Hepatitis C virus in the transplant setting.

Hepatitis C virus (HCV)-associated end-stage liver disease is a leading diagnosis in patients undergoing liver transplantation, accounting for approximately 20-25% of transplantations in many centres. In spite of universal viral recurrence, early post-transplantation infection generally results in indolent disease with good graft and patient survival, at least for the first 5-7 years, comparable to those observed in other patients undergoing transplantation for non-viral end-stage liver disease. The full consequences of HCV recurrence are however beginning to be delineated with development of progressive liver failure observed with longer follow-up in a still unknown proportion of patients. Factors which may influence the outcome include viral load at transplantation and the type/amount of immunosuppression. Currently, the only available drugs are interferon and ribavirin, alone and in combination, used either therapeutically when the disease has fully developed, or prophylactically early after transplantation. Unfortunately, interferon has been used with limited success and with concerns about toxicity. Ribavirin monotherapy has been ineffective in producing meaningful results. Preliminary results on combination therapy are promising, both when administered before hepatitis develops or when histologic disease is present. Current antiviral therapy is however unable to eliminate HCV in the liver transplant setting, suggesting that indefinite treatment designed to suppress the effects of virus may be necessary. Major therapeutic advances for HCV infection are awaited.