Clinical Case

HCV therapy following liver transplantation

Medical history• 65 yrs old HCV (+) LT recipient.• HCV-related history:

– HCV GT1b

– Naïve pre-LT• Comorbidities

– AHT (nifedipine 60 mg qd)

– IDDM (insulin)

– Frequent cephalea

• LT-related history– LT 6 yrs before– MELD 16, Child-Pugh C10– Anti-core positive donor (recipient HBV serology negative)----LAM prophylaxis– Uneventful surgery & early postLT recovery– IS: Tac + P

• Recurrent hepatitis C

– First month on-demand liver biopsy: mild NI, no fibrosis

– 6th-month on-demand liver biopsy (ALT 666 UI/ml, AST 373 UI/ml, GGT 280 UI/ml, AP 104 UI/ml) : moderate NI, F2/4

• Tests performed:– Liver ultrasound: normal – Auto-antibodies: negativos– Thyroid hormones: normal– HBV serology & viral load: negative– CMV viral load: negative– Viral load HCV: >7.692310UI/ml

Recurrent hepatitis C

Antiviral therapy (9 month postLT)

-Peg-alfa-2b 100µg/día

-Ribavirin 1000mg/día

Time postLT First month 3d month 5th-6th month

Biochemical R Yes Yes (normal) Yes (normal)

Viral R Viral load decrease Yes (84 IU/m) Yes (< 50 IU/ml)

AEs * Headache*Anxiety (alprazolam)* Irritability/depression (escitalopram)

* Headache* Improvement of depression

* Headache* Asthenia*Hand-shaking (D/C nifedipine, propranolol)3 hospital admissions

Laboratory abnormalities

* Anemia*Neutropenia*Low platelets

* Anemia (EPO)*Neutropenia*Low platelets

* Anemia (EPO)*Neutropenia*Low platelets

Clinical course during IFN-therapy

Third amission (6 months on treatment)

• Confusion, instability, disorientation, memory loss, urinary incontinence, headache, episodes of unconsciousness with hypertony

• No fever, no agitation at night, good sleep

MRI: normotensive hydrocephaly + Periventricular leucoaraiosis

LUMBAR PUNCTURE: Pressure 33 cm H2O,Glu 26 mg/dl, cells 15 (100% MN), proteins: 4,9 g/dlMicro: yeast (criptolatex positive)LOWENSTEIN: Cryptococcus neoformansBURRI Stain: capsulated yests compatible with Cryptococcus

ANFOTERICIN B + STOP antiviral therapy

-Fibroscan 2011:=6,1 Kpa

--Fibroscan 2012 = 15,1 Kpa

- Fibrscan 2013: 35 Kpa

- Liver biopsy 2014: Cirrhosis with moderate necro-inflammation + macrosteatosis

- Gastroscopy: mild esophageal varices

Child A 6 Cirrhosis, Meld 14

Baseline viremia: 1.751.000 IU/mL

Week 2 viremia: 152 IU/mL

Week 4 to 24: undetectable

SVR-4 and SVR12

Follow-up Recurrent hepatitis C

24 week- therapy with SOF+DCL+RBV