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AASLD/ILTS Liver Transplant Course
Liver Transplantation for Viral Hepatitis

Friday, November 1st, 2002

Course Directors: Anna S.F. Lok, MD, Frederico G. Villamil, MD and Sue V. McDiarmid, MD

Goals and Objectives:

  • Review the natural history of recurrent hepatitis B and C post-liver transplant
  • Gain insight into the factors associated with recurrent hepatitis B and C and pathogenesis of recurrent hepatitis C
  • Understand the impact of immunosuppressive therapy on the course of recurrent hepatitis C
  • Discuss options for preventing recurrent hepatitis B and C
  • Review treatment of recurrent hepatitis B and C
  • Discuss the pros and cons of re-transplantation and the use of anti-HBc-positive donor liver

Hepatitis C is the most common indication for liver transplantation in Western countries. Unfortunately, HCV re-infection is universal after liver transplantation. Moreover, the natural history of hepatitis C is accelerated. Thus, physicians involved in the care of liver transplant patients must have a clear understanding of the pathogenesis of recurrent hepatitis C, and the impact of immunosuppressive therapy on the course of these patients. Antiviral therapy has been used to prevent or treat recurrent hepatitis C, but tolerance is poor in post transplant patients. Physicians managing these patients need to be aware of the problems that are unique to the transplant population. Significant progress has been made in the past 15 years on the prevention of recurrent hepatitis B post-liver transplant. Outcome of patients transplanted for hepatitis B is better than that of patients transplanted for hepatitis C, but current prophylactic regimens for hepatitis B are very expensive. Optimal use of nucleos(t)ide analogs can improve the cost-effectiveness of prophylactic therapies for recurrent hepatitis B and the outcome of patients with recurrent hepatitis B.

Introduction: Liver Transplantation for Chronic Hepatitis B and C: Dilemmas and Controversies

Session 1: Hepatitis C

Chairs: Michael Sorrell, MD, and Frederico G. Villamil, MD

Session 1 will discuss the hepatitis C epidemic and morbidity, mortality, and graft loss associated with recurrent hepatitis C. The pathogenesis of recurrent hepatitis C will be reviewed. The natural history of recurrent hepatitis C and factors associated with disease progression will be discussed. The impact of immunosuppressive therapy on the course of recurrent hepatitis C will be presented.

  • Magnitude of the Problem (Jorge Rakela, MD)
  • Pathogenesis of Recurrent Hepatitis C (Geoffrey McCaughan, MD)
  • Natural History of Recurrent Hepatitis C (Marina Berenguer, MD)
  • Impact of Immunosuppressive Therapy (Gregory Everson, MD)

Session II: Hepatitis C

Chairs: Peter Neuhaus, MD and Hugo Rosen, MD

Session II will review the safety and efficacy of antiviral treatment in patients with recurrent hepatitis C post-liver transplant. The indications and outcomes of retransplantation for recurrent hepatitis C will be discussed. This session includes two debates. The first debate focuses on the pros and cons of induction immunosuppression. The second debate centers on the optimal timing to initiate antiviral therapy for recurrent hepatitis C.

  • Treatment of Recurrent Hepatitis C (Edward Gane, MD)
  • Retransplantation for Recurrent Hepatitis C (Rafik Ghobrial, MD)
  • Debate I: Immunosuppression in Hepatitis C
    • Induction Immunosuppression in Hepatitis C Virus-Infected Liver Transplant Recipients (Michael R. Lucey, MD)
    • Induction Immunosuppression for Patients Who Underwent Transplantation for Cirrhosis Caused by Hepatitis C? The Answer is No! (Andrew K. Burroughs, MD)
  • Debate II: Therapy of Recurrent Hepatitis C
    • Pre-emptive Treatment of Recurrent Hepatitis C Infection (Michael Charlton, MD)
    • I Favor Therapy for Hepatitis C Virus Recurrence After Transplantation (Didier Samuel, MD)

Session III: Hepatitis B

Chairs: Anna S. F. Lok, MD and Juan Rodes, MD

Session III will focus on liver transplantation for hepatitis B. The first talk discusses the evolution of prophylactic regimens over the last 15 years and the impact on the outcome of patients transplanted for hepatitis B. Efficacy of existing prophylactic regimens will be reviewed. Potential role of new therapies for prevention and treatment of recurrent hepatitis B are discussed. The indications for retransplantation and use of anti-HBc-positive donor livers will be covered. This session includes a debate on the use of hepatitis B immune globulin in the era of antiviral therapies: life-long versus limited duration.

  • Progress in the Last 15 Years (Federico G. Villamil, MD)
  • Prevention of Recurrent Hepatitis B (Anna S. F. Lok, MD)
  • Treatment of Recurrent Hepatitis B (Norah Terrault, MD)
  • Use of Anti-HBc (+) Donors (Santiago Munoz, MD)
  • Debate III: Hepatitis B Immunoglobulin Indefinite Passive Immunization After Liver
    • Transplantation for Hepatitis B (Timothy Pruett, MD)
    • Hepatitis B Immune Globulin for Life Versus Limited Use: I Favor Limited Duration of Therapy (John R. Lake, MD)

Source: 2002 AASLD Supplement to Liver Transplantation, Vo l8, No 10, Supplement, October 2002

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