Treatment strategy for hepatitis C after liver transplantation

A significant proportion of patients with chronic hepatitis C virus (HCV) infection develop liver cirrhosis and complications of end‐stage liver disease over periods of two to three decades and require liver transplantation, although re‐infection is common and leads to further adverse events, given that such patients receive life‐long immunosuppression. Because of the critical organ shortage worldwide, living‐donor liver transplantation has an important role in many countries, especially in the Far East. Despite previous arguments, the results of recent well‐designed studies suggest equivalent outcomes for deceased‐donor and living‐donor liver transplantation. No specific immunosuppression regimen has proven advantageous, but the general rule is “low and slow”. Combined pegylated interferon and ribavirin therapy is the current standard treatment, but compared to this therapy in the immunocompetent population, its efficacy in clearing the virus remains low. Moreover, its general application is hindered by the high prevalence of intolerability, lowering its efficacy from the aspect of intention to treat. Retransplantation becomes an option when treatment for disease progression fails, but it should be considered at an earlier stage in patients with a lower MELD (model for end‐stage liver disease) score compared to that used for primary transplantation, which is a great challenge with the current critical organ shortage. The need for new anti‐HCV drugs to further delay disease progression or even to enhance viral clearance, presumably specific HCV life‐cycle inhibitors, is urgent. The liver transplant community must maintain an open mind regarding the development of these drugs and focus on their availability for early clinical trials in liver transplant recipients.