Retransplantation for recurrent HCV cirrhosis

Retransplantation is the only therapeutic option to achieve
long-term survival in patients with decompensated HCV
cirrhosis after LT. Retransplantation for this indication ranges
from 3.6% to 44%. Patient and graft survival rates after
retransplantation are inferior to those after primary LT. HCVinfected
recipients had a significantly lower survival rate
compared to non-HCV-infected patients who underwent
retransplantation at least 90 days after primary LT.
Progression to cirrhosis is faster after retransplantation than
after primary LT, particularly in patients with severe hepatitis C
recurrence (cholestatic hepatitis and graft failure within the first
year) (Carrion 2010). Predictors of poor outcome are: bilirubin
≥10 mg/dL, serum creatinine ≥2 mg/dL, donor age >40, recipient
age >55 and early HCV recurrence (cirrhosis <1 year after LT)
(Wiesner 2003). Thus, the optimal timing to perform elective
retransplantation in HCV patients is a matter of debate.
However, bilirubin and creatinine serum levels are essential for
deciding about retransplantation candidates. Patients with a CTP
score ≥10 or a MELD score >25 have a very high risk of death
after retransplantation.
Outlook
HCV is and will continue to be the most common indication for
LT worldwide and recurrent disease associated with HCV is a
major cause of allograft loss and mortality.
A better understanding of the recipient, donor and viral risk
factors for progressive disease and vigilant post-transplant
monitoring through histologic assessment may guide
management aimed toward reducing the potential for graft
failure as well as helping identify candidates for antiviral
therapy.
Management of recurrent HCV infection following liver transplantation | 89
Antiviral therapy in patients with HCV cirrhosis awaiting LT
should be considered only in selected individuals due to poor
tolerability and limited virologic response. Pre-emptive therapy
is not well tolerated in the post-LT population. Antiviral therapy
with PegIFN/RBV should be considered in transplant recipients
with recurrent HCV infection. Achievement of SVR is associated
with increased allograft and patient survival; however, efficacy
may be limited by poor tolerability, risk of cellular rejection and
risk of alloimmune hepatitis, requirement for dose reductions,
and treatment discontinuation.
Retransplantation is the only therapeutic option to achieve
long-term survival in patients with decompensated cirrhosis
after LT.