Recurrent hepatitis C genotype 1b following liver transplantation: treatment with combination interferon-ribavirin therapy

Liver transplantation in the setting of chronic HCV

Recurrent HCV disease is the most common cause of graft loss and patient mortality in HCV-infected liver transplant (LT) recipients. Risk factors for more severe recurrence that are potentially modifiable are older donor age, prolonged cold ischaemia time, prior treated acute rejection, CMV hepatitis, IL28B donor genotype, and post-LT insulin resistance. The most effective means of preventing HCV recurrence is eradicating HCV prior to LT. Select wait-list candidates with compensated or mildly decompensated disease can be considered for antiviral treatment with peginterferon, ribavirin (and protease inhibitor if genotype 1). For the majority of LT patients, HCV treatment must be delayed until post-transplant. Treatment is generally undertaken if histologic severity reaches grade 3 or 4 necroinflammation or stage ≥2 fibrosis, or if cholestatic hepatitis. Achievement of sustained viral response (SVR) post-LT is associated with stabilization of fibrosis and improved graft survival. SVR is attained in ~30% of patients treated with peginterferon and ribavirin. Poor tolerability of therapy is a limitation. Combination therapy with telaprevir or boceprevir added to peginterferon and ribavirin is anticipated to increase efficacy but with higher rates of adverse effects and challenges in managing drug-drug interactions between the protease inhibitors and calcineurin inhibitors/sirolimus.

Randomised clinical trial: pre-dosing with taribavirin before starting pegylated interferon vs. standard combination regimen in treatment-naïve patients with chronic hepatitis C genotype 1

BACKGROUND

Combination therapy with the ribavirin (RBV) prodrug taribavirin (TBV) and pegylated interferon (PIFN) has produced lower rates of anaemia than with RBV and PIFN. Studies have demonstrated that the sharpest decline in viral load during TBV therapy occurs at Weeks 4 through 6, when TBV reaches steady-state blood levels.

AIM

The current proof-of-concept study was conducted to examine whether first-order viral kinetics could be influenced by pre-dosing TBV to steady state before introducing PIFN.

METHODS

Therapy-naïve patients with chronic hepatitis C virus (HCV) genotype 1 (G1) were randomised to receive (i) TBV 600 mg BID monotherapy for 4 weeks followed by combination therapy with PIFN [pre-dosing arm (n = 23)] or (ii) TBV administered concurrently with PIFN [standard dosing arm (n = 19)].

RESULTS

More patients achieved undetectable virus or a ≥2-log(10) reduction of HCV RNA at Week 4 in the pre-dosing vs. the standard dosing arm [33% vs. 22% (P = 0.497)]. There was also a trend towards greater reduction in mean log(10) change in HCV RNA in the pre-dosing vs. the standard dosing arm, which was statistically significant at Day 1 [-0.34 ± 0.46 vs. 0.09 ± 0.32 (P < 0.003)] but not at other time points up to Week 24. No significant difference was observed in the rates of anaemia (haemoglobin <10 g/dL) between study arms (4.5% vs. 5.3%).

CONCLUSIONS

Pre-dosing TBV prior to starting PIFN produces a trend towards improved efficacy although statistical significance was not reached in this small patient population. These results warrant larger clinical trials of TBV pre-dosing.

Cyclosporine inhibits profibrotic effects of interleukin-4 and transforming growth factor β on human intrahepatic fibroblasts cultured in vitro

BACKGROUND

Hepatic fibrosis, an outcome of chronic liver diseases, is characterized by an accumulation of collagen, which is produced by activated human intrahepatic fibroblasts (HIF). Transforming growth factor (TGF) β is an important inducer of fibrogenesis, in collaboration with other cytokines, such as interleukin (IL) 4. IL-4 is overexpressed in severe recurrent hepatitis C after liver transplantation, exerting profibrotic effects. In contrast, cyclosporine (CsA) had been shown to decrease fibroblast activation and collagen production. We therefore investigated the effects of CsA on TGF-β and IL-4 profibrotic activities on HIF in vitro.

METHODS

Isolated HIF were cultured without or with human TGF-β, human IL-4, CsA, or combined TGF- β+CsA or IL-4+CsA. We performed real-time polymerase chain reaction for collagen types I, III, and IV and alpha-SMA, a marker of fibroblast activation we also measured total collagen in supernates. TGF-β and IL-4 increased the expressions of alpha smooth muscle action (SMA) collagen I, III, and IV mRNAs (P < .05 vs untreated cells) as well as the overall collagen level in the supernates (P < .01). CsA decreased the expression of mRNAs encoding alpha-SMA and collagens (P < .01). Expressions of alpha-SMA and collagens I, III, and IV mRNAs were significantly lower under combined treatments (TGF-β vs TGF-β+CsA [P < .01] and IL-4 vs IL-4+CsA [P < .01]). Collagen level was decreased by combined treatments (TGF-β vs TGF-β+CsA [P < .05] and IL-4 vs IL-4+CsA [P = .05]).

CONCLUSION

CsA inhibited the profibrotic effects of TGF-β and IL-4 by decreasing the activation and production of collagen by HIF. CsA may decrease fibroblast activation and collagen accumulation, exerting beneficial effects on fibrosis progression, particularly among patients with recurrent hepatitis C.

Antiviral treatment for hepatitis C virus infection after liver transplantation

A significant proportion of patients with chronic hepatitis C virus (HCV) infection develop liver cirrhosis and complications of end-stage liver disease over two to three decades and require liver transplantation, however, reinfection is common and leads to further adverse events under immunosuppression. Pretransplant antiviral or preemptive therapy is limited to mildly decompensated patients due to poor tolerance. The mainstay of management represents directed antiviral therapy after evidence of recurrence of chronic hepatitis C. Combined pegylated interferon and ribavirin therapy is the current standard treatment with sustained viral response rates of 25% to 45%. The rate is lower than that in the immunocompetent population, partly due to the high prevalence of intolerability. To date, there is no general consensus regarding the antiviral treatment modality, timing, or dosing for HCV in patients with advanced liver disease and after liver transplantation. New anti-HCV drugs to delay disease progression or to enhance viral clearance are necessary.

Current status of organ transplantation in Japan and worldwide

Recent advances in immunosuppressant therapy have dramatically reduced the frequency of acute rejection of organ transplants. Subsequently, the short-term graft survival rate has been improved, and ABO blood type-incompatible and existing anti-HLA antibody-positive kidney transplantation has been enabled, which has increased the availability of living kidney donors. Japan has a unique history and strategies of liver transplantation (LT) for various liver diseases. The outcomes of living donor liver transplantation (LDLT) in Japan is comparable to that of deceased donor liver transplantation (DDLT) in Western countries despite the relatively short history of LT. The main disadvantage of LT in Japan is donor shortage mainly due to the small number of available deceased donors. There are some disadvantages with LDLT in autoimmune liver diseases because of the dependence on blood relative donors. The first brain-dead pancreas transplantation (PTx) was performed in 2000. Since that time, 42 brain-dead PTx, 2 non-heart beating PTx, and 14 living donor PTx had been performed by the end of 2007. One of the 44 recipients of deceased donor PTx died of unknown causes 11 months after transplantation. Although most of the deceased donors in Japan were marginal and their condition was not favorable, the results of these cases were comparable to those of Western countries. Fourteen intestinal transplantations (ITx) had been performed by the end of 2007 in four transplant centers. There were 3 deceased donor and 11 live donor transplants. The original diseases included short bowel syndrome (n = 6), intestinal function disorder (n = 6), and retransplantation (n = 2). The graft and patient survival rate are 60% and 69%, respectively. Eight recipients survived and stopped parenteral nutrition with full-functioning grafts. Amendment of the Japanese law for the utilization of deceased donors should increase the number available donors in the future.

Management of hepatitis C virus in the transplant patient

Hepatitis C virus (HCV) is a leading cause of chronic hepatitis, with 170 to 190 million people infected worldwide. The treatment of choice for patients who have HCV-related cirrhosis with or without hepatocellular carcinoma is liver transplantation. Virologic recurrence is constant after transplantation and results in chronic hepatitis in the vast majority. HCV infection now can be cured in a substantial proportion of liver transplant recipients. This review highlights the available strategies to improve outcome, including modification of factors that affect disease progression and the efficacy of antiviral therapy.

Treatment of hepatitis C virus infection

Acute and chronic hepatitis C virus (HCV) infection remains a serious health problem worldwide, however, there has been advancement in the treatment of HCV infection due to standard treatment using pegylated interferon and ribavirin. The literature indicates that therapy for HCV is becoming more individualized. In addition to considering genotype and viral RNA levels before treatment, achievement of an early virologic response (EVR) and a rapid virologic response (RVR) is now possible during therapy. Moreover, problem patients, such as non-responders, relapsers, HIV or HBV co-infected patients, patients with liver cirrhosis, and pre- or post-liver transplantation patients are an increasing fraction of the patients requiring treatment. This article reviews the literature regarding standard treatments and problem patients with acute and chronic HCV infection. It also includes discussion on contraindications and side effects of treatment with interferon and ribavirin, as well as new drug development.

Therapeutic management of recurrent hepatitis C after liver transplantation

Recurrent hepatitis C ranges from minimal damage to cirrhosis developing in a few months or years in a substantial proportion of transplant recipients. Different virus, host and donor factors are involved in the pathogenesis of recurrence, but many are poorly understood. Therapeutic strategies can be utilized in the pre-, peri- or posttransplantation setting. Antiviral therapy using interferon and ribavirin and modifying immunosuppression are the main strategies to prevent progression disease. The efficacy of interferon and ribavirin is limited and side effects, reduction/withdrawal are frequent. Current sustained virological response rates are approximately 28%. An optimal immunosuppression regimen has not been established. The choice of calcineurin inhibitors has not clearly been shown to affect histological hepatitis C virus (HCV) but higher cumulative exposure to corticosteroids to treat acute rejection is associated with more severe recurrence. The manner in which the doses of immunosuppression are modified has more influence on HCV recurrence than the use of a specific drug per se. Debate about the influence of immunosuppressive regimens on HCV recurrence is ongoing. Potential antifibrotic therapy and new agents targeting HCV infection and replication are emerging and are anticipated to be added to our armentarium in battling recurrent HCV post-LT.

Rejection under alpha interferon therapy in liver transplant recipients

Interferon alpha (IFN) is the corner stone drug for the treatment of recurrent hepatitis C (HCV) in liver transplant (LT) recipients. One of its serious potential adverse effects is acute and chronic rejection. The aim of this study was to review our experience using IFN-based therapy, in order to examine the incidence and the risk factors for rejection, and the outcome of patients who developed rejection. Between September 1990 and December 2004, 70 LT recipients were treated. Patients started antiviral treatment 16 (1-137) months after LT. Histological follow-up was available in all patients according to protocol biopsies. Rejection was diagnosed and graded according to Banff classification. Twenty-one percent of patients developed acute rejection (5 mild, 9 moderate and 1 severe) during IFN-based therapy. Patients were treated for 8 (1-15) months prior to rejection. Previous history of acute rejection before IFN therapy and treatment with pegylated-IFN was significantly associated with rejection (p = 0.04 and p = 0.02, respectively). The rejection was successfully treated in 87% of patients. No chronic rejection or graft losses were observed. Acute rejection under IFN-based therapy often occurs in LT recipients, but early diagnosis with protocol biopsies and early treatment can lead to a favorable outcome.

Antiviral therapy for hepatitis C in the setting of liver transplantation

Hepatitis C viremia after liver transplantation for hepatitis C virus (HCV) liver disease is universal. Progressive HCV disease after transplantation is the leading cause of death, graft failure, and retransplantation. Whether to treat, with which agents, and timing of therapy are unanswered questions. Timing options include pretransplantation, prophylactic, post-transplantation preemptive, and post-transplantation recurrence-based therapy. The latter is most commonly utilized. There are little data for each of these, much less comparisons. Pegylated interferon-alpha has supplanted standard interferon-alpha due to increased efficacy and is generally used in combination with ribavirin (RBV). Efficacy is less than in nontransplant settings due to immunosuppression, an increased prevalence of genotype 1 HCV, patient comorbidities, and decreased functional status. Administration of HCV therapy to cirrhotic patients prior to transplantation may eradicate or suppress HCV and prevent or reduce severity of recurrence. Sustained virological response (SVR) as high as 50% was attained in genotypes 2 or 3 HCV. Comparison of preemptive and histology-based post-transplantation HCV therapy should be done, and more data will be available on pretransplantation therapy. Post-transplant patients are less tolerant of therapy, particularly RBV. SVR, the primary goal of therapy, likely halts disease progression, but only 20% to 30% of treated patients achieve SVR. Preemptive therapy early after transplantation may have advantages due to the potential to delay or blunt severity of graft infection and recurrent hepatitis. In post-transplant therapy, RBV toxicity is attenuated in relation to decreased renal function, and side effects of interferon are more prominent. An ongoing trial will assess preemptive therapy with treatment after histologic recurrence. Novel anti-HCV therapies such as protease and polymerase inhibitors are emerging. These must be tested with urgency in the transplant setting. Retransplantation for progressive HCV disease is more controversial due to poor outcomes, graft shortage, and disease recurrence.

Hépatite C et transplantation hépatique

Hepatitis C virus-related end-stage liver disease, alone or in combination with alcohol, has become the leading indication for liver transplantation in most transplant programs accounting for approximately half of transplants performed in European centers. Hepatitis C virus infection recurs virtually in every post-transplant patient. The natural history of hepatitis C after liver transplantation is variable. Progression of chronic hepatitis C virus is more aggressive after liver transplantation with a cumulative probability of developing graft cirrhosis estimated to reach 30% at 5 years. Approximately 10% of the patients with recurrent disease will die or require re-transplantation within 5 years post-transplantation. Several factors, including those related to the virus, the host, the environment and the donor, are probably implicated in the outcome. The immune status represents the main significant variable in influencing disease severity in hepatitis C virus-infected patients; with higher HCV viral load and the significant association described between the degree of immunosuppression and disease severity. Interventions to prevent, improve, or halt the recurrence of hepatitis C virus infection have been evaluated by multiple small studies worldwide with similar overall rates of virological clearance of approximately 9-30%. Current consensus recommends combination therapy with pegylated interferon and ribavirin for those patients with histological recurrence of hepatitis C virus infection and fibrosis. Therapy is adjusted to tolerance and rescued with granulocyte colony-stimulating factor and erythropoietin for bone marrow suppression. In this article we present a comprehensive review of post-transplant hepatitis C virus infection; in particular fibrosis progression and the major challenges according to treatment.

[Management of hepatitis C virus infection in liver transplantation]

Because of graft reinfection and recurrence of the primary disease in the graft, patients who undergo transplantation due to cirrhosis caused by chronic hepatitis C virus (HCV) infection have a poorer long-term prognosis than non-HCV-infected transplant recipients. Apart from antiviral therapy, which can occasionally eradicate HCV infection before transplantation, there are no effective measures to prevent graft reinfection. Pre-transplantation antiviral therapy, however, is of limited applicability with currently available drugs. After liver transplantation, 2 options can be used to prevent graft loss due to HCV progression: early treatment in the first 4-6 weeks when there is still no evidence of histological injury and treatment of established HCV infection. Early antiviral therapy is limited not only by its scarce applicability but also by poor tolerability and limited effectiveness (sustained virological response in approximately 20-30% of patients). Treatment of established HCV infection, especially in patients with evidence of disease progression in biopsy, is the most cost-effective alternative with an efficacy of around 35-45% when pegylated interferon combined with ribavirin is used. Adverse effects, such as cytopenia and even induction of rejection, are the main limitation and lead to premature withdrawal in 30% of patients.

Interferon-based combination anti-viral therapy for hepatitis C virus after liver transplantation: a review and quantitative analysis

Recurrence of hepatitis C virus (HCV) infection after liver transplantation (LT) is universal. However, the efficacy, tolerability and safety of combination interferon and ribavirin (IFN-RIB) or peginterferon and ribavirin (PEG-RIB) anti-viral therapies post-LT are uncertain. We performed a comprehensive search of major medical databases (1980-2005) and conference proceedings (1996-2005). The main outcome measure was sustained virological response (SVR, undetectable HCV RNA) at 6 months. Summary estimates were calculated using random-effects models. Twenty-seven IFN-RIB and 21 PEG-RIB studies were included. IFN-RIB was associated with a pooled SVR rate of 24% (95% CI, 20-27%), while PEG-RIB was associated with an SVR rate of 27% (23-31%). Pooled discontinuation rates were 24% (21-27%) with IFN-RIB and 26% (20-32%) with PEG-RIB. The pooled rate of acute graft rejection was 2% (1-3%) with IFN-RIB and 5% (3-7%) with PEG-RIB. IFN-RIB and PEG-RIB therapies in HCV infection post-LT were associated with similar but overall low SVR and were poorly tolerated. The rate of acute rejection was small. The therapeutic advantage of PEG-RIB therapy observed in non-transplant chronic HCV infection appears to be attenuated post-LT. Clinical trials are needed to evaluate reasons for this post-transplant therapeutic disadvantage and to find strategies to ameliorate them.

Efficacy, predictors of response, and potential risks associated with antiviral therapy in liver transplant recipients with recurrent hepatitis C

There are unresolved issues regarding sustained virological response (SVR), tolerance and risk of rejection following antiviral therapy in liver transplantation (LT). The aim of our study was to determine efficacy, rejection risk and factors associated with SVR. HCV-infected LT patients with at least 6 months of follow-up following end-of-therapy (EOT) received combination therapy of ribavirin (Rbvr) + standard (n = 31)/pegIFN (n = 36) between 1999 and 2004 (95% genotype 1). An EOT and SVR was obtained in 46% and 33%, respectively. Type of antiviral therapy, use of erythropoietin, compliance, and early virologic response (EVR) were predictive of SVR, but only the latter remained in the multivariate analysis. Premature discontinuation, not impacted by the use of erythropoietin or GCSF, occurred in 40% patients. None of the variables predicted rejection (acute n = 2, chronic n = 4). A SVR occurred in 3/4 patients with chronic rejection. In conclusion, the efficacy of pegIFN-Rbvr is similar to the non-transplant population. An EVR at 3 months is useful to predict lack of response. The type of calcineurin inhibitor and history of prior non-response to IFN before LT do not influence the outcome of therapy. Severe rejection may lead to graft loss, a complication difficult to predict.

Pegylated interferon alpha-2b for patients with HCV recurrence and graft fibrosis following liver transplantation

Chronic hepatitis C is a principal indication for liver transplantation. Recurrent viral infection is inevitable and graft disease is common. We report tolerability, safety and efficacy of pegylated interferon alpha 2b (PEG-IFN) monotherapy for patients with hepatitis C virus (HCV) recurrence and fibrosis after liver transplantation. Repeated measurements of serum HCV titer permitted assessment of the kinetics of the antiviral response for all patients. We screened 63 patients transplanted for HCV at our center for antiviral treatment, 14 were eligible and treated, but only 6 completed the proposed 52 weeks of therapy. Eight were withdrawn because of severe/life-threatening side effects/events, including liver dysfunction (4 patients). None of those 8 achieved a sustained virological response (SVR). Five of 6 who completed treatment were HCV RNA negative at the end of treatment, and 2 achieved an SVR. Viral kinetics were similar to published observations for treatment of non-transplanted HCV patients. Patients with genotype non-1 infection displayed a more rapid decline of viral titer than was observed for genotype 1 infection. Post-transplant HCV patients are frequently unsuitable for, or intolerant of PEG-IFN. Liver dysfunction was a major concern.

Management of hepatitis C in liver transplant recipients

Recurrent hepatitis C virus (HCV) disease is the leading cause of graft loss in liver transplant recipients with pre-transplant HCV infection. While natural history is variable, median time to recurrent cirrhosis is less than a decade. Factors contributing to risk of recurrence and rate of fibrosis progression are only partially known. Older donor age, treatment of acute rejection, cytomegalovirus infection and high pre-transplant viral load are most consistently linked with worse outcomes. Whether these factors can be modified to positively impact on HCV disease progression is unknown. The main therapeutic approach for patients with recurrent HCV disease has been the treatment with interferon and ribavirin (RBV) once recurrent disease is documented or progressive. Efficacy is lower than in nontransplant patients and tolerability, especially of RBV, is a major limitation. Stable or improved fibrosis scores are seen in the majority of sustained responders. Optimal dose, duration and timing of treatment have not been determined. Alternative strategies under study include pre-transplant treatment of decompensated cirrhotics, preemptive antiviral therapy started within weeks of transplantation and prophylactic therapy using HCV antibodies. Ongoing studies may establish a future role for alternative treatment approaches. Additionally, limited overall efficacy of interferon-based therapy in the transplant setting highlights the urgent need for new drug therapies.

Treatment of hepatitis C after liver transplantation

This article summarizes the current therapies, with particular emphasis on antiviral therapy. Because these alternatives have substantial limitations, pretransplant or early post-transplant recognition of patients with high risk of severe post-transplantation outcome is desirable to target these patients for intervention. Alternatively, the implementation of measures aimed at reducing or avoiding factors known to be associated with an aggressive recurrence is an additional strategy that needs to be explored.

Treatment of Hepatitis C Virus Reinfection after Liver Transplantation

Most liver transplant recipients become reinfected with hepatitis C virus after OLT followed by allograft dysfunction, transplant cirrhosis and graft failure in a significant proportion of patients. Both in the pre-emptive prophylactic setting and in the treatment setting sustained virological response rates are poor compared to the precirrhotic hepatitis state. Patients with significant hepatitis should be always treated before developing cirrhosis or even with early cirrhosis. After transplantation pegylated interferon in combination with ribavirin is the most successful treatment opportunity to date, however the best time point and treatment duration as well as doses for pegylated interferons and rebavirin have to be defined.