Management of Hepatitis C in the Setting of Liver Transplantation

HCV infection of the liver allograft is universal and is associated with an accelerated rate of disease progression. Before liver transplantation, treatment with hepatitis C with the LADR regimen should be strongly considered for cirrhotic patients who have a MELD score of 18 or lower or a CTP score of 7 or lower. The use of growth factors (erythropoietin or GM-CSF) may minimize the need for dose reductions and optimize the chance of a response in these patients. After transplantation, one option is preemptive treatment before there is histologic evidence of hepatitis C. The main limitation of preemptive treatment is the poor tolerability of antiviral therapy in the immediate posttransplantation period. Even in patients thought to be stable enough to undergo treatment, discontinuation rates are high. Treatment of histologically confirmed recurrent hepatitis is associated with lower SVR than seen in patients before transplantation but should be strongly considered given the aggressive course of recurrent hepatitis. Most of the experience is with standard interferon and ribavirin; however, new studies show more benefit with pegylated interferon and ribavirin. Addition of growth factors is usually necessary because of the poor tolerability of therapy in the posttransplantation period. The exact duration of therapy is unknown at this time; most studies have used pegylated interferon and ribavirin for genotype 1 for 48 weeks.