LIVER TRANSPLANTATION FOR THE MANAGEMENT OF HEPATITIS C

Field: Medicine (Health Sciences)

176 During the last decade, medicine has defined the clinical entity of hepatitis C (HVC), while liver transplantation has been met with frustration in the management of these patients. We reviewed our experience with HCV patients who received liver transplants over the last 8 years. Methods: We retrospectively reviewed all HCV patients identified pre-operatively by serology or PCR and postoperatively by a retrospective analysis stored specimens. From Jan '91 to Dec '98, 116 patients were transplanted for HCV. Charts were reviewed for patient demographics, pre and post-operative management, mean time to recurrence, need for re-transplantation and mortality. Hepatitis C recurrence was defined by PCR detected HCV or lobulitis on liver biopsy. Statistical evaluations were performed by Chi-square. Results: The mean age at transplantation was 51.0 years. 91 patients received primary transplants and 25 patients re-transplant. Diagnoses associated with HCV were laennec's cirrhosis 20/116 (17%), hepatoma (HCC) 11/116 (9%), and PBC 1/116 (1%). 18 patients (16%) received pre-operative interferon (INF) therapy. 11 patients were started on tacrolimus and 105 patients on cyclosporine. 4 received post-operative INF therapy. The recurrence rate of HCV was 51/116 (44%) at 1 year and 69/116 (59%) by 3 years. Mean time to recurrence of HCV 7.7 mos (range of 1-88 mos). At 1 month, 18 patients recurred with a mortality of 13/18 (72%) and a mean time to mortality of 9.5 mos (range 2-26 mos). This was significantly different than patients without recurrence by 1 month.(24/97 {28%}:p<0.01). No difference in mortality was noted between patients recurring after 1 month 22% (12/55) vs. those without recurrence 29% (12/42);(p=0.4). 74 episodes of acute rejection occurred in 65 patients (56%) and 3 episodes (3%) of chronic rejection were also biopsy proven. 41 episode of rejection were managed by corticosteroids alone, 14 by tacrolimus and 1 by OKT3. Re-transplantation was required in 25 patients for: biliary manifestations of HCV 8, PNF 5, recurrent HCV 4, vascular or septic complications 6, and rejection. 2. The 1,3,5 year patient survival for primary transplants was 66/78 (85%), 46/66 (70%) and 35/56 (63%) respectively. The 1,3,5 year survivals for patients requiring re-transplantation were 18/25 (72%), 13/24 (54%) and 11/23 (48%) respectively. Mortality in the primary transplant group were from: sepsis 12/22 (55%), recurrent HCC 3/22 (14%), recurrent HCV 3/22 (14%), and medical co-morbidity's 4/22 (18%). Mortality in the re-transplantation group were from: sepsis 9/13 (69%), recurrent HCV 2/13 (15%), intraoperative death 1/13 (8%) and medical co-morbidity's 1/13 (8%). Conclusions: Mortality is significantly greater when there is serologic or biopsy proven recurrent HCV at one month. Routine post-operative INF is not necessary to obtain good survival after transplantation. Re-transplantation for HCV, like all other re-transplants carries a significant mortality but this should not prohibit re-transplantation in this group. Early PCR monitoring and further investigation of INF for patients who have early evidence of recurrence are needed.