Changing faces-natural course and treatment of hepatitis C after liver transplantation

Interferon Treatment of Hepatitis C Reinfection after Liver Transplantation: A Meta-Analysis

Background. Graft reinfection with hepatitis C (HCV) after liver transplantation is a significant problem in transplant hepatology. This meta-analysis was performed to compare the effectiveness and risk of adverse events of interferon-based therapy with no treatment after liver transplantation. Methods. We searched electronic databases up to July 31, 2013, to obtain relevant research reports that satisfied the inclusion criteria. Meta-analyses were done on randomized controlled trials (RCTs) and nonrandomized trials. Results. A meta-analysis was performed on 2 RCTs and 2 cohort studies comprising a total of 326 patients (171 of whom accepted interferon-based antiviral therapy). The treatment group was found to have higher virological response (VR) rates than controls at 12, 24, 48, and 72 weeks. Patients in the antiviral group had higher sustained virological response (SVR) rates and lower mean alanine aminotransferase levels relative to controls at 48 weeks, but more total serious adverse events (AEs) than controls. Conclusions. Interferon-based treatment has some efficacy in the treatment of HCV graft reinfection following liver transplantation.

Treatment of hepatitis C virus infection

Acute and chronic hepatitis C virus (HCV) infection remains a serious health problem worldwide, however, there has been advancement in the treatment of HCV infection due to standard treatment using pegylated interferon and ribavirin. The literature indicates that therapy for HCV is becoming more individualized. In addition to considering genotype and viral RNA levels before treatment, achievement of an early virologic response (EVR) and a rapid virologic response (RVR) is now possible during therapy. Moreover, problem patients, such as non-responders, relapsers, HIV or HBV co-infected patients, patients with liver cirrhosis, and pre- or post-liver transplantation patients are an increasing fraction of the patients requiring treatment. This article reviews the literature regarding standard treatments and problem patients with acute and chronic HCV infection. It also includes discussion on contraindications and side effects of treatment with interferon and ribavirin, as well as new drug development.

Interferon-based combination anti-viral therapy for hepatitis C virus after liver transplantation: a review and quantitative analysis

Recurrence of hepatitis C virus (HCV) infection after liver transplantation (LT) is universal. However, the efficacy, tolerability and safety of combination interferon and ribavirin (IFN-RIB) or peginterferon and ribavirin (PEG-RIB) anti-viral therapies post-LT are uncertain. We performed a comprehensive search of major medical databases (1980-2005) and conference proceedings (1996-2005). The main outcome measure was sustained virological response (SVR, undetectable HCV RNA) at 6 months. Summary estimates were calculated using random-effects models. Twenty-seven IFN-RIB and 21 PEG-RIB studies were included. IFN-RIB was associated with a pooled SVR rate of 24% (95% CI, 20-27%), while PEG-RIB was associated with an SVR rate of 27% (23-31%). Pooled discontinuation rates were 24% (21-27%) with IFN-RIB and 26% (20-32%) with PEG-RIB. The pooled rate of acute graft rejection was 2% (1-3%) with IFN-RIB and 5% (3-7%) with PEG-RIB. IFN-RIB and PEG-RIB therapies in HCV infection post-LT were associated with similar but overall low SVR and were poorly tolerated. The rate of acute rejection was small. The therapeutic advantage of PEG-RIB therapy observed in non-transplant chronic HCV infection appears to be attenuated post-LT. Clinical trials are needed to evaluate reasons for this post-transplant therapeutic disadvantage and to find strategies to ameliorate them.

Corticosteroid-Free Strategies in Liver Transplantation

Corticosteroid avoidance is feasible and may be desirable in liver transplantation. Approximately 50% of liver transplant recipients who use calcineurin inhibitors and azathioprine do not need corticosteroids. The availability of newer agents, such as mycophenolate mofetil and antibody therapy, has increased the percentage of patients who do not need to use corticosteroids to about 75%. The feasibility of corticosteroid-free immunosuppression has been established by controlled trials demonstrating non-inferiority with respect to patterns of rejection as well as patient and graft survival. However, the evidence available to date does not unequivocally establish the benefits of corticosteroid-free immunosuppression, although some advantage has been established relating to post-transplant diabetes mellitus, cytomegalovirus infection and growth patterns in children. The effect of corticosteroid-free immunosuppression in hepatitis C liver transplant recipients is yet to be resolved.

Retrospective analysis of the impact of immunosuppression on the course of recurrent hepatitis C after liver transplantation

INTRODUCTION

In a substantial proportion of patients, recurrent hepatitis C after liver transplantation (OLT) rapidly progresses to graft cirrhosis. The role of different immunosuppressive schemes is not well evaluated.

PATIENTS AND METHODS

The clinical course of 130 patients with recurrent hepatitis C after OLT was retrospectively analyzed. Mean trough levels of calcineurin inhibitors and cumulative doses of the remaining immunosuppressants were calculated. The results were compared with liver function tests, histological fibrosis progression, and survival.

RESULTS

Survival and fibrosis progression were similar in patients with tacrolimus and cyclosporine and did not correlate with mean trough levels. In contrast, the application of azathioprine (mean dose of more than 25 mg/d during the first 3 months after OLT) was associated with significantly less progression of fibrosis (P = .01). Administration of azathioprine after the early postoperative phase was not related to the long-term outcome. The dose of prednisolone in the long-term course after OLT significantly correlated with the rate of fibrosis progression (P = .008).

CONCLUSIONS

The clinical course of recurrent hepatitis C was variable. Survival and fibrosis progression did not correlate with the type or trough level of calcineurin inhibitors. Azathioprine early in the course after OLT and prolonged administration of prednisolone were associated with less fibrosis progression.

Peginterferon alfa-2a for hepatitis C after liver transplantation: two randomized, controlled trials

There is currently no effective treatment for recurrent hepatitis C after orthotopic liver transplantation (OLT). We therefore performed two randomized, controlled trials--a prophylaxis trial and a treatment trial--to evaluate the safety and efficacy of peginterferon alfa-2a in patients who had undergone OLT. The prophylaxis trial enrolled 54 patients within 3 weeks after OLT, and the treatment trial enrolled 67 patients 6 to 60 months after OLT. In each trial, patients were randomized to treatment with once weekly injections of 180 microg peginterferon alfa-2a or no antiviral treatment for 48 weeks and were followed up for 24 weeks thereafter. Peginterferon alfa-2a treated patients had significantly lower hepatitis C virus RNA levels and more favorable changes in hepatic histological features compared with untreated controls. However, only 2 treated patients in the prophylaxis trial (8%) and 3 in the treatment trial (12%) achieved a sustained virological response. In the prophylaxis trial, 8 patients (31%) in the peginterferon alfa-2a group and 9 (32%) in the untreated group were withdrawn prematurely; whereas in the treatment trial, 10 patients (30%) in the peginterferon alfa-2a group and 6 (19%) in the untreated group were withdrawn prematurely. The incidence of acute rejection was similar in the treated and untreated groups in both the prophylaxis (12% vs. 21%; P = .5) and treatment (12% vs. 0%; P = .1) trials. In conclusion, peginterferon alfa-2a treatment for 48 weeks is safe and tolerable and offers some efficacy in the post-OLT setting. Randomized controlled studies are needed to establish the efficacy of pegylated interferon and ribavirin in patients who have undergone OLT.