The question of when to treat liver transplant patients with chronic hepatitis C virus (HCV) infection is vital. HCV is the diagnosis most commonly leading to liver transplantation, and recurrence of HCV after transplant is nearly universal. An estimated 30% of HCV liver transplant recipients experience recurrence within five years of transplantation, resulting in death or loss of the allograft because of cirrhosis or graft failure.1 Thus, if we knew when and how to treat HCV in this population, we could envision a world in which liver transplants would not be required—and certainly one in which retransplant because of HCV would never be needed.
In planning to treat HCV-positive patients who need a liver transplant, the question arises: Do we treat them preoperatively, perioperatively, or postoperatively? And if we select postoperative treatment, do we wait until the graft shows HCV recurrence, or do we treat prophylactically—knowing that recurrence is likely?
Results from multiple small studies of interferon-free treatment of HCV, both prior to and following recurrence of HCV posttransplant, have been reported. The SOLAR trial, which used ribavirin plus sofosbuvir, demonstrated a sustained viral response (SVR) rate of 70%.2 The SOLAR-1 trial of ledipasvir/sofosbuvir (Harvoni®) plus ribavirin in patients with genotype 1 or 4 who were treated following posttransplant recurrence showed an average SVR rate of 96%.3 Duration of treatment varied, depending on genotype and presence of cirrhosis, and there was differing dosing and addition of ribavirin at multiple doses. A 10% mortality rate was reported, but deaths occurred mainly in patients with severe cirrhosis.
A small trial was also conducted of genotype 3 patients treated with ledipasvir/sofosbuvir, with or without ribavirin.4 The addition of ribavirin appeared to shorten treatment, but patients in both treatment groups had excellent rates of SVR. However, further study is needed before this combination of medications can be recommended and/or FDA approved. Full details are available at http://hcvguidelines.org.
Ombitasvir/paritaprevir/ ritonavir with dasabuvir (Viekira Pak™) plus ribavirin for 24 weeks was evaluated in patients with HCV recurrence following liver transplant.5 This group of patients had very minimal fibrosis and essentially normal liver function. In this study group, an SVR rate exceeding 95% was achieved.
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