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Treatment of HCV infection in patients with advanced cirrhosis
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Hepatology
Volume 40, Issue 2, August 2004
Xavier Forns, M.D., Miquel Navasa, M.D., Juan Rodés, M.D.
Liver Unit, Hospital Clínic, Barcelona, Spain
Letter
To the Editor:
The recent AASLD Practice Guideline on Diagnosis, Management, and Treatment of Hepatitis C dealt with the topic of antiviral therapy in patients with decompensated cirrhosis. In their recommendations, Strader et al.[1] suggest that antiviral therapy might be initiated at low dose in hepatitis C virus (HCV)-infected patients with mild degrees of hepatic compromise, preferably in patients who have been accepted as candidates for liver transplantation. This recommendation is essentially based on the data reported by Everson et al. after treatment of 102 cirrhotic patients awaiting liver transplantation.[2] We recently analyzed the safety and efficacy of antiviral treatment in a cohort of 30 HCV-infected patients awaiting liver transplantation.[3] Half of these patients had compensated cirrhosis and hepatocellular carcinoma, whereas the other half had Child-Pugh B or C cirrhosis. Our approach was completely different from that of Everson et al.: We initiated treatment (interferon alfa-2b, 3 MU/day; ribavirin, 800 mg/day) when the expected time for liver transplantation was around 4 months. Our rationale to initiate treatment when patients approached transplantation was the assumption that most virological responders would achieve HCV-RNA negativization by week 12. This strategy might be sufficient to prevent infection of the graft in these patients, since the main source of virions (the liver) will be removed. In addition, this strategy would avoid a long treatment course in patients prone to develop severe side effects. Interferon was administered daily to avoid peaks and valleys of serum interferon concentrations, which might be crucial at the time of liver transplantation. Although pegylated interferon would have been an alternative, we were afraid of a longer duration of hematological side effects in patients waiting for a major surgical procedure. After a median treatment duration of 12 weeks, 9 (30%) of 30 patients achieved on-treatment virological response, which persisted in 6 (20%) after transplantation. Although based on a small number of patients, our results are comparable to those obtained by Everson et al. In fact, we believe that a short course of antiviral therapy might be a good alternative to treat HCV-infected patients with advanced cirrhosis when the date of transplantation is known (living donor liver transplantation), or in transplant programs where the waiting time can be predicted with reasonable accuracy.
References
1 Strader DB, Wright T, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C. Hepatology 2004; 39: 1147-1171. Links
2 Everson GT. Treatment of patients with hepatitis C virus on the waiting list. Liver Transpl 2003; 9( Suppl): S90-S94. Links
3 Forns X, Garcia-Retortillo M, Serrano T, Feliu A, Suarez F, de la MM, et al. Antiviral therapy of patients with decompensated cirrhosis to prevent recurrence of hepatitis C after liver transplantation. J Hepatol 2003; 39: 389-396. Links
Xavier Forns, M.D., Miquel Navasa, M.D., Juan Rodés, M.D.
Liver Unit, Hospital Clínic, Barcelona, Spain
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