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Recurrence of HCV after the transplant

For people who still have the virus at the time of their transplant it is very likely that their new liver will become re-infected with hepatitis C. After the new liver has been implanted, virus levels drop for up to 23 hours. They then began to rise again, doubling every 2 days, and are likely to reach pre-transplant levels within a few days of the procedure.

For people who have achieved SVR (sustained viral response) with interferon-based therapy just before their transplant the evidence is less clear. Most people will, however, experience viral recurrence. This is caused by low level hepatitis C genetic material that remains in the body, usually in peripheral blood mononuclear cells (a type of white blood cell of the immune system).

This is undetectable using standard hepatitis C tests. Some studies indicate that pre-transplant treatment prevents hepatitis C recurring in up to 25% of cases. This tends to suggest that it may well be worth having treatment before the operation, contrary to what has been the consensus so far. The problem is that people awaiting transplants are typically seriously ill, and often find the side effects of the treatment intolerable.

After a liver transplant the rate of hepatitis C-related disease progression and the increases in viral load, are generally faster than in hepatitis C infected pre-transplant patient. This is due to the body’s lower resistance to fighting the virus caused by the immunosuppressant drugs. As with hepatitis C infection before transplant, the outcome varies significantly between individuals. After a few years some people may have persistent viraemia with no significant liver damage, while others may have developed severe fibrosis.

Factors that may accelerate liver disease after transplantation

Whilst no single factor can predict who will progress to cirrhosis after transplantation, the main risk factors are thought to be:

High viral load at the time of transplantation or soon after surgery

There is a lot of evidence suggesting that the lower one’s hepatitis C viral load is at the time of transplantation, the lesser the chances of recurrence are and the greater the chance of slower disease progression. So any significant reduction in hepatitis C RNA is likely to prove beneficial.

Infection with genotype 1 (especially 1b) or 4

The age of the donor

In one study, the age of the donor seemed to make a significant difference to the progression of the disease in the person receiving the liver. 14% of people with hepatitis C who received livers from donors younger than 30 experienced recurrent post-transplant cirrhosis. That is compared with 45% of those who received livers from donors age 31-59, and 52% who received organs from donors older than 59. In the UK between 2001 and 2005 these are the ages of the liver donors:

Liver transplants for patients with hepatitis C in the UK, 1 January 2001 - 31 December 2005, by donor age group

Donor Age Group

2001

2002

2003

2004

2005

TOTAL

<10

1

0

0

0

0

1

10-19

7

3

4

6

2

22

20-29

9

17

8

7

5

46

30-39

18

13

9

23

14

77

40-49

21

25

24

22

15

107

50-59

34

27

30

24

13

128

60

16

21

14

21

6

78

TOTAL

106

106

89

103

55

459

Figures supplied by UK Transplant

Ischemic time

This refers to the amount of time that the liver is kept on ice without a supply of oxygen, after its removal from the donor. If there is an overly long time spent re-warming the liver before it is implanted then there seems to be a higher risk of HCV infection recurring more severely. In one study, the risk of severe hepatitis C disease at 1 year was 19% for a re-warming time of 30 minutes compared to 65% for 90 minutes. If this data is confirmed then it seems vital that that the re-warming time should be kept to an absolute minimum.

Female gender

Being female has also been linked to worse progression. So far is not known why this happens but seems strange as among non-transplant patients, women usually fare better than men.

Outcomes

It is clear, though, that there is a significant increase in the rate of disease progression in the first ten years after transplant compared to the first ten years of infection before a transplant.

One study has shown that approximately 25% of transplant recipients develop cirrhosis in the grafted liver within 5-10 years, compared with 10-40 years in non-transplant patients. Around 20% of people will develop cirrhosis within one year and a small proportion die of hepatitis C related liver disease within five years. However, the overwhelming majority of people who survive the transplant will live without serious damage from hepatitis C infection for five years.