ReviewHepatitis C and liver transplantation
Section snippets
Natural history of hepatitis C virus-related hepatitis
Hepatitis C virus (HCV) infection is a prevalent infection in most developed countries affecting 1.5–2% of the general population [1]. The natural history of this infection has been extensively evaluated. One of the most striking features is the high risk of persistence after viral acquisition with eventual development of cirrhosis in 20–25% of patients. The time-frame between infection and development of cirrhosis is calculated in decades and appears to be influenced by alcohol abuse [2]. The
Source of infection
The most common source of infection is pre-transplantation infection. Indeed, recurrent infection occurs universally in patients who are infected at the time of transplantation [11].
The virus may be acquired in those without evidence of prior viral infection from contaminated blood and organ donors, and by nosocomial acquisition of virus during the transplant hospitalization [11]. De novo acquisition of HCV infection is currently extremely low (<5%) due to routine donor screening for HCV [12].
Immune response
The pathogenesis of liver injury following liver transplantation is only partly understood. In general, the level of antibody reactivity is comparable in transplant patients and in non-transplant chronic HCV carriers [65], but this antibody response is unable to induce protective immunity. The T-cell immune response to different HCV antigens may result in direct cytolysis of the infected cells and/or inhibition of viral replication through the secretion of antiviral cytokines. In
Retransplantation
With the prospect of an increase in the number of HCV-infected recipients in need of retransplantation, it has become imperative to determine whether all patients with graft failure due to recurrent HCV disease are candidates for further transplantation. To date, there is a certain reluctance to accept these patients for retransplantation, particularly those who have developed recurrent disease leading to graft failure in a short period of time. This fear with retransplantation is related to
Patient management
There is little consensus on the optimal approach to patients with HCV infection undergoing liver transplantation. This is likely due to two reasons: (1) limited efficacy of available therapies; and (2) inability to interpret current studies due to the non-randomized non-controlled nature of their design.
While preventing HCV recurrence is the major end-point, there is currently no available intervention to effectively prevent recurrence. There are four potential alternative and/or complementary
Conclusions
There are a certain number of proven concepts regarding HCV infection in the setting of liver transplantation. These include: (i) a progressive increase in the number of patients infected with HCV in need of a first or second transplantation; (ii) universal viral recurrence; (iii) extremely low de novo HCV infection; (iv) recurrent HCV hepatitis in the majority with progression to cirrhosis in a substantial proportion of patients with continued follow-up; (v) a variable natural history of
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