The first generation direct
antiviral agents (DAAs) highlighted substantial prognosis improvement among
liver transplant (LT) candidates and recipients with recurrent hepatitis C virus (HCV)
infection. During 2014, second generation DAAs are associated with high sustained virological response rates (> 95%), shortened duration courses and relatively few toxicities. In keeping with the currently available data, patients with decompensated
cirrhosis awaiting LT is preferable to be treated with
interferon-free, new generation DAAs, with or without
ribavirin combinations. Although data about the safety of new DAAs combinations in this patient population are limited,
sofosbuvir and
daclatasvir pharmacokinetics do not appear to change significantly in moderate or severe liver impairment, while other new DAAs (
simeprevir,
asunaprevir) seem to be contraindicated in patients with severe liver impairment (Child-Pugh class C). On the other hand,
sofosbuvir should not be given in patients with glomerular filtration rate ≤ 30 mL/min, but ongoing trials will clarify better this issue. With the objective that newer
antiviral combinations will yield safer and more efficient manipulation of HCV recurrence post-transplant, the European Association for the Study of the Liver has recently updated its recommendations towards this direction. Nevertheless the new
antivirals' high cost may be the biggest challenge to their implementation worldwide.