Transplant for chronic hepatitis C - when and what to treat

Abstract

The management of chronic hepatitis C has been revolutionized within the last several years with the approval of direct acting antivirals (DAAs). In addition to the significantly higher rates of sustained virological response (SVR) that can be achieved with DAAs, the improvement in safety profile compared with IFN allows previously IFN-eligible patients to be considered for treatment. In the pretransplant setting for patients on the waiting list, these include patients who have decompensated cirrhosis whereby no antiviral treatment option was available previously. As the SVR in the post transplant setting is high with DAA treatment, the decision to commence therapy on the waiting list is based on whether antiviral therapy can improve the symptoms and liver function, and in selected cases even alleviate the need for transplantation altogether. The length of waiting time is also an important factor, such that those with high MELD scores may be more suitable for treatment after transplantation. Transplantation should not be delayed because of antiviral therapy. Therefore, an adequate treatment length should be anticipated before embarking on DAA therapy for waitlisted patients. After transplantation, all viremic patients should be considered for DAA therapy in a timely manner to prevent fibrosing cholestatic hepatitis and the development of significant fibrosis and cirrhosis.