis stage of 2.5 were treated. Two were HCV treatment naïve and two were prior null-responders post-LTx. The mean duration of treatment was 10.75 weeks (range 8-16 weeks). The pre-treatment TAC dose ranged from 1-3 mg twice daily. The TAC dose required to maintain therapeutic levels was found to be approximately ¼- ½ the pre-treatment daily dose at a frequency of once weekly. The mean area under the concentration time curve (AUC) for TAC while on TVR was 1353.46 ng.hr/mL (range 685.25-2040.05) compared to an expected AUC of 67 ng.hr/mL without TVR. The highest TAC level that we encountered in our study was 16.2 ng/mL (at 12-hour level after the initial dose). Clinically significant anemia (Hb <10 g/dL) developed in 2, requiring a decrease of the ribavirin dose to 400 mg daily and starting epoietin. No significant neurologic toxicity was encountered. The mean creatinine increased from 1.12 to 1.35 mg/dL. We did not encounter any infections or episodes of acute rejection. Conclusion: 1. TVR had a profound effect on TAC metabolism; 2. Dose reduction of TAC based on blood levels is associated with normal TAC blood levels; 3. TVR therapy for HCV recurrence post-OLT in patients on TAC-based immunosuppression appears feasible; 4. The effect on renal function requires additional study. Longer follow-up is needed to demonstrate efficacy in achieving control of HCV. Disclosure: Naim Alkhouri, MD - Speaker's Bureau and Advisory Board Member of Vertex (makers of telaprevir). Nizar N Zein - Speaker's Bureau and Advisory Board Member of Vertex (makers of telaprevir).

OC-041 IL28B haplotypes and IP-10 predict treatment response for recurrent HCV post transplant

IntroductionHepatitis C virus (HCV) recurrence post liver transplant (LT) is universal. Sustained virological response (SVR) rates post LT with pegylated interferon (PEG-IFN) and ribavirin (RIB) range between 26% and 50%...

OC-107 Morphometric analysis of fibrosis and inflammatory activity in recurrent HCV infection post liver transplantation

IntroductionHepatitis C virus (HCV) recurrence post liver transplantation (LT) is universal. Ishak score (IS) is widely used in the histological assessment of recurrent HCV. Smooth muscle actin (SMA) expression is...

PTU-059 Hepatitis C virus infection abrogates the effect of liver transplantation on NK cell activation

IntroductionHepatitis C virus (HCV) infection is the leading cause for liver transplantation (LT) and recurrence post LT is universal. The role of NK cells in this context is poorly understood,...

The role of hepatitis B immunoglobulin in hepatitis B related liver transplantation: Canadian Transplant Centre Position Paper

Introduction. Hepatitis B virus (HBV) related liver transplant (LT) recipients face a high risk of HBV reinfection in the absence of continuous post-operative HBV prophylaxis. Combination HBV prophylaxis with hepa-titis B immune globulin (HBIg) and nucleos(t)ide anti-viral agents prevents HBV recurrence in 90 to 100% of patients who undergo transplantation for hepatitis B and is considered the standard of care in Canada. Post liver transplant HBV prophylaxis protocols vary with regard to the dosing, duration and routes of HBIg administration. All Canadian transplant centres managing liver transplant patients were surveyed as to their HBV transplant protocols.Results. Results of the survey showed that the majority of the Canadian transplant centres use an oral antiviral in combination with long term or indefinite HBIg for prevention of HBV recurrence post liver transplantation. Studies were done to test new protocols using lower HBIg doses given intramuscularly or subcutaneously alone or in combination with antiviral agents.Conclusion. Long term HBIg administration post transplantation in combination with antiviral agents is an integral part of Canadian HBV related liver transplant protocol.

HCV Recurrence in HIV-Infected Patients After Liver Transplant

Patients coinfected with hepatitis C virus (HCV) and HIV undergoing liver transplantation (LT) are at risk of early, aggressive HCV recurrence. This study investigates the use of frequent protocol-driven biopsies to identify HCV recurrence post LT in coinfected patients. Five consecutive HIV/HCV-coinfected patients underwent LT. Liver biopsies were obtained post LT at 1 hour; days 7, 120, and 365; then annually; and as clinically indicated. Stage 2 (Ishak) or higher fibrosis occurred in 4 of the 5 patients by 60, 120, 270, and 365 days. Two patients died of HCV recurrence and liver failure at 6 and 35 months post LT. Three patients survived more than 4 years after LT, 2 having sustained virologic responses to anti-HCV treatment. Another has histologic recurrence not responding to treatment. Hepatitis C virus recurrence can be rapid and aggressive after LT in HIV-coinfected patients. Serial biopsies identify recurrence early, allowing for prompt initiation of treatment.