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SPONTANEOUS CLEARANCE OF HEPATITIS C POST LIVER AND KIDNEY TRANSPLANT
CH Dale, P Burns, M McCutcheon, R Hernandez, MA Levstik, CN Ghent, PJ Marotta
Liver Unit, Multi-organ Transplant Program London Health Science Centre, London Ontario
A 52 year old female underwent liver transplantation in 1988 for fulminant Wilson Disease. She acquired Hepatitis C (HCV) at time of transplant. She went on to develop cirrhotic stage HCV over the next 15 years. In 2001 she underwent renal transplantation for focal glomerulosclerosis and possible calcineurin inhibitor toxicity. She was known to be viremic and was HCV genotype 1. As a renal transplant recipient she was unable to be treated with interferon based therapy. By 2005 she developed progressive renal graft impairment resulting in hemodialysis and simultaneous liver decompensation. She was assessed and listed for combined liver kidney transplantation. She underwent transplant in July 2006. On the day of her transplant the HCV RNA was positive (>50 iu/ml). Her initial post-operative course was complicated by intra-abdominal abscesses. Her immunosuppression consisted of tacrolimus (levels 2-10), mycophenolate mofetil, and tapering doses of prednisone. She also received CMV prophylaxis. Three months post transplant she developed a significant elevation of her liver enzymes (ALT> 250, AST> 250). She underwent liver biopsy which was reported as minimal non-specific changes and no evidence of rejection. Given persistent enzyme elevation, a second biopsy was performed 29 days later and reported as, moderate interface hepatitis, and mild portal fibrosis. A third biopsy done 6 weeks later due to ongoing enzyme elevation (ALT> 450, AST> 400), was reported as acute hepatitis with bridging necrosis and no rejection. Antiviral therapy was initiated due to worsening histological features. Low dose pegylated interferon alpha-2a was started. On day of treatment initiation a repeat HCV RNA (quantitative test) and genotype were sent to the public health lab. This was reported as HCV RNA < 600 iu/ml. The anti-viral therapy was subsequently discontinued. Thirteen months post transplant, the patient remains HCV RNA negative (<50 iu/ml).
CONCLUSION: This case demonstrates that, despite large amounts of immunosuppressive therapy, individuals can spontaneously clear HCV. We feel the rapid rise in liver enzymes may represent a “clearance phase hepatitis”, although this phenomenon is not well described. Prior to initiating anti-viral therapy, confirmatory testing of HCV RNA status should be performed.