Clinician-to-Clinician Update Clinician-to-Clinician Update

New Therapies for Recurrent Hepatitis C after Liver Transplant

February 2016

LimThompson LiverTransplantMed
— M Health liver transplant medicine specialists Nicolas Lim, MD, and Julie Thompson, MD, review patient data.

Between 2.7 and 3.9 million people in the United States have chronic hepatitis C virus (HCV) infections.1 Liver diseases precipitated by HCV, including cirrhosis and hepatocellular carcinoma, are the most common indications for liver transplantation.2 Unfortunately, histological recurrence of the disease appears in 80% of these patients within 5 years after liver transplantation. This manifests most often as severe chronic HCV infection, but in some cases can appear as an aggressive cholestatic hepatitis (see Case Study).3 Recurring HCV infection after transplantation is responsible for about 30% to 40% of liver retransplantations.4

Historically, post-transplant patients with recurring HCV infections were treated with interferon-based regimens, a treatment that produced a sustained virologic response in only a third of patients.5 Beginning in 2013, a new class of antiviral medications called direct-acting antivirals (DAAs) came on the market. DAAs inhibit specific stages of the HCV replication cycle and have proved to be highly effective. Current third-generation DAAs produce a sustained virologic response in nearly 100% of patients with chronic HCV infection, even among those who have been previously treated.6

Given these positive results, researchers have examined the use of DAAs for patients experiencing a recurrence of HCV infection post-transplant. Reported outcomes in this difficult-to-treat population have been equally encouraging. In the CORAL-I trial of ritonavir-boosted paritaprevir, ombitasvir, dasabuvir, and ribavirin, 97% of patients achieved a sustained virologic response after 24 weeks of therapy.7 In the SOLAR-I trial of ledipasvir, sofosbuvir, and ribavirin, the sustained virologic response rate after 24 weeks of treatment was a reported 98% for noncirrhotic patients and 96% for those with compensated cirrhosis.8

175913-M-Health-SOT-Liver-CONSULT-Table-1
175913-M-Health-SOT-Liver-CONSULT-Table-2

Viral hepatitis is a research focus for physicians practicing at the Liver Clinic at University of Minnesota Medical Center. These clinic providers have extensive expertise in HCV treatments, including best practice in use of DAAs for patients with recurrent disease (Tables 1 and 2). The clinic, working in conjunction with the medical center’s nationally renowned Transplant Services, also provides evaluation for liver transplant. In addition, eligible patients at the clinic have access to the latest clinical trials.

References

1. Centers for Disease Control and Prevention. Viral Hepatitis – Statistics & Surveillance. Available at http://www.cdc.gov/hepatitis/statistics/.

2. Merion RM. Current status and future of liver transplantation. Semin Liver Dis. 2010;30:411-421.

3. Gane EJ. The natural history of recurrent hepatitis C and what influences this. Liver Transpl. 2008;14 Suppl 2:S36-S44.

4. Yoo PS, et al. Retransplantation of the liver: review of current literature for decision making and technical considerations. Transplant Proc. 2013;45:854-859.

5. Guillouche P, Féray C. Systematic review: anti-viral therapy of recurrent hepatitis C after liver transplantation. Aliment Pharmacol Ther. 2011;33:163-174.

6. Fung J. Era of direct acting antivirals in chronic hepatitis C: Who will benefit? World J Hepatol. 2015;7:2543-2450.

7. Kwo PY, et al. An interferon-free antiviral regimen for HCV after liver transplantation. N Engl J Med. 2014;371:2375-2382.

8. Charlton M, et al. Ledipasvir and sofosbuvir plus ribavirin for treatment of HCV infection in patients with advanced liver disease. Gastroenterology. 2015;149:649-659.

9. Adapted from AASLD/IDSA/IAS–USA. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org. Accessed November 28, 2015.

When To Refer

The Liver Clinic at University of Minnesota Medical Center provides comprehensive, coordinated care for the diagnosis and treatment of all liver diseases, including evaluation for liver transplant. Some of the conditions we treat are:

  • Ascites
  • Biliary and liver anomalies
  • Budd-Chiari syndrome
  • Cirrhosis
  • Esophageal varices
  • Hepatitis (viral and alcoholic)
  • Jaundice
  • Porphyria
  • Portal hypertension
  • Portal vein thrombosis

Patients with urgent medical or surgical needs are given priority. Appointments for nonurgent problems are scheduled several days to several weeks in advance.

Multidisciplinary, Collaborative Care

Our multidisciplinary team provides diagnostic to follow-up care for patients with all types of liver disease. We are a national leader in liver transplants. In the event of a transplant, our physicians work closely with surgeons and staff across specialties to ensure seamless coordination and the highest level of care. Our providers have expertise in leading-edge treatments for patients with hepatitis C infection. For patients with cirrhosis and their families, our Prevention in Liver Disease Program provides individualized education and care plans.

We consider the referring provider to be a vital part of the care team, and we are committed to timely communication and collaboration with you to ensure optimal outcomes for your patients.

Related Articles

February 2016

Liver Care Specialty Updates

Clinical trials on hepatitis C treatments open. Access the trial information and learn about the new specialists joining the Liver Clinic team.

Continue reading

February 2016

Severe, Recurrent Hepatitis C Virus Infection Successfully Treated

A 54-year-old man with very severe HCV infection recurring 9 months post-liver transplant was successfully treated in a clinical trial of a direct-acting antiviral combination therapy.

Continue reading