Chapter 23
Hepatitis C Management in Transplant Candidates and Recipients
| Hepatitis C | |
| Pre-transplant | Post-transplant |
| Liver transplant candidate/recipient | |
| Compensated cirrhosis (Child-Pugh class A) Consider therapy with PEG-IFN + ribavirina (note that ribavirin relatively contraindicated if GFR < 50 mL/min) Decompensated cirrhosis (Child-Pugh class B or C) Therapy is poorly tolerated – it carries a high risk of infectious complications and worsening of liver function and has a low chance of success and is therefore generally contraindicated [1] |
Recurrence of HCV infection is universal 10–25% develop cirrhosis by 5 years post-transplant. Most centers perform protocol liver biopsies (e.g. every 1–2 years) to monitor for evidence of histological recurrence and reserve HCV therapy for patients who develop biopsy-proven recurrence (grade 3 or stage 1–2 by Metavir) [2] In those with histologic recurrence therapy should be initiated with PEG-IFN + ribavirina; overall SVR 27% [3] Pre-emptive therapy is generally not recommend as it is very poorly tolerated and has not been clearly shown to delay onset of recurrence |
| Non-hepatic transplant candidate/recipient | |
| Liver biopsy to assess histologic disease should be performed as part of transplant assessment [4] Mild disease (Metavir stage F0–F2) may be considered for a trial of therapy with PEG-IFN + ribavirina; if not treated or fails therapy, list for non-hepatic transplant Moderate–advanced disease (Metavir Stage F3-F4) – treat for hepatitis C with PEG-IFN ± ribavirin (note that therapy contraindicated in cardiac transplant candidates; ribavirin is relatively contraindicated if GFR < 50 mL/min) If SVR is achieved, list for transplant; if SVR is not achieved, there is a high risk of end-stage liver disease post-transplant. Options include listing on a case-by-case basis for non-hepatic transplant alone, combined transplant, decline/defer for transplant |
There are no data to guide optimal post-transplant monitoring. Most centers perform liver enzymes and liver function tests every 3–6 months and ultrasound yearly. Consideration may be given to liver biopsy 3-5 years posttransplant in those who are potential candidates for HCV therapy In recipients of life-sustaining (e.g. heart, lung) transplants, interferon-based therapy should be avoided due to risk of rejection In renal transplant recipients, PEG-IFN ± ribavirin may be considered on a case-by-case basis in the setting of significant HCV-related liver or renal disease after weighing potential risks (including rejection) and benefits [4] |
GFR, glomerular filtration rate; HCV, hepatitis C virus; PEG-IFN, pegylated interferon; SVR, sustained virologic response.
aPEG-IFN and ribavirin dose:
- Genotype 1,4: PEG-IFN-α-2a 180 μg subcutaneously (SC) weekly + ribavirin 1000 mg (≥75 kg), 1200 mg (<75 kg) daily × 48–72 weeks or PEG-IFN-α-2b 1.5 μg/kg SC weekly + ribavirin daily based on weight: 800 mg (<65 kg), 1000 mg (66–80 kg), 1200 mg (81–105 kg), 1400 mg (>105 kg) × 48–72 weeks
- Genotype 2,3: PEG-IFN-α-2a 180 μg SC weekly + ribavirin 800 mg daily × 24-48 weeks or PEG-IFN-α-2b 1.5 μg/kg SC weekly + ribavirin daily based on weight: 800 mg (<65 kg), 1000 mg (66–80 kg), 1200 mg (81–105 kg), 1400 mg (>105 kg) × 24–48 weeks.
References: Hepatology 2005; 42: 255; [2] Liver Transplantation 2003; 9(11): S1; [3] Am J Transplantation 2006; 6: 1586; [4] Am J Transplantation 2009; 9(S4).