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The Second Time Around: Retransplantation for Recurrent Hepatitis C
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Roayaie et al. present a sobering view of the outcome of re-transplantation for re-current HCV. Of 116 patients relisted more than 90 days after initial transplantation, 32% died while waiting, 24% still are waiting, and 44% (51 patients)received a second transplant.Forty-two of these 51 lost their first transplant because of HCV-induced cirrhosis and are the focus of the study.Of the 42,only 13 (31%)are alive,at a median of 41 months follow-up; 20 patients (48%)died after <6 months, 65%of these 20 due to sepsis; 9 (21%) died >6 months after transplantation, 66%of these 9 due to recurrent HCV.
Overall, 70% of patients receiving second transplants died after <3 years due to early sepsis or late complications of HCV. The median survival time was 12.9±6.7 months. Of the 13 living patients, only 4 are faring well.Seven patients underwent a third transplantation; five of these seven died.Patients who underwent retrans-
plantation for HCV fared significantly worse (P=0.002)than did those who received transplants for other conditions. The most significant predictors of poor outcome in a multivariate analysis were PT (Prothrombin Time) >16 and donor age >60 years. The pretransplantation MELD score was not correlated with survival after the second transplantation.
Thus, if hepatitis C is severe the first time around, it will be more severe the second time around, and still more severe the third time around. This raises the eternal dilemma of the seed versus the soil.Is this process selecting bad hosts or virulent agents? Are there more-virulent strains of HCV that initially result in cirrhosis and then cause increasingly rapid cirrhosis as they reinfect each new liver,or are there hosts who, by virtue of genetic make-up and/or impaired immunity, constitute the 20%--30% who develop cirrhosis from the primary infection
and then again each time they receive an HCV-naive liver? This issue cannot be resolved at present,but it is fundamental to our understanding of the pathogenesis of hepatitis C.
This study also raises difficult ethical issues. Given these poor outcomes in a subset of patients, are we justified in using the limited number of available livers for retransplantation rather than primary transplantation in patients who might fare better? Are we under obligation to provide a second liver, if necessary, once committed to a patient for the primary transplantation? These will remain incredibly difficult questions as long as the supply of organs remains limited. Overall, we need better seed, better soil,and more livers (or liver equivalents).(See Hepatology 2003;38:1428 --1436.)
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