Retransplantation for Recurrent Hepatitis C Virus Infection

1
Retransplantation for Recurrent Hepatitis C Virus
Infection

• Elizabeth Gross, M.D.
• PGY5 Rush University Medical Center

2
Liver Transplantation and Hepatitis C

• For the last decade, hepatitis C has been the
  most common indication for LTX
• Reinfection is universal and is often resistant
  to treatment

3
Recurrent Hepatitis C Infection after Liver
Transplantation

• Following LTX a 10-20 fold increase in viremia
  occurs
• Viremia is not always associated with graft damage

Berenguer M. LTS 20028S14-S18.
4
Recurrent Hepatitis C Infection after Liver
Transplantation

• Progression to cirrhosis is variable and
  unpredictable
• As many as 30 will develop cirrhosis at 5 years
  after LTX

Berenguer M. LTS 20028S14-S18.
5
Variables Possibly Associated Early Progression
to Cirrhosis Following LTX for Hepatitis C

• Use of Steroids
• Use of older donor
• Infection with type 1b
• Rejection requiring treatment
• Occurrence of acute hepatitis

6
Since Hepatitis C Reinfects the Transplanted
Allograft, What is the Outcome?

• The majority of single center trials have shown
  similar patient survival rates in HCV and HCV-
  patients at 1,2 and 5 years
• Multi-center data from UNOS registry has shown a
  slight decrease in survival in HCV patients at 5
  years (69.9 vs 76.6)

7
Are Patients Actively Undergoing
Retransplantation?

• Retransplants account for only 8-9 of total
  liver transplants (includes all indications)
• Retransplants for Hepatitis C virus infection
  accounted for only 2-3 as of 2/2003

Wall JW LTS,9, 2003 ppS73-S78
8
Data on Retransplantation for Hepatitis C Virus
Infection

• Two single center retrospective reviews
• Roayaie S.-42 patients, has control data (Mt.
  Sinai)
• Ghobrial R.-13 patients, no control data (UCLA)

• Two reviews of UNOS database
• Rosen H.-All patients undergoing retx 1990-1996
• McCashland T.- All patients undergoing retx
  1996-2002

9
UNOS Data on Retransplantation Hepatitis C
Positive Patients

• Both included all indications for Retx in
  patients HCV
• 40 of Retx were done in HCV patients in both
  studies
• Rosen found renal failure to be predictive of
  mortality
• McCash. found higher MELD to be predictive of
  mortality

10
Summary of UNOS Reviews of Retransplantation

• The number of patients undergoing
  retransplantation for HCV remains unchanged at
  approximately 40
• McCashland found retx in HCV patients had a
  similar outcome to retx in patients with other
  diseases except HBV and autoimmmune hepatitis

11
Mt. Sinai Single Center Review of
Retransplantation for Hepatitis C

• Early mortality due to septic complications
• Late mortality from recurrent infection
• Factors predictive of mortality
• PT 16 seconds
• Plts
• Donor age 60

12
Conclusions of Mt. Sinai Review of Hepatic Retx
For HCV

• Survival following retx for HCV is significantly
  shorter when compared to retx for other causes
• Most deaths occur within first 6 months and are
  due to sepsis
• Candidates with PT less than 60 yo can expect improved survival

13
Limitations of Mt. Sinai Study

• Data collection/presentation ongoing since
  1980s.
• Operative techniques being developed
• Quantitative PCR testing not available
• No pathologic criteria for recurrent hepatitis
• Single center trial
• High mortality was largely due to death from
  sepsis within 6 months

14
Comments on Available Data on Retransplantation
for HCV

• Retransplantation must be performed with low
  perioperative mortality to be justified
• Additional studies are needed to determine if
  acceptable long-term survival rates can be
  achieved

15
Retransplantation for HCV Infection at Rush Since
9/02

• 21 retransplantations have been performed in
  patients (6mths) over last 2 yrs
• Listing criteria included normal echocardiogram,
  negative HIV serologies
• 12/21 retransplantations were performed for
  recurrent HCV infection
• Average duration between retxs for HCV was 3
  years (range 0.6-5.2 yrs)

16
Operative Course in 12 Patients Following
Retransplantation for Hepatitis C Virus Infection

• Porto-systemic bypass was used in all 12 cases
• 6 arterials grafts were required, 2 Roux-en Ys
• Average transfusion was 19 units PRBCs per case
  (range 5-48 units)
• One patient required pericardotomy for cross
  clamping of the supra-hepatic cava
• 5/12 patients (42) required reoperation (1 bile
  leak, 4 post-op hemorrhage)

17
Pathological Review of Explants

• Cirrhosis secondary to Hepatitis C virus
  infection was the primary diagnosis in 12/12
  patients
• Co-diagnosis of biliary casts was made in 4/12
  patients

18
Post-operative Courses in 12 Patients Following
Retransplantation for Recurrent HCV Infection

• Retransplatation was required in 2/12 patients
  for primary non-function and rejection
• Patient who required pericardotomy developed
  bacterial pericarditis requiring percardectomy

19
Survival Following Hepatic Retransplantation for
Recurrent HCV Infection

• 11/12 patients are alive and doing well with a
  range of 3-22 months
• One death at 2 months due to both DGF and
  recurrent hepatitis

20
Summary of Results with Retransplantation for HCV
at Rush

• Acceptable rates of survival are possible (92)
• High incidence of post-operative complications
• Exceptional methods for revascularization,
  cross-clamping and drainage are needed
• Retransplantation for recurrent Hepatitis C virus
  infection should be offered to all candidates
  with normal echocardiogram