Liver retransplantation for hepatitis C: Seeing is believing

A childhood friend of mine told me that it wasn’t until she was fitted for glasses at age 10 yr that she realized trees were not shimmering green objects but rather comprised of many leaves. And there were branches. By analogy, transplant physicians have had impaired “vision” when it comes to seeing liver retransplantation. This relates to the fact that most of the published analyses have been based on registry data, which by their very nature have limited resolution, or small series with anecdotal experiences whose outcomes could be easily affected by technical differences among surgeons, misinterpretation of histologic findings, and other common factors. The lack of precise vision has resulted in a wide spectrum of expressed opinions, from the impassioned plea to abandon retransplantation entirely for recurrent disease (because it is not fair) to the view that patients needing retransplantation be awarded priority points because their natural history and rate of dying is accelerated. In this issue of Liver Transplantation, McCashland et al., from more than 10 centers, are to be commended for cooperatively collecting their “high resolution” experiences in retransplantation and sharing them with the transplant community; indeed, it is the first time this has been done in the United States. They report their intriguing findings, which are principally summarized as follows: 1) overall 1and 3-yr survival rates for patients retransplanted for hepatitis C virus (HCV) is comparable to HCV-uninfected patients who underwent retransplantation; 2) approximately one-third of patients with HCV-related graft failure are not even considered for retransplantation and only one-half of those evaluated are relisted; 3) the proportion of patients with HCV-related graft failure who are being denied retransplantation has doubled in recent years; 4) of those patients with recurrent HCV who are relisted, almost 80% die waiting; 5) currently, less than 1% of transplantations at these centers are being performed for HCVrelated graft failure; and 6) Model for End-Stage Liver disease (MELD) scores greater than 30 are associated with particularly poor survival following retransplantation. The first large analysis of United Network for Organ Sharing registry data (about 10 yr ago) demonstrated that HCV infection per se was associated with an increased risk of mortality following liver retransplantation. Using the Scientific Registry of Transplant Recipients database for patients retransplanted in the next era (1997-2002), Pelletier et al. found that the relative risk of mortality attributable to HCV was almost identical to the previous report: 1.30 vs. 1.36. How can one reconcile these results with those of the current report? It is important to recognize that all database-derived analyses include a highly heterogeneous group of patients, i.e., many of the HCV-infected patients likely did not have graft failure related to HCV; rather, their graft failure was related to other causes. It is also possible that HCV has other effects on the immune response not easily measured by routine biochemical tests and that this may affect survival. By the authors’ admission, the patients studied in the current analysis are a highly selected subset of patients, and, moreover, it is likely