Transplant and hep c

[dickl]

I have hep c and cirrhosis and my liver is about shot . My liver doc says treatment for the virus would probablt be fatal due to the fragile state of health I'm in . I fortunately have been stable and take 2 diuretics and follow fluid restriction and low sodium diet to fight moderate acitese. I am some what active and get out and about which is a blessing from Feb. when I was in the hospital with liver failure and acute acitese. My doc says transplant is probably inevitable and since I'm not ancient ( 59 ) would be preferable to waiting too long. I've been drug and alcohol free for over 3 months and I think the doc might be waiting to get a few months further to guarentee I show no signs of narcotis use before going before a tansplant board . My questions are what happens to the untreated hep , does it improve if the transplant is successful or after I recover do I look at treatment for the virus. Many days I feel like I've got the flu and this could be from virus , the meds, or the acitese . I would hope if the transplant works I might enjoy better health and not have this draconian fluid restriction lifted . I'm probably very naive about what's in store , although my son had  a marrow transplant for AML ( leukemia ) in 96 . It was really rough,  many complications , eye opening . He is 20 now and been cancer free since the transplant , it probably took 1-2 yrs. before he was active and healthy . I assume this is quite possible for a 59 yr. old. I welcome any input and please be candid I'm thhick skinned and prefer no candy coating.

                                                                                                     Thanks,
                                                                                                      dickl

[mikesimon]

My understanding is that the trend is to eliminate or wean early steroid therapy post transplant. According to the article regarding Berenguer group approach steroid therapy might not be as inappropriate as I believed.
The immune system and its response and effect on HCV is way too complex for me to have any concrete beliefs about. Many "experts" have expressed the belief that HCV is not, in and of itself, cytopathic. It is the immune response to the presence of infection which in mainly responsible for the liver damage which can result from HCV infection. Its attack on the infected liver cells results in bystander cells being destroyed and thus starts the chain of the cell death, inflammation, fibrosis and in time cirrhosis. So the notion that a suppressed immune system is the only or the primary explanation for the often seen rapid liver damage in the transplant recipient struck me as a little too simplistic. Am I certain about any of this stuff? No, unfortunately I grapple with this subject daily. That was really my point and why I posted. And, of course, I am somewhat biased since I have one of those livers in me as I type. Maybe I am just defending my hallowed ground. I probably am but I try to be reasonable while doing so.
Mike

[HectorSF]

Mike, point well taken. Thanks for pointing that numerous factors that are involved in the reoccurrence of HCV in the donated liver. The point I was trying to make (and wasn't clear about) was that by modifying a variable factor that can be controlled, namely the amount of immunosuppressant therapy, it may be possible to slow the advancement of the HVC liver disease in the post transplant patient and thus have a better long term outcome. Since the majority of liver transplant patients in the US have liver disease caused by HCV, any improvements in the outcome of post transplant patients with HCV will have a major positive impact on thousands of patients.

"Management of Recurrent Viral Hepatitis B and C After Liver Transplantation"
  
Marzia Montalbano, MD and Guy W. Neff, MD
Current Gastroenterology Reports Feb 2006, 8:60-66

"The effects of non-antiviral-related strategies (immunosuppression agents and angiotensin-converting enzyme inhibitors)

Immune suppression has always been implicated as the primary reason for the poor response to antiviral therapy and the aggressive nature of HCV after liver transplantation. The use of steroids and calcineurin inhibitors has been analyzed and contested as promoting HCV recurrence in the post-transplant period. Steroids have been either encouraged or disapproved of based on the retrospective analysis of different phases after transplantation. A tendency toward increase in serum HCV RNA levels seems to be associated with the early phase after transplantation when the use of immunosuppression is greatest and the use of a steroid bolus more frequent. In fact, Berenguer et al. showed in an analysis based on the historic timing of transplantation more aggressive HCV recurrence in those patients who were given a shorter course of steroids. Several factors within this analysis, including treatment variations among transplant teams and the increased use of marginal donors, may have affected their outcomes. Recently the same group reviewed their position and concluded that severe recurrence of HCV tended to be lower in patients who received reduced immunosuppression and a longer duration of steroid therapy. In addition, no differences were shown between patients on cyclosporine as opposed to tacrolimus, as previously demonstrated when comparing the long-term histologic results in these two groups of patients.

Stable immune suppression, in particular calcineurin inhibitors, is vital for long-term allograft function. We found that long-term allograft survival in transplant recipients with HCV was improved when immune suppression was well controlled and was maintained within normal ranges. In fact, calcineurin inhibitor maintained at normal serum levels (7-9 ng), when compared with groups with elevated or low calcineurin inhibitor serum levels, fared the best in terms of allograft survival and function. Overall, the best strategy for liver transplant recipients with HCV seems to be associated with avoidance of both abrupt changes and overuse of immunosuppression".

Cheers!
Hector

[mikesimon]

You said:
"What happens is that the anti-rejection drugs bring the virus back in a big way because they lower the immune systems response in order to not reject the new liver."
While immunosuppression is a factor, I believe that fibrosis progression post transplant is a bit more complicated than you suggest. There are other factors such as donor age, VL, genotype and host factors that are thought to play a role in fibrosis progression. Donor age for example is thought to be a very significant factor in the virulence of HCV recurrence post transplant.
Mike

[HectorSF]

I'm sorry to hear about your illness. You appear to have a great attitude considering what you are dealing with. I give you a lot of credit for doing so well. This is also something the transplant center will be looking for as it show a willingness to fight the good fight and overcome the odds. Plus giving up the drink and drugs show you are on the right path. Congratulations!

I believe that it is common experience that between 5 and 10 years post treatment the liver disease will cause to liver to fail again. This process happens much more quickly then the decades it takes for Stage 4 liver disease to originally progress. What happens is that the anti-rejection drugs bring the virus back in a big way because they lower the immune systems response in order to not reject the new liver.

One hopeful sign is that there is now a trial (here at UCSF) where they treat patients just before transplant for just long enough to get an undetectable level of virus, then they do the transplant. I have heard this is highly successful in stopping HCV from reappearing in the new liver. This could save many many lives if it turns out to be something that becomes standard practice.

Best wishes to you!
Hector

[HCA]

The new liver does indeed become infected,so most transplant recipients take anti-virals.
That's a way down the road though.Good luck-I have read many encouraging stories on this forum from people who have returned to good health from the place you are at now.

[mikesimon]

I believe that a longer period of abstinence will be required before you will be considered for an organ transplant. Most centers that I am familiar with require 1 year of absolute abstinence and I would guess that will be the requirement at the center(s) in your area.
The virus recurs almost universally post transplant so HCV will likely be an issue. I can't predict how it will affect your new liver. Some people get along well for years without treatment while other people don't and decide to treat post transplant. The success rate - the percentage of post transplant patients who achieve SVR - is around 26% to 30% - I think that's pretty accurate but I may be off a few percentage points. I would expect that your ascites would resolve post transplant because your new liver would be functional but recovery is not always trouble free. There are too many issues for me to go any further here but there is a lot of information on the net and you might start trying to educate yourself. Look up a center nearby and see if they list there exclusionary factors - eg. length of abstinence etc.. Then Google "liver transplant" and you should be able to learn a lot.
Good luck, Mike

[nygirl7]

Dickl

You'll find a few people in here who are experienced in this matter and have been transplanted and are doing wonderfully - living life to the fullest!

I'm sure they will let you know all the details but since I haven't been a transplant patient I hesitate to answer to that because it's not something I'm familiar with.

I just wanted to congratulate you on being drug free for 3 months.  It's not easy (I know).  I had a friend who was transplanted and IMMEDIATELY went back to partying. He developed liver cancer, had a leg amputated because of his diabetes and then he died.

Sometimes that helps keep me on the straight and narrow so to speak.  If the hep is left untreated you will need to make sure you stay on the same long boring road as me (i have been clear of the disease for 18 months after 72 weeks of treatment) - it's not a fun road to be on but with liver damage and disease we just gotta be there.

I wanted to wish you all of the best.

Deb