ORIGINAL ARTICLE

Efficacy, Predictors of Response, and PotentialRisks Associated With Antiviral Therapy in LiverTransplant Recipients with Recurrent Hepatitis CMarina Berenguer,1 Antonio Palau,1 Alberto Fernandez,1 Salvador Benlloch,1 Victoria Aguilera,1

Martın Prieto,1 Jose-Miguel Rayon,2 and Joaquın Berenguer1

1HepatoGastroenterology Service, Hospital Universitari La Fe, Valencia, Spain, and 2Pathology Service,Hospital Universitari La Fe, Valencia, Spain

There are unresolved issues regarding sustained virological response (SVR), tolerance and risk of rejection following antiviraltherapy in liver transplantation (LT). The aim of our study was to determine efficacy, rejection risk and factors associated withSVR. HCV-infected LT patients with at least 6 months of follow-up following end-of-therapy (EOT) received combinationtherapy of ribavirin (Rbvr) � standard (n�31)/pegIFN (n�36) between 1999 and 2004 (95% genotype 1). An EOT and SVRwas obtained in 46% and 33%, respectively. Type of antiviral therapy, use of erythropoietin, compliance, and early virologicresponse (EVR) were predictive of SVR, but only the latter remained in the multivariate analysis. Premature discontinuation,not impacted by the use of erythropoietin or GCSF, occurred in 40% patients. None of the variables predicted rejection (acuten�2, chronic n�4). A SVR occurred in 3/4 patients with chronic rejection. In conclusion, the efficacy of pegIFN-Rbvr is similarto the non-transplant population. An EVR at 3 months is useful to predict lack of response. The type of calcineurin inhibitor andhistory of prior non-response to IFN before LT do not influence the outcome of therapy. Severe rejection may lead to graft loss,a complication difficult to predict. Liver Transpl 12:1067-1076, 2006. © 2006 AASLD.

Received December 5, 2005; accepted January 5, 2006.

See Editorial on Page 1044

Hepatitis C-related end-stage liver disease is currentlythe most common indication for liver transplantation inthe United States and Europe. Unfortunately, recurrentviremia is a universal event with potential serious con-sequences within 5 to 10 yr posttransplantation.1,2 In-deed, several large multicenter and single-center stud-ies show a reduced 5- and 10-yr survival of thesepatients compared to uninfected recipients,3-5 largelyas a consequence of the recurrence of the original dis-ease. Antiviral agents to treat recurrence, such as in-terferon and ribavirin, are limited by their low efficacyand low tolerance profile.2,6 In fact, interferon-alphamonotherapy has not proven to be efficacious in thissetting. While the efficacy has increased with the addi-

tion of ribavirin, it still yields limited success, with arate of sustained viral eradication of about 20% rangingfrom 10% to 30%.2,6 As in nontransplant patients, thebest results reported to date have been achieved withthe combination pegylated interferon-ribavirin with asustained response ranging from 26 to 45%.7-11 Stud-ies using these agents though are few and include smallcohorts so that the effectiveness still needs to be con-firmed in clinical practice. In addition, there are a num-ber of unresolved issues regarding this therapy, includ-ing: 1) defining predictors of response, particularly atan early stage so that a toxic therapy is not continued inthe subgroup of patients with a low likelihood of re-sponse; 2) evaluating whether rejection is still a matterof concern as initially suggested in studies based oninterferon monotherapy12; and 3) determining whether

Abbreviations: HCV, hepatitis C virus; SVR, sustained virological response.Supported in part by a grant from the Instituto de Salud Carlos III (C03/02); S.B. has a contract from the Instituto de Salud CarlosIII, Ministerio de Sanidad (CM04/00217).Address reprint requests to Dr. Marina Berenguer, Servicio de HepatoGastroenterologıa, Hospital Universitario La Fe, Avenida Campanar, 21,46009 Valencia, Spain. Telephone: 34-96-3868792; FAX: 34-96-3987333; E-mail: mbhaym@teleline.es

DOI 10.1002/lt.20737Published online in Wiley InterScience (www.interscience.wiley.com).

LIVER TRANSPLANTATION 12:1067-1076, 2006

© 2006 American Association for the Study of Liver Diseases.

the underlying immunosuppression plays a role inachieving a sustained viral eradication. Indeed, thereare preliminary data suggesting that the rate of sus-tained viral eradication is higher among patients un-dergoing treatment with cyclosporine,13 possibly as aconsequence of the hypothetical antiviral effect shownin vitro of this immunosuppressive agent.14

We report our experience with antiviral therapy (ei-ther standard or pegylated interferon in combinationwith ribavirin) in hepatitis C liver transplant recipientsin a university hospital-based hepatology clinic. We hy-pothesized that the sustained virologic response (SVR)as a marker of effectiveness would be as follows: 1)better with pegylated interferon-ribavirin than withstandard interferon-ribavirin; 2) similar under cyclos-porine-based regimes than under tacrolimus; and 3)worse in previously treated (before transplantation) asopposed to treatment-naive patients. We also hypothe-sized that the same predictors of response described inthe immune competent population, namely genotypeand viral load pretherapy and at 3 months of therapy,would apply to the liver transplant patients. Finally, wehypothesized that, possibly due to its longer half-life,pegylated interferon would trigger rejection episodesmore frequently than standard interferon.

The aims of this study were therefore: 1) to determinethe SVR and the proportion of patients who requireddose reduction/premature discontinuation of therapy;2) to identify baseline and on-treatment factors associ-ated with an SVR; and 3) to define the rate of rejectionassociated with antiviral therapy and potential risk fac-tors that might predict this complication.

PATIENTS AND METHODS

A retrospective chart review was performed on all hep-atitis C virus (HCV)-infected liver transplant patientswho received combination therapy of standard/pegy-lated interferon and ribavirin at the Hepatology Clinicbetween March 1999 and October 2004. Only patientswith at least 6 months of follow-up following the dis-continuation of antiviral therapy are included in thisanalysis.

Patient Selection

Yearly protocol liver biopsies are routinely performed inHCV-infected recipients at our institution. Additionalliver biopsies are performed if clinically indicated, gen-erally within the first months posttransplantation toexclude coexistent diseases or complications such asrejection. In fact, all patients had an initial liver biopsyto assess the severity of liver disease. The decision toinitiate treatment was individualized and made jointlyby the patient and attending hepatologist. In general,though, during the first era when only standard inter-feron was available and data regarding its efficacy werevery limited and disappointing, therapy was only initi-ated when there was evidence of disease progressionbetween several yearly biopsies or if the first biopsyshowed signs of aggressive disease (i.e., cholestatichepatitis, bridging fibrosis, or cirrhosis). In the last 2 yr

though, following the introduction of pegylated inter-feron with improved efficacy and simpler administra-tion demonstrated in the nontransplant population,15

therapy was generally initiated at an earlier stage, typ-ically based on the first-yr protocol liver biopsy. Thispolicy was based on previous studies, including ourown, that had demonstrated that a first-yr liver biopsyshowing portal fibrosis is a predictor of subsequentprogressive disease.16,17 In addition, therapy was alsoinitiated when in a “clinically-indicated liver biopsy”there were changes compatible with aggressive disease(i.e., progression to fibrosis and/or moderate-to-severenecroinflammation within the first yr posttransplanta-tion; change in the stage of fibrosis of more than 1 unitin a short period of time; and change in the pattern ofrecurrent hepatitis to a more cholestatic form duringfollow-up). Patient acceptance to undergo antiviraltherapy was always taken into account. Viral load didnot impact on the decision process. These guidelineswere standardized for all patients.

No patient without established recurrence (i.e., pre-emptive therapy) was included. Other causes of graftdysfunction including rejection, biliary or vascularcomplications, and other viral infections had been care-fully excluded by Doppler ultrasound, cholangiograms,cultures, and histological examination of the graft (mul-tiple if necessary).

Patients with ongoing rejection, evidence of autoim-mune hepatitis, and a history of heart disease were nottreated. In addition, therapy was stopped in patientswho developed a severe episode of rejection under in-terferon therapy.

Antiviral Treatment Regimen

Standard interferon alfa 2b (Intron A; Schering-Plough,Kenilworth, NJ), pegylated interferon (Pegasys, Roche,Basel, Switzerland; Pegintron, Schering-Plough) andribavirin (Rebetol; Schering-Plough) were started at fullor reduced doses depending on the hemoglobin, totalwhite blood cell count, absolute neutrophil count, orplatelet count. Doses were modified according to stan-dard criteria taking into consideration the known ef-fects of both drugs. Adjuvant therapies including eryth-ropoietin and granulocyte colony stimulating factorinjections were used whenever considered appropriateby the hepatologist in charge. The intended duration oftherapy was 48 weeks whenever possible.

A biochemical response was defined by normalizationof liver enzyme levels (serum alanine aminotransferaseand aspartate aminotransferase). In addition, a virolog-ical response was defined by the negativity of HCV ri-bonucleic acid in serum by qualitative polymerasechain reaction. The response was considered completeif it occurred at the end of completion of therapy. Asustained response was achieved when both a bio-chemical and virological responses were observed 6months after completion of therapy. In addition, histo-logical improvement was defined by the decrease of atleast 2 points in the activity grade or 1 point in thefibrosis stage in posttreatment biopsies.

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Virological Assays.

HCV ribonucleic acid was detected in serum at base-line, at 4, 12, 24, and 48 weeks of therapy, and at 24weeks posttreatment. HCV-ribonucleic acid (qualita-tive) was detected using the Cobas Amplicor HCV testv2.0 (Roche Diagnostics, Branchburg, NJ).

HCV-ribonucleic acid quantitation was performed ei-ther with the Cobas Amplicor HCV Monitor test v2.0(Roche Diagnostics), or with the branched-DNA (bDNA)assay v3.0 (Bayer Diagnostics, Tarrytown, NY). The vi-ral load values (in IU/mL) obtained with the 2 tech-niques within their respective dynamic range have beenshown to be highly correlated.18 HCV genotyping wasperformed using a commercial reverse-hybridizationgenotyping assay (Inno-LIPA HCV II; Innogenetics, Zwi-jndrecht, Belgium).

Histological Examination

Liver biopsies were available before therapy and subse-quently at the end of completion of therapy, if possible.All biopsy specimens were read by a single pathologist(J.M.R.) who was blinded to biochemical and virologicalresponses of the patient. Histological recurrence of HCVand disease severity were defined as previously de-scribed.19 Briefly, the specimens were scored accordingto a slight modification of the histologic activity indexproposed by Knodell, and their histological grade (ac-tivity) and stage (fibrosis) were evaluated separately.The grade was determined by combining the histologicactivity index scores for periportal necrosis, scored 0-6(0, none; 1, mild piecemeal necrosis; 3, moderate piece-meal necrosis; 4, marked piecemeal necrosis; 5, mod-erate piecemeal necrosis plus bridging necrosis; and 6,marked piecemeal necrosis plus bridging necrosis), lob-ular degeneration and necrosis (0-4), and portal inflam-mation (0-4), and was defined as follows: 1 to 2, mini-mal; 3 to 6, mild; 7 to 10, moderate; and 11 to 14,severe. In addition, liver biopsy samples were stagedaccording to the original histologic activity index fibro-sis score: 0, none; 1, fibrous portal expansion; 3, bridg-ing fibrosis; and 4, cirrhosis.

Graft biopsy specimens were also examined for fea-tures of acute and chronic rejection. Cellular rejectionwas always based on histological findings, includingmixed portal infiltrate, venous endothelitis, and bileduct injury. A formal Banff score was not given due tothe overlap with recurrent hepatitis C. Chronic rejec-tion was defined by the presence of bile duct atrophy/pyknosis, bile duct paucity, and foam cell obliterativearteriopathy.

Statistical Analysis

The primary end-point of the analysis is SVR. Second-ary end-points are end-of-treatment biochemical andvirological responses, histological improvement, andtolerability of treatment with particular emphasis onrejection-induced episodes. Baseline characteristicsand measures of tolerability and efficacy of treatmentare described as proportions or medians and range.

Comparisons between sustained responders and non-responders are made using 2-sided Fisher’s exact andWilcoxon’s tests. Multivariate analysis was performedto identify independent predictors of SVR using logisticregression. A P value of � 0.05 was considered statis-tically significant.

RESULTS

Patient Population

This study included 67 hepatitis C-infected liver trans-plant patients treated with either standard or pegylatedinterferon in combination with ribavirin for recurrentHCV-related liver disease with a minimum of 6 monthssince discontinuation of antiviral therapy (Table 1). Ofthese, 67% were men and the median age was 54 yr(range 30-67). The median patient body mass index was26 (17.5-38.0). The majority of the patients were in-fected with HCV genotype 1 (n � 62, 92.5%). Except for1 patient, the remainder had elevated alanine amino-transferase levels before starting therapy (median 198IU/L; range 26-1,547). While 63 patients were treatedfor recurrent hepatitis C after a first liver transplant, 4were treated following retransplantation for recurrentHCV-graft failure of the first graft at 56, 82, 133, and581 days post-retransplantation, respectively. The me-dian time to treatment after liver transplantation was513 days (56-3,978 days). Sixty-five patients had abaseline liver biopsy before starting therapy. In 2 pa-tients with elevated transaminases for more than 1 yrsince transplantation, an immediate pretherapy biopsywas not available because it was considered to be toorisky due to comorbidities. The median time from pre-treatment biopsy to treatment was 65 days (2-852days). Nine (15%) patients had biopsy-proven cirrhosis,whereas 6 (9%) had histological signs compatible withsevere acute lobular hepatitis with cholestasis. Whilenone of the patients had clinical evidence of hepaticdecompensation, 11 (16.5%) had a bilirubin levelhigher than 3 gm/dL. In addition, 17 (25%) of the pa-tients had a platelet count �100,000/mm3, 6 (9%) hada leukocyte count �3,000/mm3, and 8 (12%) had he-moglobin �12 gm/dL. Immunosuppression consistedof cyclosporine Neoral in 28 (42%) and tacrolimus in 39(58%). The vast majority were off steroids at initiation oftherapy (n � 59, 88%).

End-of-Treatment and Sustained Biochemicaland Virological Responses

End-of-treatment biochemical response and end-of-treatment virological response were seen in 34 (51%)and 31 (46%) of patients, respectively. Sustained bio-chemical response and SVR were seen in 23 (34%) and22 (33%) of patients, respectively.

Dose Reductions and Premature Terminationof Therapy.

Twenty-seven (40%) patients had premature discontin-uation of either interferon (n � 24, 36%), ribavirin (n �

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25, 37%) or both agents secondary to adverse eventsincluding: anemia (22%), rejection episodes (22%), in-tolerance (15%), miscellaneous (41%). The prematurediscontinuation of either drug was not impacted by theuse of either erythropoietin or granulocyte stimulatingfactor (data not shown). In addition, 38 (57%) patientshad adverse events, mainly anemia, neutropenia, orthrombocytopenia, necessitating interferon (n � 24,36%) or ribavirin (n � 30, 45%) dose reductions.

SVR rates were not significantly impacted by prema-ture discontinuation of antiviral therapy (both inter-feron and ribavirin). In fact, an SVR was achieved in29.5% (n � 8/27) of the patients who prematurely dis-continued therapy at a median of 26 weeks from initi-ation compared to 35% (n � 14/40) in those who fin-ished the established 48 weeks of treatment (Table 2).Therapy had been discontinued in 3 of 8 cases due tochronic rejection at 171, 161, and 174 days from startof therapy. In the remainder, the cause and time ofdiscontinuation were intolerance (81 and 191 days),chest pain (213 days), and anemia (296 and 325 days).Although not statistically significant, discontinuationof interferon had a greater impact on virologic responsethan discontinuation of ribavirin (SVR in 37% of thosenot discontinuing interferon compared to 25% of thosewith premature discontinuation of interferon comparedto 33% and 32% in the case of ribavirin). Dose reduc-tions though appeared to influence outcome with anSVR achieved in 52% (10/19) of those who had receivedmore than 80% of the dose for more than 80% of thetime compared to only 25% (12/48) in those receiving

less than 80% during less than 80% of the time (P �0.03) (Table 2).

Rejection Episodes

Histologically documented rejection developed in 6 pa-tients, 1 under interferon therapy and 5 under peg-ylated interferon (Table 3). The rate of rejection washence 3% in those treated with standard interferoncompared to 14% in those treated with pegylated inter-feron. The rejection episodes were acute in 2 cases andchronic in 4. Antirejection therapy consisted of 3 gramsof methyl-prednisolone in the acute cases, whereas inpatients with chronic rejection, baseline immunosup-pression was switched to a more potent one (changefrom cyclosporine to tacrolimus, addition of mycophe-nolate mofetil and prednisone). A SVR was achieved in3 of 4 patients who developed chronic rejection, but innone of the acute rejection cases. All chronic rejectionepisodes occurred after viral clearance. The outcomewas variable. The 2 patients developing acute rejectionresponded to 3 boluses of methylprednisolone; 1 is alivewith progressive HCV-disease (patient 1), while the sec-ond died due to recurrent HCV disease (patient 6). Re-garding the 4 cases of chronic rejection, 2 (patients 2and 3) have shown a progressive improvement in theliver function after changing their baseline immuno-suppression without reaching though, a complete nor-malization of all laboratory parameters (in particular,gamma-glutamyl transpeptidase and alkaline phos-phatase) despite viral clearance in 1 of them. Of the

TABLE 1. Baseline Features (n � 67)

Gender (% Male) 45 (67%)Age at therapy (yr) 54 (30–67)Genotype (% 1) 62 (92.5%)Viral load pretherapy (IU/mL) 7.1 � 104 (0.2 � 104 � 77 � 105)Pretransplantation antiviral therapy 13 (19%)History of rejection (%) 14 (22%)Baseline Immunosuppression

Cyclosporine 28 (42%)Tacrolimus 39 (58%)

Steroids at initiation of therapy 8 (12%)Type of therapy

IFN�-Rbv 31 (46%)Peg�2a-Rbv 23 (34.5%)Peg�2b-Rbv 13 (19.5%)

Histology at initiation*Acute hepatitis 4 (6%)Chronic hepatitis

F � 0 3 (4.5%)F � 1 15 (23%)F � 3 34 (51%)F � 4 9 (13%)

Body mass index at initiation 26 (17.5-38)Time to therapy since transplantation (months) 17.1 (1.86-132.6)Time to therapy since baseline liver biopsy (days) 65 (2-852)

Abbreviations: IFN, interferon; Peg2a, interferon pegylated alfa 2a; Peg2b, interferon pegylated alfa-2b; Rbv, ribavirin.*A baseline liver biopsy was not available in 2 patients.

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remainding 2 cases of chronic rejection, 1 is alive fol-lowing retransplantation with no detectable HCV ribo-nucleic acid in serum (patient 5), while the other diedwaiting for retransplantation despite an initial improve-ment following the introduction of potent immunosup-pressive agents (patient 4). None of the variables ana-lyzed, including the degree of fibrosis at baseline, age,gender, donor age, baseline immunosuppression, typeof antiviral therapy, time from transplantation, use ofgrowth factors, maintenance ribavirin, and trough lev-els of calcineurin inhibitors at baseline and at 1 month,were predictive of rejection (data not shown).

Histological Data

Paired biopsies at baseline and at end-of-therapy/end-of-follow up were available in 38 patients, 25 who hadcompleted therapy and 13 who had prematurely dis-continued treatment due to side effects. A comparisonof activity scores between month 0 and months 12 to 18showed significant improvements in activity in 60% ofvirological responders; in contrast, improvement in fi-brosis was only observed in 20%. The changes in activ-ity and fibrosis scores observed following therapy areshown in Table 4.

Predictors of SVR (Table 5)

Univariate analysis demonstrated that there was a sig-nificant difference in SVR between those treated withstandard as opposed to pegylated interferon (13% vs.50%). The response was also substantially higheramong those in whom erythropoietin had been used asopposed to those who did not use this factor (53% vs.26%, P � 0.04). In addition, viral load at 3 months oftherapy was significantly associated with SVR, so that aSVR was achieved in 55% of those with an early viro-logical response (defined as a decline in viral loadhigher than 2 logs from baseline) as opposed to 5% inthose with persistent viremia (�2 logs) at 3 months oftherapy (P � 0.001). Among patients with genotype, 2 of3 patients were more likely to achieve an SVR thanthose infected with genotype 1 (60% vs. 30%), but therewere only 5 non-genotype 1 infected patients and thedifference did not reach statistical significance.

SVR rates were not significantly impacted by tran-sient dose reductions of either drug alone. However,dose reductions or premature terminations of therapythat resulted in the patient not reaching 80% of therecommended dose of both drugs during 80% of therecommended duration resulted in lower response

TABLE 2. Impact of Dose and Duration of Combination Antiviral Therapy on Sustained Virologic Response

SVR NR P value

Duration of therapy (days) 349.5 (81-385) 365 (13-462) nsEarly Discontinuation

Yes (n � 27) 30% 70% nsNo (n � 40) 35% 65%

IFN early discontinuation nsYes (n � 24) 25% 75%No (n � 43) 37% 63%

Rbvr early discontinuation nsYes (n � 25) 32% 68%No (n � 42) 33% 67%

Dose reductionsYes (n � 38) 32% 68% nsNo (n � 29) 35% 65%

IFN dose reduction nsYes (n � 24) 33% 67%No (n � 43) 33% 67%

Rbv dose reduction nsYes (n � 30) 30% 70%No (n � 37) 35% 65%

IFN dose ns�80% recommended (n � 25) 44% 56%�80% recommended (n � 33) 27% 73%

Rbv dose 0.05�80% recommended (n � 22) 50% 50%�80% recommended (n � 36) 25% 75%

Overall dose and duration 0.03�80/80/80 (n � 19) 54% 46%�80/80/80 (n � 48) 25% 75%

Abbreviations: Rbv, ribavirin; IFN, interferon; SVR, sustained virologic response; NR, nonresponse; 80/80/80, 80% of therecommended dose of both drugs (interferon and ribavirin) during 80% of the recommended duration.

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rates (Table 2). The SVR rate among patients achievingat least 80% of recommended dose for each drug and80% of recommended duration of therapy was 54% vs.25% for patients who were unable to achieve all criteria(P � 0.03).

The remainder variables analyzed including gender,age, pretransplantation antiviral therapy, or history ofsignificant alcohol consumption, Child-Turcotte-Pughclassification and hepatocellular carcinoma at trans-plantation, baseline immunosuppression, disease se-verity, laboratory tests, and body mass index at initia-tion of therapy, time from transplantation to therapy,use of granulocyte colony growth factors, or past rejec-tion episodes, had no significant effect on SVR (Table 5).In particular, an SVR was achieved in the same propor-tion of patients under cyclosporine compared to thoseunder tacrolimus (11/28, 39% vs. 11/39, 28%; P �0.3). Baseline characteristics that differed between thecyclosporine and tacrolimus group were: a higher pro-portion of patients with advanced fibrosis (F3 and F4)(81% vs. 55%, P � 0.035) and a longer duration fromtransplant to antiviral therapy in the former vs. thelatter group (median 1,251 vs. 473 days, P � 0.03). Allremaining baseline characteristics did not differ amongthese 2 groups (data not shown). Likewise, the propor-tion of patients achieving a SVR was similar in thosewho had been previously treated with antivirals com-pared to those who had not received antiviral agentsprior to liver transplantation (31% vs. 33%, P � 0.8).The only variable that differed between these 2 groupswas donor age (median of 22 yr in the group of patientswho had received antiviral therapy in the past com-pared to 47 yr in those never treated; P � 0.03). Theremaining variables did not differ among these 2 groups(data not shown).

The same results were obtained when only genotype 1infected patients were analyzed (data not shown).

Multivariate analysis using logistic regression analy-

sis was performed for the variables that showed a levelof significance of P � 0.1. The only variable that re-mained in the model was “the early virologic response at3 months” (P � 0.01). The same results were foundwhen only patients with genotype 1 were analyzed (datanot shown).

DISCUSSION

The need to optimize outcomes for hepatitis C-infectedrecipients is one of the most pressing issues facingtransplant physicians.1,2 Antivirals have been used inan attempt to modify the course of HCV-disease. In-deed, data from prior studies suggest that sustainedviral eradication leads in most cases to histologic im-provement.20,21 Changes in histology, though, are gen-erally not immediate but rather occur several yearsafter viral clearance. However, while substantial im-provements have been made in the treatment of chronichepatitis C in the non-immune compromised host inthe last few years, with the combination of interferon-ribavirin and more lately peg-interferon/ribavirin,15 re-sults in the liver transplant setting have been less im-pressive.6 With standard interferon in combinationwith ribavirin,6 an SVR is achieved in only 22% oftreated transplant recipients, a percentage significantlylower to that reported in the immune competent popu-lation treated with the same regime.6,15,19,22 Reasonsfor this lower response include a high prevalence offactors known to be associated with lack of response inthe nontransplant population (high viral load, highprevalence of HCV genotype 1, low tolerability with dif-ficulties in achieving full-dose treatment, and highprevalence of prior nonresponders) and presumably, alower response to HCV therapy in patients with im-paired immune function. The recent success of peg-ylated interferon with ribavirin in the nonimmunosup-pressed population15 has prompted most centers toswitch from standard interferon to pegylated interferon.Data on this approach though are scarce,6-11 and thereare still several issues which remain to be addressed. Inparticular, determining pre and on-treatment factorsassociated with viral clearance and defining the risk ofrejection. These aspects, which we believe are extremelyrelevant in the management of transplant recipients,were the 2 major aims of our study. The conclusionsfrom this study based on “a treatment-on-recurrencestrategy” may be summarized as follows: 1) HCV clear-ance is achieved in a significantly higher proportion ofHCV-infected liver transplant recipients treated withpegylated interferon-ribavirin compared to standard in-terferon-ribavirin; 2) A lack of early virologic responseat 3 months of therapy is a very useful tool to predictfailure of therapy; 3) The type of calcineurin inhibitorused does not influence the outcome of antiviral ther-apy; 4) A history of prior nonresponse to interferontherapy before transplantation does not influence theoutcome following posttransplantation antiviral ther-apy; 5) Although HCV clearance is achieved in a signif-icant proportion of HCV-1b infected liver transplantrecipients treated with pegylated or standard interferon-

TABLE 4. Comparison of Histological Findings

Between Pretherapy and Posttreatment Liver

Biopsy (n � 38)

Sustained

virological

response

(n � 10)

Nonresponse

(n � 38) P value

Fibrosis nsBetter 20% 14%No change 40% 47%Worse 40% 39%

Activity nsBetter 60% 37%No change 30% 37%Worse 10% 26%

NOTE: Not all patients had a posttreatment liver biopsy sothat comparison was only made in those with pre- andposttreatment liver biopsy.

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ribavirin, treatment may be hampered by the develop-ment of severe rejection, potentially leading to graftloss; and 6) Rejection following the use of interferon/pegylated interferon therapy is difficult to predict withcurrent easily obtainable variables, but appears to bemore common with the pegylated form of interferon.

In our study, an SVR was achieved in 47% of HCV-genotype 1 patients treated with the combination peg-ylated interferon-ribavirin and in 75% of those infected

with genotypes 2 or 3. These results are in accordancewith some of the earlier studies reporting their experi-ence with this new therapy,7,8,10 thus confirming thesignificant improvement achieved with the introductionof the pegylated form of interferon as opposed to stan-dard interferon. In fact, the results from our and otherstudies suggest that, as opposed to standard inter-feron, the rate of sustained viral clearance is relativelysimilar in transplant and nonimmunosuppressed pa-

TABLE 5. Baseline and “On-Treatment” Predictive Factors of Sustained Virological Response

SVR

(n � 22)

NR

(n � 45) P value

Type of therapyStandard IFN (n � 31) 4 (13%) 27 (87%) 0.001Peg-IFN (n � 36) 18 (50%) 18 (50%)

GenotypeGenotype 1 (n � 62) 19 (31%) 43 (69%) nsGenotypes non-1 (n � 5) 3 (60%) 2 (40%)

Viral load at baseline (IU/L) 5.0 � 105 (4.5 � 104 � 19 � 106) 10.5 � 105 (2.1 � 104 � 16.1 � 106) nsAcute hepatitis pretherapy

Yes (n � 6) 1 (17%) 5 (83%) nsNo (n � 59) 20 (34%) 39 (66%)

GenderMale (n � 43) 15 (33%) 30 (67%) nsFemale (n � 22) 7 (32%) 15 (68%)

Age at therapy (yr) 47 (30-64) 54 (33-67) nsBody mass index at therapy 26 (17-31) 26 (20-38) nsDonor age (yr) 41 (17-69) 47 (16-76) nsFibrosis pretherapy

F 0-F 1 (n � 18) 3 (17%) 15 (83%) nsF 3-F 4 (n � 43) 17 (33%) 26 (60.5%)

Cirrhosis pretherapyYes (n � 9) 3 (33%) 6 (67%) nsNo (n � 52) 17 (33%) 35 (67%)

Necroinflammatory gradepretherapy

9 (6-13) 9 (0-13) ns

Antiviral therapy in thepast (beforetransplantation)

ns

Yes (n � 13) 4 (31%) 9 (69%)No (n � 54) 18 (33%) 36 (67%)

Prior rejection episodeYes (n � 14) 4 (29%) 10 (71%)No (n � 49) 18 (37%) 31 (63%) ns

ImmunosuppressionCyclosporine (n � 28) 11 (39%) 17 (61%) nsTacrolimus (n � 39) 11 (28%) 28 (72%)

Time from transplantationto therapy (yr)

571 (122-3978) 480 (156-3055) ns

Early VR at 3 months 0.0001Yes (n � 29) 16 (55%) 13 (45%)No (n � 20) 1 (6%) 19 (95%)

Erythopoietin useYes (n � 17) 9 (53%) 8 (47%) 0.04No (n � 50) 13 (26%) 37 (74%)

GCSF useYes (n � 9) 5 (56%) 4 (44%) nsNo (n � 58) 17 (29%) 41 (71%)

Abbreviations: GCSF, granulocyte colony stimulating factor; SVR, sustained virologic response; NR, nonresponse; VR,virological response.

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tients. In addition, results in this study were similarregardless of time of initiation (in the acute vs. chronicphase of the disease) as recently suggested by Castellset al.23 We believe, though, that patients treated afterseveral months from transplantation are less sick anddebilitated and more eager to receive a “difficult-to-tolerate” therapy than those treated in the first monthsfollowing the surgery. In addition, it is known fromprevious studies that a substantial proportion of pa-tients have a nonprogressive disease and that histolog-ical findings in the early biopsies, performed either byprotocol or due to clinical indication, are extremelyhelpful in predicting subsequent progressive dis-ease.17,19 Finally, it is clear from this and other studiesthat therapy with interferon in the transplant popula-tion is associated with serious side-effects, includingchronic rejection.24,25 Based on these assumptions, webelieve that antiviral therapy with pegylated interferonand ribavirin should be preferentially recommended inpatients in whom disease progression is evidenced inserial liver biopsies.

Factors known to negatively influence response toantiviral therapy in the nontransplant population ap-pear to also apply in the transplant population. Indeed,response was higher in genotypes 2 and 3 infected pa-tients than in those infected with genotype 1, althoughdue to the small number of non-genotype 1 patients,the difference did not reach statistical significance. Vi-ral load at 3 months was very useful in predicting thefailure to achieve a sustained viral clearance. Indeed,only 1 of 18 among those who did not achieve an earlyvirological response had an SVR. These findings, al-ready useful in the nontransplant population,15 aremore relevant in the liver transplant setting, in whichside effects are more frequent and also more problem-atic to deal with. However, given the progressive natureof hepatitis C in the liver transplant setting, it may beworthwhile, at least in recipients with advanced diseaseand relatively good tolerance to antiviral therapy, tocontinue the treatment despite a lack of early virologicresponse in order to stabilize and/or improve histologicdamage. However, whether continuing therapy in thiscontext will eventually lead to an improvement in out-come needs to be fully explored in a prospective ran-domized way.

Interestingly, the duration of therapy did not appearto impact treatment response. Almost 1 of 3 patientswho had treatment interrupted before reaching month12 due to side-effects had an SVR percentage not sta-tistically different from that found in patients who didnot interrupt therapy prematurely. However, the com-bination of dose and duration of therapy was found tobe predictive of outcome with the rule 80 � 80 � 80 alsoapplying in our transplant population. These resultsemphasize the importance of support to maximizetreatment compliance with an interferon-based regi-men. In that sense, the use of erythropoietin, a variablefound to be predictive of response in univariate analy-sis, may be a useful tool in enhancing patient adher-ence, and therefore optimizing dosing and duration oftherapy.

As reported previously in several studies assessingantiviral therapy in the liver transplant popula-tion,6,11-15 the tolerance was problematic with morethan half of the patients requiring dose reductions,specially of ribavirin; in addition, therapy was prema-turely discontinued in 40%. Neither the use of erythro-poietin nor granulocyte stimulating factor had an ap-parent effect on treatment discontinuation. Treatmentwas discontinued in 35% of those using erythropoietinas opposed to 42% of those in whom this drug was notused, and in 44% of those in whom granulocyte stimu-lating factor was used compared to 40% of those inwhom granulocyte stimulating factor was not used.However, these results may reflect the small number ofpatients treated with either agent.

One of the most severe side effects leading to treat-ment discontinuation was rejection. This complicationoccurred in 6 patients, 1 under standard interferontherapy and 5 under pegylated interferon. Though notstatistically significant, possibly due to the small num-ber of events, patients were relatively equally-dividedbetween standard interferon and pegylated interferon,suggesting that the use of pegylated interferon is a riskfactor for rejection. Unfortunately, none of the variablesanalyzed were predictive of rejection, again possiblyreflecting the small number of patients developing thiscomplication. In contrast to other studies,26 the levelsof immunosuppressive agents before the developmentof rejection were in the correct range (data not shown).Interestingly, an SVR was achieved in 3 of 4 patientswho developed chronic rejection despite the early ter-mination of therapy and the addition of potent immu-nosuppressive agents to treat rejection.

Recently, some studies have suggested that cyclo-sporine may have an antiviral effect,14 which may inturn increase the rate of viral clearance.13 We were,however, unable to show differences in treatment re-sponse among those immunosuppressed with cyclo-sporine as opposed to those who used tacrolimus. How-ever, treatment had been started at a later stage inthose under cyclosporine (higher proportion of patientswith advanced fibrosis), probably reflecting the morerecent introduction of tacrolimus (longer time elapsedfrom transplantation to antiviral therapy in those undercyclosporine than in those under tacrolimus).

Likewise, a history of prior treatment with antiviralsbefore liver transplantation did not appear to impacttreatment success following antiviral therapy in theposttransplantation period. While this is an interestingobservation, it must be interpreted with caution, sincein most cases we were unable to assess whether boththe dose and duration of therapy in the past had beenadequate.

In conclusion, our results indicate that response ofhepatitis C liver transplant patients to pegylated inter-feron-ribavirin can closely mirror the response ob-tained in the nontransplant population. The tolerancethough is unsatisfactory, and rejection remains a mat-ter of concern in these patients.

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