Wednesday, July 17, 2024

Hepatitis C And Liver Transplantation

Liver Transplant For Hepatitis C

Hepatitis C: A Disappearing Disease? – UCSF Liver Transplant Conference 2014

A hepatitis C diagnosis can come as a shock to many people. Because the virus causes few if any physical symptoms, it often goes undetected for years or even decades, which can lead to cirrhosis , liver failure, or even liver cancer.

Liver damage, particularly cirrhosis, plays out over a few decades, explains Andrew Muir, MD, chief of the division of gastroenterology at Duke University in Durham, North Carolina. While many people with hepatitis C can be treated with direct-acting antiviral medications, some, including those whove suffered liver damage from cirrhosis or developed liver cancer, may also need to have a liver transplant.

The key is separating out the presence of the virus and how sick the liver is, says Dr. Muir. We have to ask, Is this liver so damaged that the patient will not feel better with other treatments? Will his or her quality of life be drastically affected without a transplant? Or, worse, Could they potentially die if they dont get a transplant? We always first want to try to treat the patient before ever going the transplantation route.

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Future Directions And Needs

Despite the difficulties that the physician faces in the treatment of HCV infection, it cannot be ignored because of the vast number of patients it affects worldwide. Indeed, all efforts need to focus on better designed multicenter trials, instead of small, sporadic studies that leave conflicting trails and better diagnostic accuracy in distinguishing between recurrent HCV infection and acute cellular rejection. Some encouraging news may arise from the direction of new medications, such as new HCV protease inhibitors or long acting types of interferon, which may be combined in order to improve the results and, possibly, decrease the side effects45. These are being evaluated in ongoing human trials, initially in the pretransplant chronic HCV population, with the transplant data yet to come.

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Diagnosis Of Recurrent Autoimmune Hepatitis Its Risk Factors And Management

Despite receiving successful LT, several LT centers have reported recurrent AIH posttransplantation , since the first report by Neuberger et al. in 1984 . However, there are no specific biomarkers to diagnose recurrent AIH. Currently proposed diagnostic criteria for recurrent AIH are shown as Table 1 it is essential to distinguish from other etiologies causing liver damage such as rejection, drug induced liver injury, biliary problems and viral hepatitis .

Safety In Covid Situation

Management of HCV in Liver Transplant Candidates and ...

We take all the necessary precautions and follow all COVID-related protocols strictly to safeguard you and your family members from the COVID virus. A liver transplant can be a life-saving procedure and hence can be necessary to do on an urgent basis. Given the COVID pandemic, you should also take care of wearing masks and maintaining social distance at all times to prevent your patient from getting infected at this point.

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Natural History Of Hepatitis C After Orthotopic Liver Transplantation

Accumulating perspectives of disease recurrence in HCV-infected recipients have been obtained in DDLT within the last two decades. HCV reinfection occurs just after reperfusion followed by a rapid increase in HCV ribonucleic acid levels within 4 postoperative months . The histologic features of liver injury usually resemble those of nontransplant HCV hepatitis typically developing after 3 months, but the clinical presentation, severity, and outcome are extremely heterogeneous and more profound compared to those in immune competent patients . Progression to cirrhosis usually takes 9 to 12 years after liver transplantation with a linear progression of histologic fibrosis . A less common, but well-documented, form of recurrence is called fibrosing cholestatic hepatitis , possibly mediated by a direct cytopathic mechanism under an extremely high viral load and immune-compromised condition. Graft failure occurs in 50% of recipients within a few months after fibrosing cholestatic hepatitis develops . Some HCV-reinfected recipients, however, show no apparent disease progression for at least the first decade and their graft injury remains mild or even absent despite a high viral burden.

Treatment Of Hcv Recurrence

After transplantation factors other than HCV infection may lead to fibrosis, such as cytokine interactions secondary to rejection, the effect of certain viruses, such as cytomegalovirus , and modulation of fibrogenesis/ fibrolysis by immunosuppressive agents. Therefore changes in histology as well as the viral status need to be documented in response to antiviral therapy. Moreover, as in nontransplant setting, clinical benefit may occur even when viral clearance is not achieved, leading to histological and clinical improvement.

The first option is that of pre-emptive therapy, early post-transplant, with the rationale that low HCV RNA titers are likely to be more susceptible. The difficulty with this strategy is that it is poorly tolerated, mainly due to associated problems such as leucopenia and renal failure, which in turn lead to a low SVR, because of frequently required dose reductions. Furthermore, there is no difference in the histological outcome when compared with treatment of established, recurrent HCV.

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Risks Factors After Liver Transplants

There are certain risk factors that make the patient more susceptible to catch infections after a liver transplant. These include the following risk factors:

  • The underlying condition of the recipient such as malnutrition
  • Co-morbidities like diabetes, obesity, COPD, renal failure, and dialysis
  • Prolonged hospital stay and catheters before or after liver transplant
  • Acute liver failure
  • Ease during the procedure

Hepatitis C Cirrhosis And Liver Transplants By The Numbers

Can a liver transplant cure Hepatitis C?

Most liver transplants in the United States are due to cirrhosis caused by hepatitis C. In the U.S., 3.9 million people are infected with the hepatitis C virus, and nearly 70 percent of them experience chronic symptoms. Between 17 and 29 percent of people with chronic hepatitis C experience cirrhosis.

The numbers also show that most often, the hepatitis C virus persists in people after their operation.

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Natural History Of Hepatitis C Virus Infection After Liver Transplantation

Although the median term survival rate of HCV infected patients is similar to that of uninfected controls,, published series have yet to include enough patients to detect minor differences in outcome. Furthermore, factors which potentially affect the natural history of HCV, and are present both before and after liver transplantation, are often not identified or have not been included in most published series. Finally, the duration of follow up in previous studies may not be sufficient to detect differences in outcomes, as full manifestation of HCV related liver disease may not be apparent until after a prolonged period of infection. In a recent study, protocol biopsy samples were taken annually from all HCV infected patients. The percentage of patients reaching fibrosis scores of 3 or 4 increased significantly with time . The annual rate of fibrosis progression may be higher than reported in the non-transplant population, suggesting that the length of time needed to develop significant HCV related liver damage could be shorter in immunosuppressed patients than in immunocompetent ones.

Currently, good short and medium term survival rates warrant continued transplantation in this group of patients. However, patients with an increased risk of severe disease after transplantation should be better defined in order to improve their management.

How Does Hepatitis C Affect The Kidney

Hepatitis C infection causes chronic inflammation that can damage the kidneys in the long term. Most of the time, it affects the tiny blood vessels of the glomerulus, a net-like unit that filters toxins from the bloodstream. There are around 1 million glomeruli in each kidney.

Kidney-related complications in people with HCV are well documented. According to a 2017 review , people who are HCV-positive are more likely to develop kidney disease and kidney failure. Their kidney disease may progress faster and their chances of survival may decrease.

People with hepatitis C who undergo kidney dialysis are at an increased risk of death from heart or liver failure. HCV also presents risks in kidney transplants. This is explored in further detail below.

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How Much Time A New Liver Might Give You

A successful organ transplant allows you to live longer than your diseased liver would have allowed. For how long and with what quality of life? These unknowns depend on many factors, including your age and overall health. Because each case is different, predictions are difficult.

Some have reported that liver recipients can live normally for over 30 years after their transplant. Generally, about 72 percent of people who receive livers from deceased donors live at least five more years. In the case of a living donor transplant, which often means a shorter wait, 78 percent of recipients live at least five more years, according to the Mayo Clinic.

One study showed that in recent decades, as medical science has introduced new drugs, survival rates have increased. The study found that as many as 48 percent lived 18 years with a new liver. Recurrence of hepatitis C did compromise life expectancy, but only after the five-year mark.

Liver Transplantation And Hepatitis C

Ohio State liver transplant program nationally ranked in ...

Yasuhiko Sugawara

1Department of Hepato-Biliary-Pancreatic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Tsujido-cho, Kamoda, Kawagoe, Saitama 350-8550, Japan

2Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan

Academic Editor:


1. Introduction

End-stage liver disease caused by chronic hepatitis C virus infection is the leading cause of liver transplantation in developed countries , including Japan . Unfortunately, liver transplantation does not cure HCV-infected recipients, but reinfection of HCV universally occurs and disease progression is accelerated compared with that in the nontransplant population, resulting in poor outcomes for HCV-infected recipients. Although several studies have investigated the factors affecting the natural history of recurrent HCV, many aspects remain unclear and require further investigation . For patients with progressive fibrosis, it is essential to monitor disease progression and the only strategy that is known to modify the outcome is antiviral therapy at an appropriate disease stage. In this paper, we address the issues that transplant physicians face in the management of patients with recurrent hepatitis C, review the results of antiviral treatments, and discuss on living donor liver transplantation for HCV cirrhosis.

2. Natural History of Hepatitis C after Liver Transplantation


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Factors Influencing Disease Severity And Disease Progression

The factors influencing the rate of disease progression are largely unknown, but may relate to the characteristics of the infecting viral strains, the genetically determined characteristics of the infected individual, or environmental and/or iatrogenic influences on the infected individualâfor example, immunosuppression or alcohol consumption.

Treatment Of Chronic Hcv Infection

The main reason to treat patients with chronic HCV infection, no matter how imperfect the treatment may be, is the fact that 20% of chronic hepatitis patients, will develop cirrhosis over 20-30 years and have to endure a 30% risk of decompensation and a 3-4% annual risk of HCC. Regarding treatment, there is an accepted terminology, which includes:

  • EVR : > 2-log decrease in HCV-RNA within 12 weeks of treatment

  • Improvement of organised multidisciplinary foot care throughout the country

  • ETVR : absence of HCV-RNA at completion of treatment, and

  • SVR : persistent absence of HCV-RNA 6 months after the completion of treatment

  • The guidelines for treatment of HCV infection in the non-transplant population are mainly aimed at patients with high risk of cirrhosis 15. The current guidelines include treatment with pegylated interferon at 180μg/week and Ribavirin at 1000 mg/day or 1200 mg/day . Complications of therapy include those attributed to a) IFN: depression, exacerbation of autoimmune diseases/transplant rejection, bone marrow suppression and flu-like syndrome, and b) Ribavirin: hemolytic anemia and teratogenicity making contraception mandatory during and 6 months after treatment

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    Hepatitis C And Liver Transplants

    Liver failure caused by hepatitis C is one of the most common conditions that require a liver transplant. A liver transplant helps the patient live a better life as compared to living with a diseased liver. Not getting a liver transplant in a timely manner can even lead to the death of the patient.

    But one thing to keep in mind is that in most people the virus exists in the bodies throughout their life. This can lead to reinfection in the transplanted liver as well. Reinfection after liver transplantation is universal and chronic liver disease develops in at least 70% of patients in 3 years. This infection usually occurs at an accelerated rate as compared to the original liver.

    Despite this occurrence of reinfection, patients undergoing liver transplants have significantly improved quality of life. According to some studies, the following are the survival rates of patients.

    • The survival rate for 1 year after liver transplant 84%
    • The survival rate 5 years after liver transplant 60%
    • The survival rate 10 years after liver transplant 56%

    Can I Donate A Kidney If I Have Hepatitis C

    Hepatitis-C and its Effects on Liver Transplantation

    In the past, having hepatitis made it impossible to donate a kidney. Now that HCV is curable, recommendations are changing.

    Whether you can donate will likely come down to your overall health, and the health of your kidney. If your HCV was left untreated for a long time, your kidneys might be damaged.

    Your healthcare team will conduct tests to determine if youre healthy enough to donate a kidney. If youre currently HCV-positive, your doctor might recommend treating the infection with DAAs prior to the transplant surgery to eradicate the virus.

    You should ask your doctor whether previously having HCV increases the risk of complications after donating your kidney.

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    Can I Receive A Kidney Transplant If I Have Hepatitis C

    Yes, its possible to receive a kidney transplant if you have hepatitis C. Being HCV-positive shouldnt affect your eligibility. With that said, not everyone who has HCV is a good candidate for transplantation and it can be difficult to procure a donor kidney.

    Your healthcare team will conduct extensive tests before recommending a transplant. If youre HCV-positive, theyll pay extra attention to your liver health. If you have complications, such as cirrhosis or liver cancer, you might not be healthy enough to undergo a kidney transplant.

    On the other hand, if your liver is compromised but youre otherwise healthy, your healthcare team might consider doing a liver transplant alongside your kidney transplant. This option can involve a longer wait, though, as it requires two donor organs.

    If youre recommended for a transplant, a friend or family member might be able to donate one of their kidneys to you. Otherwise, youll be placed on the Organ Procurement and Transplantation Network waiting list for a kidney from a recently deceased person.

    You might have to wait more than 5 years. If youre HCV-positive, you could potentially receive a transplant faster by accepting a kidney from an HCV-positive donor.

    new medical regimen for HCV revolutionized treatment.

    Direct-acting antivirals can now eradicate the virus in most people. This is known as a sustained virologic response , and it means that the virus is no longer detectable in your body after a certain amount of time.

    What Your Doctor Needs To Know

    Your hepatologist, infectious disease specialist, or gastroenterologist will determine if youre a candidate for a liver transplant. To choose liver recipients, doctors consider a persons current medical tests, health history, and support system. They want to be confident your immune system, heart, and lungs are strong, and that your postoperative care is in place. Your doctor and the transplant center team want your body to have the best chance of accepting the new organ.

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    Indication Of Liver Transplantation For Chronic And Acute Liver Failure Due To Autoimmune Hepatitis

    The majority of patients with AIH are presented with chronic disease . Its diagnostic criteria have been standardized and validated by the International Autoimmune Hepatitis Group and is widely used . On the other hand, although several useful prognostic models are proposed in other autoimmune liver diseases such as primary biliary cirrhosis and primary sclerosing cholangitis , there are no useful prognostic tools available in AIH. Thus, the indication for LT based on the prognosis of the native liver in the AIH setting should be evaluated similarly as other non-autoimmune liver diseases LT is usually indicated in patients with chronic decompensated liver disease with a Model for End-Stage Liver Disease score of 15 . Complications of hepatopulmonary syndrome, portopulmonary hypertension and hepatocellular carcinoma with or without an elevated Child-Pugh score can be other factors in consideration for the timing of LT and a MELD exceptional point .

    Ldlt As A Risk Factor For Recurrent Hepatitis C Studies Comparing Outcomes Of Ldlt And Ddlt

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    Based on the significant negative impact of recurrent hepatitis C on recipients’ outcome, it is critical to identify the factors related to severe recurrent hepatitis C . In the transplant setting, many factors contribute to disease progression compared with nontransplant patients , including, viral-related factors , donor age , recipient-related factors , graft and surgical factors , and immunosuppressive agents however, many aspects remain unclear and require further investigation . Among those, the possibility of increased severity of recurrent HCV in LDLT patients had been one of the hottest debates. The benefit of LDLT might be offset if the outcome of LDLT for HCV-positive recipients is worse than that of DDLT.

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