ABSTRACT
BACKGROUND: Clearance of hepatitis C virus (HCV) under antiviral therapy, including direct-acting antivirals (DAAs), has been associated with higher risk of rejection. Whether patients who are not on immunosuppression (IS) during DAA therapy are at higher risk of rejection is unknown. METHODS: Four transplant recipients who were off IS and treated with DAA therapy were identified. RESULTS: All patients were genotype 1 infection and treated for 12 weeks with sofosbuvir/ledipasvir/ribavirin. At the time of DAA therapy, patients were off IS for a median of 9.5 years. Time from liver transplant (LT) to treatment was 12.9 years. Median baseline ALT was 70 IU/L, at follow-up week 12 was 18 IU/L. No signs of rejection were observed during DAA therapy or follow-up after the end of therapy. All 4 patients obtained sustained virological response. CONCLUSION: Direct-acting antivirals therapy in HCV patients off IS post-LT can be successfully undertaken without the need to restart IS.
Subject(s)
Antiviral Agents/therapeutic use , Graft Rejection/drug therapy , Hepacivirus/isolation & purification , Hepatitis C, Chronic/surgery , Liver Transplantation/adverse effects , Postoperative Complications/drug therapy , Aged , Drug Therapy, Combination , Female , Follow-Up Studies , Graft Rejection/etiology , Graft Rejection/pathology , Graft Survival , Humans , Immunosuppression Therapy , Male , Middle Aged , Postoperative Complications/etiology , Postoperative Complications/pathology , Retrospective Studies , Risk Factors , Survival Rate , Sustained Virologic Response , Transplant Recipients , Treatment OutcomeABSTRACT
The shortage of livers has led most transplant centers to use extended criteria donors. Hepatitis C virus (HCV) RNA-positive donor organs are typically not given to patients who have cleared HCV. A 64-year-old male with chronic hepatitis C, genotype 1b was listed for LT with hepatocellular carcinoma. While on the waiting list, the patient was treated with sofosbuvir, ledipasvir, and ribavirin and achieved an HCV RNA <15 IU/mL by week 10. At week 18 of a planned 24-week treatment course, the patient underwent deceased-donor LT and received an organ from an anti-HCV-positive donor. Treatment was stopped at LT. At week 3 post LT, HCV RNA was detectable and revealed a genotype 3 HCV infection, compatible with transplantation of an organ with established infection. With retreatment with sofosbuvir, daclatasvir, and ribavirin for 12 weeks, the patient achieved a sustained virologic response. This report highlights how antiviral therapies can be used to optimize the outcomes of HCV-infected transplant patients.
Subject(s)
Hepacivirus/genetics , Liver Transplantation , Liver/virology , RNA, Viral/drug effects , Antiviral Agents/therapeutic use , Benzimidazoles/therapeutic use , Carcinoma, Hepatocellular/drug therapy , Carcinoma, Hepatocellular/virology , Drug Therapy, Combination , Fluorenes/therapeutic use , Genotype , Hepacivirus/drug effects , Hepatitis C/drug therapy , Hepatitis C/virology , Hepatitis C, Chronic/drug therapy , Hepatitis C, Chronic/virology , Humans , Male , Middle Aged , Neoplasm Recurrence, Local/drug therapy , RNA, Viral/blood , Ribavirin/therapeutic use , Sofosbuvir/therapeutic use , Sustained Virologic Response , Tissue Donors , Transplant Recipients , Viral Load/drug effectsABSTRACT
Although steroid avoidance (SA) has been studied in deceased donor liver transplant, little is known about SA in living donor liver transplant (LDLT). We report the characteristics and outcomes, including the incidence of early acute rejection (AR) and complications of steroid use, in 2 cohorts of LDLT recipients. Methods: Routine steroid maintenance (SM) after LDLT was stopped in December 2017. Our single-center retrospective cohort study spans 2 eras. Two hundred forty-two adult recipients underwent LDLT with SM (January 2000-December 2017), and 83 adult recipients (December 2017-August 2021) underwent LDLT with SA. Early AR was defined as a biopsy showing pathologic characteristics within 6 mo after LDLT. Univariate and multivariate logistic regressions were performed to evaluate the effects of relevant recipient and donor characteristics on the incidence of early AR in our cohort. Results: Neither the difference in early AR rate between cohorts (SA 19/83 [22.9%] versus SM 41/242 [17%]; P = 0.46) nor a subset analysis of patients with autoimmune disease (SA 5/17 [29.4%] versus SM 19/58 [22.4%]; P = 0.71) reached statistical significance. Univariate and multivariate logistic regressions for early AR identified recipient age to be a statistically significant risk factor (P < 0.001). Of the patients without diabetes before LDLT, 3 of 56 (5.4%) on SA versus 26 of 200 (13%) on SM needed medications prescribed for glucose control at the time of discharge (P = 0.11). Patient survival was similar between SA and SM cohorts (SA 94% versus SM 91%, P = 0.34) 3 y after transplant. Conclusions: LDLT recipients treated with SA do not exhibit significantly higher rates of rejection or increased mortality than patients treated with SM. Notably, this result is similar for recipients with autoimmune disease.