HCV in Liver Transplant Recipients: How do you Approach Them?

HCV recurrence is universal after liver transplantation and survival is lower compared with patients without HCV. Treatment after liver transplantation is challenging. Options include pre-emptive therapy and therapy once recurrence is established. In general, post-transplant patients have lower sustained virological response (SVR) rates compared with pretransplant patients. Pre-emptive therapy is very difficult to apply due to poor patient tolerance and serious adverse effects and is not recommended. Protocol liver biopsies and/or hepatic venous gradients should be performed to confirm HCV recurrence. Once significant HCV recurrence is established, treatment with peginterferon and ribavirin using the low-accelerating dose regimen should be initiated. Using this approach, SVR rates of 20-50% may be achieved. However, obstacles to treatment include poor patient tolerance, development of significant cytopenias, and risk of cellular rejection and alloimmune hepatitis. Further prospective studies are needed to determine how to optimally manage these complicated patients.