Liver transplantation for hepatitis C (HCV) has its successes and difficulties, that’s for sure. This lecture focused on post-transplant outcomes in viral hepatitis. Twenty-five to 40% of liver transplants are for this indication, and the overall survival is slightly less than for other indications; in fact, Arizona has stopped transplanting HCV altogether. Nevertheless, it is still common practice, and you should be familiar with the common sequelae.
Recurrent HCV infection in the allograft is universal. Treatment typically is offered as soon as the graft shows evidence of advanced (ie. F2) disease or a severe recurrence (ie. high viral load and markedly abnormal LFT). It is clear that with severe recurrences, the risk for cirrhosis by post-op year 5 is very high.
One variant of recurrent disease is referred to as fibrosing cholestatic hepatitis (FCH), and occurs in 5-10% of cases. Here, you see very high viral loads and an alkaline phosphatase > 400; it often occurs within the first year of transplant. This variant can also be seen in HBV infection (and in the native liver when there is HIV coinfection or severe immunosuppression). This condition must be treated aggressively to prevent allograft failure.
Another variant of HCV recurrence is plasma cell hepatitis. It is often very difficult to differentiate this entity as a variation of HCV recurrence vs. a de novo alloimmune phenomenon. And to be sure, it is critical that you make the correct diagnosis because the treatment is antiviral therapy vs. corticosteroids, respectively. We learned that HCV treatment post transplant is more often successful when the patient is naive to interferon treatment pre-transplant.
Furthermore, antiviral therapy with interferon can trigger a plasma cell immune response, which makes the picture even more blurry. An experienced hepatopathologist should help guide you in the correct direction.
Lastly, we discussed post-transplant treatment for hepatitis B infection (HBV). With the use of HBIG (IV or IM), allograft dysfunction is fortunately rare. In situations where risk for severe recurrence is high (ie. high pre-transplant viral load, HIV coinfection), an oral agent (or two) is also used.