Clinical management of patients with recurrent viral hepatitis after liver transplantation

Abstract

Liver transplantation is indicated in end-stage chronic viral liver disease, but unless adequate prophylaxis is administered, the patient will in most cases develop recurrent hepatitis B (HBV) and C (HCV) virus infection. Today, patients receiving prophylaxis using nucleoside analogue drugs with or without specific immune globulin drugs in connection with orthotopic liver transplantation for HBV related cirrhosis, present low risk of relapse and high 5-10 year survival rates. Lamivudine was the first drug used in the prophylactic treatment, but this drug has increasingly been combined with or replaced by adefovir due to the low genetic barrier, which causes viral resistance. Most patients develop viral recurrence after orthotopic liver transplantation for HCV related cirrhosis, and in an elevated number of cases, cirrhosis and hepatic insufficiency set in after a few years. Prophylaxis before transplantation and pre-emptive treatment using interferon and ribavirin present numerous side effects resulting in reduction of doses and suspension of therapy, with consequently low sustained virological remission rates and risk of rejection.The treatment is better tolerated by patients with histologically confirmed chronic disease, but also in these patients virological remission rates are low. This pathology requires new therapeutic protocols and/or new drugs in order to obtain better compliance and better responses.

Keywords: Cirrhosis; Interferon; Transplantation.

Fig. 1

Parasaggital right side scan of a patient lying on the left side. The graft appears echographically homogeneous with hyperecogenous areas in the periportal and peribiliary tissues due to advanced fibrosis: Cholestatic fibrosing hepatitis in a patient with recurrent HCV infection after orthotopic liver transplantation. Fig. 1 Scansione obliqua sottocostale destra in paziente in decubito laterale sinistro Il fegato presenta accentuazione omogenea dell'ecostruttura e intensa iperecogenicità del tessuto periportale e peribiliare per intensa fibrosi: Epatite fibrosante colestatica in paziente con recidiva di epatite C dopo trapianto ortotopico di fegato.

Fig. 2

Parasaggital right side scan shows the presence of coarse, prolonged echos and inhomogeneous parenchyma: Coarse liver pattern in a patient with recurrent HCV infection 3 years after transplantation. Fig. 2 Scansione obliqua sottocostale destra Il parenchima epatico mostra la presenza di echi grossolani e allungati che rendono disomogeneo il parenchima. Coarse liver pattern in paziente in recidiva di epatite C a 3 anni dal trapianto.

Fig. 3

Longitudinal scan of the inferior vena cava. The shape of the liver is irregular impressing the venous ligaments and the lower margin of the liver (arrows), due to micro and macro nodules caused by recurrent HCV related cirrhosis 4 years after transplantation. Fig. 3 Scansione longitudinale passante per la vena cava inferiore. I contorni del fegato mostrano piccole irregolarità che improntano il legamento venoso e il margine inferiore del fegato (frecce), dovuto a micro e macronoduli secondari a cirrosi epatica HCV correlata per recidiva a distanza di 4 anni dal trapianto.