Recurrent Hepatitis C Post OLT for HCC and Cirrhosis

History 76 year old white female with chronic hepatitis C (genotype 1b) acquired in 1975 through blood transfusion HCV cirrhosis H/O varices No encephalopathy No ascites

Hepatitis C Biopsy G-4 S-3 (June 1999) Interferon (standard) and RBV in 1999 – 2000 (6 months) Virological and biochemical remission Stopped after 6 months due to Profound anemia Erythema nodosum Pegylated interferon (40mcg) + RBV (800mg) in 2001. Stopped after 3 months due to severe anemia despite GF supplementation. Cirrhosis of liver documented on biopsy in 2002 (grade 4 and stage 4)

Clinical Course AFP high 25.5 in March 2003 but U/S negative Development of pedal edema (03) and ascites (April 04) – MELD of 9 (August 04) Secondary iron overload with ferritin of 1417, iron 235 MRI showed nodules (Siderotic?) HFE phenotype is negative Phlebotomy 250 cc/month EGD showed esophageal varices (grade 2–3), never bled, on nadolol

Clinical Course Decompensated cirrhosis with a MELD score of 10 AFP 14 (4/06) US in 4/06 showed 3 lesions in the right lobe measuring 1.2x1.2x1.3cm, 2.7x3.2x3.3 cm and 1.8x1.4X2 cm

Liver Transplantation Roux-en-Y liver transplant on 7/9/06 for decompensated cirrhosis and HCC (within Milan criteria) CMV +D/–R Explant pathology Well to moderately differentiated multifocal HCC Total 5 lesions, largest 2.5cm (necrotic)

Post Transplant Course Recurrent HCV infection on biopsy (grade 3 and stage 1 with mild ACR) Treated for rejection episode Malnutrition and anemia CMV positive by PCR and CMV positive on liver biopsy. Treated with gancyclovir Episode of rejection when CMV positive Most recently on Rapa and steroid

Follow-up AFP within 2–3 range since transplanted (6 years) No HCC recurrence Recurrent HCV not treated after the OLT due to severe adverse effects in the past

Follow-up triple phase CT at one year

Follow-up triple phase CT (one year) Follow-up triple phase CT at two years