Page 81 - The Flying Publisher Guide to Hepatitis C Treatment

Management of recurrent HCV infection following liver transplantation | 81

more severe HCV recurrence, although overall graft survival was
not influenced (Langrehr 2006).
Donor factors. Evidence suggests the following donor factors
to be associated with negative outcome in HCV-infected LT
recipients: donor age, donor fat content (>30%) and ischemic
time. Older donor age (≥50 years) was an independent predictor
for HCV related cirrhosis after 5 years and reduced graft survival
in several studies (Iacob 2007, Samonakis 2005). Prolonged warm
ischemia time (begins as the liver is secured in place and extends
until reperfusion with recipient blood starts) represents a higher
risk for a severe histological recurrence; this risk increases by
13% for each hour increase of cold ischemia time (time elapsed
between removal and cooling of the donor liver and extends
until the donor liver is rewarmed during implantation). Recent
studies have demonstrated that living-related LT is not a risk
factor for severe HCV recurrence. The HCV histological
recurrence rate was 58% after 4 months, 90% at 1 year and 100%
after 2 years in patients transplanted with a living donor
compared to 71% at 4 months, 94% at 1 year and 95%,
respectively, after 2 years in deceased donor LT (Guo 2006).
Clinical factors. A number of potentially modifiable post-
transplant factors have also been associated with increased
severity of HCV recurrence and poorer patient and graft survival
such as immunosuppression, acute rejection episodes treated
with bolus corticosteroids or T-lymphocyte depleting agents,
cytomegalovirus or herpes simplex 6 virus infection, metabolic
syndrome or insulin resistance.
Much emphasis has been placed on the different
immunosuppressive regimens and their changes during the
last 20 years. CHC is more aggressive in LT recipients than in
immuno-competent patients. However, a sudden change in the
degree of immunosuppression, rather than the absolute amount
of immunosuppression, is deleterious for HCV-infected
recipients.
Regarding the calcineurin inhibitors (CNI), most of the studies
suggest that there is no significant difference between