This monograph is specifically focused on the management of viral hepatitis in the liver transplantation setting. In the majority of cases, chronic hepatitis B and C are slowly progressing diseases, taking decades to reach their final stages. Nonetheless, their long-term sequelae – decompensated cirrhosis and hepatocellular carcinoma – are still the leading indication for liver transplantation (LT). According to the European Liver Transplantation Registry, up to 39% (19,646 cases) of all LT performed in Europe from 1988 to 2010 for cirrhosis is virus-related. Of these cases, those related to the hepatitis C virus (HCV) represent the vast majority, due in part to the successful management of cirrhosis associated with hepatitis B virus (HBV) with potent nucleoside and nucleotide analogues. This situation is rendered more problematic by post-LT recurrent infection and disease. Although recurrent HBV infection has been almost entirely eliminated by different prophylaxis protocols, HCV infection recurs soon after LT in virtually all patients, with the majority of them developing chronic hepatitis within one year of LT. The fact that recurrent hepatitis C post-LT progresses more rapidly than in immunocompetent individuals, coupled with the difficulty in treating these cases with interferon-a-based regimens, accounts for the relatively poorer prognosis.
The first article provides a critical discussion of the various prophylaxis protocols aimed at preventing HBV reinfection of the liver graft. The pivotal role of immunoprophylaxis using hepatitis B immunoglobulins is particularly stressed and remains significant even in the era of nucleos(t)ide analogues. The author, Dr. Marzano, who is a leading hepatologist in Turin, Italy where one of the largest LT programs in continental Europe is located, maintains a wary attitude towards novel schedules promoting antiviral drugs.
The two articles that follow deal with the management of post-LT recurrent hepatitis C. Dr. Serper and Dr. Levitsky, from Northwestern University Hospital, Chicago, review the clinical and histological features of post-LT hepatitis C, analyzing in detail the risk factors for recurrence and liver disease progression and providing guidelines for management. An interesting chapter is devoted to the effects of HCV on the combined liver-kidney transplant.
Finally, Dr. Giostra from Geneva University Hospital and Dr. Dumortier from the Edouard Herriot Hospital, Lyon review the available evidence on the antiviral therapy of recurrent hepatitis C. Current treatment is based on the standard combination of pegylated interferon-α and ribavirin, with response rates of about 30-35%, i.e., still well below that attained in immunocompetent chronic hepatitis C patients. Here, however, the arrival of novel direct-acting antivirals, despite the risks of drug-drug interactions and toxicity, will certainly change the long-term perspectives, although the data available to date is still very limited.