Chronic hepatitis C virus (HCV)
infection is the leading cause of death from
liver disease and the leading indication for
liver transplantation (LT) in the United States and Western Europe. LT represents the best therapeutic alternative for patients with advanced chronic
liver disease caused by HCV or those who develop hepatocarcinoma.
Reinfection by HCV of the graft is universal and occurs in 95% of transplant patients. This
reinfection can compromise graft function and patient survival. In a few cases, the histological recurrence is minimal and non-progressive; however, in most patients it follows a more rapid course than in immunocompetent persons, and frequently evolves into
cirrhosis with graft loss. In fact, the five-year and ten-year survival of patients transplanted because of HCV are 75% and 68%, respectively, compared with 85% and 78% in patients transplanted for other reasons. There is also a pattern of recurrence that is very severe, but rare (< 10%), called fibrosing cholestatic
hepatitis, which often involves rapid graft loss. Patients who present a negative HCV
viremia after
antiviral treatment have better survival. Many studies published over recent years have shown that
antiviral treatment of post-transplant HCV
hepatitis carried out during the late phase is the best option for improving the prognosis of these patients. Until 2011, PEGylated
interferon plus
ribavirin was the standard of care, resulting in a sustained virological response in around 30% of recipients. The addition of
protease inhibitors, such as
boceprevir or
telaprevir, to the standard of care, or the use of other direct-acting
antiviral drugs may involve therapeutic changes in the context of HCV recurrence. This may result a better prognosis for these patients, particularly those with severe recurrence or factors predicting rapid progression of
fibrosis. However, the use of these agents in LT still requires clarification in terms of safety and efficacy.