HCV recurrence after LT is almost universal and severity depends

HCV recurrence after LT is almost universal and severity depends on several host, viral, donor, and transplant factors. Graft and patient survival are significantly reduced after LT in HCV-positive recipients.[1-4]

A subset of patients (2%) may develop CDK phosphorylation post-LT cholestatic hepatitis C, which is characterized by persistent cholestasis of at least 4 weeks in duration, high HCV RNA levels, hepatocyte ballooning, rapid progression to graft failure, and, in the absence of biliary and hepatic artery complications, sepsis and drug-related cholestasis.[5] The overall outcome of antiviral therapy in this group of patients is suboptimal, although it can be successfully pursued in select patients. The unique challenges of HCV treatment in this population include management of AEs, adjusting immunosuppressive regimens because of

DDIs in those on direct-acting antivirals (DAAs), and monitoring for graft rejection. Although selection criteria for treatment of chronic HCV in LT patients is variable, antiviral therapy is generally considered in those who develop significant or progressive recurrent HCV disease, as defined by moderate-to-severe necroinflammatory activity (grade 3-4) and/or significant fibrosis (stage 2-4) on histologic evaluation.[6] Treatment of recurrent HCV in LT recipients, particularly with successful viral eradication, is associated with increased graft and patient survival.[7] In various experiences published, the majority of patients included this website were genotype 1, had a reduced dose of RBV (400-800 mg/day) and/or PEG-IFN, and had use of ESAs. The pooled estimate of sustained viral response (SVR) from prospective

studies was 24%-40%, and virologic relapse was 21%-43%. Biochemical and histological responses were observed in approximately 50% of treated patients.[8, 9] Two thirds of SDHB patients required dose reductions of either PEG-IFN or RBV and one fourth discontinued treatment early.[2] The approval of two protease inhibitors, telaprevir and boceprevir, has ushered in a new era of HCV treatment. In those with chronic HCV, one of these have been used in combination with PEG-IFN and RBV, and the regimens have enhanced response rates and shortened duration of therapy, whereas they have added to the side-effect profile.[10] Cost of treatment for boceprevir triple therapy is variable, and in instances of treatment duration similar to this case, the expense of therapy is approximately $71,000.[11] However, there are other expenses of close monitoring and frequently following immunosuppression drug levels, which then increase the cost relative to a patient who has not had LT. An incremental rate and degree of anemia has been observed with both TT regimens, which does present a challenge in the transplant recipients who are prone to anemia.

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