Second Forum on Liver Transplantation Liver transplantation for hepatitis C: how to control the virus?

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This second Forum on Liver Transplantation will focus on hepatitis C, which is the current leading indication for transplantation in industrialized countries, with an increasing incidence of infection worldwide. The major issue with hepatitis C virus is its inevitable reappearance in the graft with rapid evolution to severe recurrent forms of liver diseases and cirrhosis in many patients. Therefore, several strategies have been proposed to overcome this negative pattern. Marina Berenguer presents in an excellent review the natural history of recurrent hepatitis C after liver transplantation. She provides compelling evidence that no single factor can predict which patients will ultimately progress to cirrhosis after transplantation from those with a benign course. The main risk factors include high viral load at the time of transplantation or early following surgery, the infection by HCV genotype 1b, the use of older donors, and immuno-suppression. She provides a useful survey of the various immunosuppressive agents related to their impact on recurrent hepatitis C after liver transplantation. Greg Everson addresses the question whether we should treat patients with chronic hepatitis C on the waiting list for liver transplantation. This question remains largely open, but is worth exploring further as pre-transplant therapies currently prevent a fourth of recurrent hepatitis C after surgery. However, these treatments are often poorly tolerated in this sick population of patients awaiting a graft. Isabelle Morard and Franco Negro look at the approach of treating patients after transplantation. The current data on preemptive therapy, i.e. treating patients early after transplantation prior to apparent recurrences, has been disappointing. The best approach rather seems to selectively treat recipients when histological evidence of progressive liver fibrosis or inflammation develops. Laura Llado, Jose Castellote and Juan Figueras address the difficult issue of re-transplanting patients with severe recurrent forms of Hepatitis C. They propose a very conservative approach, where redo transplantation should be limited to those with late recurrence, stable renal function, and who have not yet been treated fully with antiviral therapy. Finally, Yasuhiko Sugawara and Masatoshi Makuuchi provide an excellent discussion on the benefits vs. risks of living related liver transplantation for hepatitis C cirrhosis. They conclude that the earlier reported dramatically poorer outcomes using living donor grafts may be related to the learning curve and lack of effective antiviral therapies, and that recent data including their own series from Tokyo suggest comparable results in patients receiving a cadaveric and living donor grafts. They however emphasize the need to identify associated strategies such as preemptive therapies to minimize the risk of severe recurrent diseases.

With this Forum the readers will gather a comprehensive overview of our current knowledge and remaining questions on hepatitis C related to liver transplantation, and the challenges ahead, particularly considering the increasing number of long term patients transplanted for hepatitis C related liver diseases.

From now on we will also publish at the end of each Forum letters related to the previous Forum to serve as a platform to discuss controversial issues. Here we propose two letters related to the article by R. Freeman on the MELD system currently used for organ allocation in the US.