A 45-year-old female patient received a living-related kidney transplant. Prior to surgery, her screening for hepatitis C virus (HCV) was negative; posttransplantation ELISA for HCV and polymerase chain reaction (PCR) quantitative screening (5 million copies) demonstrate acute hepatitis with severe hypertransaminasemia (in the range of 3000 mg/dL). What is your recommendation for treatment?
Hugo Páez, MD
This is a very interesting question. This patient is the classic patient with acute hepatitis due to HCV infection. The most important thing we need to know is the timing. It looks as if she clearly was negative before transplantation and now is positive by both virologic and enzymatic evaluation; therefore, she meets the criteria for acute hepatitis. If she has evidence of hepatitis for at least 6 months and hasn't cleared the virus spontaneously (occurs in at least 50% of acute hepatitis C cases), then she should be considered for treatment with interferon (IFN) and ribavirin. There is not much data on pegylated IFN, but I would imagine the efficacy of this agent would be even better. In the literature on IFN-alpha-2b, the response rate is very high (> 95%) in this setting. Therefore, I would recommend treatment with a combination of pegylated IFN and ribavirin for 4 months if the patient is a candidate, with the hope that she will respond. At the same time, there is evidence that antiviral therapy may exacerbate acute cellular graft rejection; therefore, graft function should be monitored very closely.