How can we identify better those with recurrent hepatitis C who will respond to therapy? What are the optimal treatment regimen and treatment duration?

Key points 1. Treatment responses are lower in immune compromised patients such as those with hepatitis C virus (HCV) disease following liver transplantation than in immune competent patients with HCV disease. 2. Predictors of nonresponse, extrapolated from studies of immune competent patients, are overly represented in liver transplantation patients (high levels of HCV RNA and genotype 1 infection). 3. Tolerability of peginterferon plus ribavirin therapy is lower in transplant patients than in immune competent patients with HCV disease, in part because of a baseline renal insufficiency that increases the likelihood of ribavirin‐associated anemia. 4. Clear recommendations regarding optimal treatment regimens for patients with posttransplantation HCV disease are problematic since there are few prospective, randomized, controlled trials that evaluated different treatment regimens. 5. If treatment is undertaken, baseline creatinine clearance should be measured and patients should be started on a dose of ribavirin of 400mg bid, or lower if renal function is impaired. 6. Tolerated peginterferon doses may be somewhat lower than for the standard immune competent patients. It is likely that lower doses will not greatly compromise response (1.0 ug/kg/week for peginterferon alfa 2b and 135 ug/week for peginterferon alfa 2a). 7. Optimal treatment duration is unknown. In patients with an on‐treatment response, at least 12 months of therapy is recommended. 8. More potent drugs with fewer toxicities are needed for patients with progressive posttransplantation liver disease.