ABSTRACT
Hepatitis C is the most common cause of end-stage liver disease leading to liver transplant.
The disease can recur after transplant, resulting in clinical hepatitis in up to 75%
of patients and severe disease in approximately 7%. Treatment of rejection with steroid
boluses and treatment of steroid-resistant rejection with OKT3 have both been shown
to increase the incidence of recurrent hepatitis C. The use of OKT3 for steroid-resistant
rejection is reportedly associated with more severe recurrence. The calcineurin inhibitors
tacrolimus and cyclosporine have not been conclusively associated with different rates
or severity of recurrence. Viral levels rise 10- to 15-fold after transplant and appear
to be associated with the use of immunosuppression. Studies suggest that high viral
levels, either pretransplant or early after transplant, may be associated with severe
recurrent disease. Although the role of genotype is still unclear, genotype 1b is
known to be associated with a poorer prognosis in nontransplanted patients and a lesser
response to treatment than other genotypes. Furthermore, some reports suggest that
after transplant, recurrent disease may progress more rapidly in patients with genotype
1. Treatment options after recurrence remain poor. Neither interferon nor ribavirin
alone provides any true benefit. Combination therapy appears to have a better short-term
outcome but may be poorly tolerated, and long-term benefits are unknown. Prophylaxis
with combination therapy may be a better option but requires further study. Finally,
retransplantation for recurrent hepatitis C is complicated not by rapid recurrence
of disease in the new allograft but by high perioperative mortality that may be predicted
by the presence of renal failure or sepsis preretransplant.
KEYWORD
hepatitis C - liver transplantation - recurrence - immunosuppression
