Background: the natural history of recurrent hepatitis C after liver transplantation (LT) is extremely variable, with progression to allograft failure in a substantial proportion of patients. The identification of factors associated with this poorer outcome may improve results. While donor age has been identified as one of the most important factors, the actual options to modify this variable are limited.
Objectives: a) to describe the natural history of HCV(+) liver transplant recipients depending on donor age ( < or = 50 years), including clinical, biochemical, and histological outcomes; and b) to identify in the subgroup of organ recipients from aged donors (= 50 years) factors associated with an aggressive course.
Methods: a retrospective study of clinical and histological data including protocol liver biopsies for 162 HCV (+) liver transplant patients between 1997 and 2001 with at least one year of follow-up. Aggressive recurrent hepatitis C was defined as a progression to fibrosis > 1 during the first year post-LT, development of a cholestatic form of recurrent hepatitis C, and /or graft failure due to HCV during the first five years post-LT. Factors analyzed as potentially associated with recurrent hepatitis C included: a) recipient-related: demographics (age, sex), pre-transplantation (hepatocellular carcinoma, Child-Pugh classification, history of alcohol, HBV serological markers, antiviral treatment, nutritional status, biochemical variables); b) donor-related: demographics (age, sex), cause of death, grade of steatosis defined as minimal vs. moderate-severe > 10%); c) surgery-related: cold preservation and rewarming time, duration of procedure, blood transfusion; and d) post-LT management-related: immunosuppression, liver enzymes in the first 14 days post-LT, acute hepatitis post-LT, surgical complications (vascular and/or biliary).
Results: patients were divided into two groups according to donor age group 1 ( < 50 years), n = 83, 51%, and group 2 (= 50 years), n = 79, 49%). Median follow-up was 5 years (range: 3 months-8.5 years). Aggressive recurrent hepatitis C occurred significantly more frequently in the older donor group (64 vs. 20.5%, p < 0.0001). In this group, potent immunosuppression -triple and quadruple regimens- (p = 0.04) and acute hepatitis post-LT (p = 0.03) were the only variables associated with aggressive recurrence. Degree of donor steatosis was not associated with the prognosis of recurrent hepatitis C.
Conclusion: the use of aged donors is partly responsible for the accelerated progression of hepatitis C after LT. When old donors are used we should avoid over-immunosuppression, and probably evaluate antiviral therapy in those with acute recurrent hepatitis C.