Acute liver graft cellular rejection after interferon-free antiviral treatment for HCV infection. Is there a risk? A warning about three cases.

All patients transplanted for hepatitis C (HCV)- related cirrhosis will experience a recurrence of the viral disease on the liver graft with an accelerated course of the disease and a progression to advanced liver fibrosis in up to 50% of the patients at 5 years post-liver transplantation. HCV infection is a high risk for graft lost. We report here three cases of patients transplanted for hepatocellular carcinoma on HCV-related cirrhosis. All cases experienced an acute cellular rejection after the end of HCV therapy with direct acting antivirals (DAAs). We thus advocate for a close monitoring of tacrolimus and liver tests even a few months after the end of the treatment. Clinicians using DAAs after liver transplantation should be aware of the dynamics of tacrolimus levels during therapy and immunological changes that can occur even several weeks (or months) after the end of DAA treatment.