treatment in kidney transplant patient

[sangeet000]

hi, my father is a renal transplant recipient for last 5 years. from last one year he had raised serum liver enzymes (sgpt around 100). tested positive by hcv- rna method. he is presently asymptomatic, immunosuppresants being used- mycophenolate sodium and steroids. is there any treatment available for him? if not what will be the natural course of the disease in him?

[mikesimon]

If your Father was HCV negative pre-transplant then his liver may be relatively healthy. HCV damages the liver over time so his liver condition would probably depend to some extent on when he was infected. I would still question the advisability of steroids in an HCV setting. I know that the trend in liver transplant patients with HCV is to wean them off steroids soon post transplant and in more and more transplant facilities steroids are not being administered at all because HCV damage accelerates in patients who take steroids.
The most definitive test of the condition of the liver is liver biopsy where a sample of the liver tissue is removed and examined with state of the art equipment. There are other less invasive tests based on ultrasound elastography which measures liver stiffness -  one being Fibroscan but, that test is not currently available in many places. There are also some formulas for blood values that can suggest liver condition but this approach is not as accurate as the above mentioned approaches in determining less advanced fibrosis. Ultrasound and even x-ray can reveal gross abnormalities in liver architecture such as significant liver swelling or liver shrinking seen in cirrhotic patients. A significantly low platelet count or an increased prothrombin time (clotting time) can also suggest liver damage but there could be other causes as well.
I think you should sit down with his physicians and discuss these issues fully with them.
Good luck,
Mike

[sangeet000]

hi mike, thanx for your response. can u please tell what additional information do you require regarding liver condtion of my father. also it seems to me that his hcv infection is post transplant , as i could gather from my memories now that he had been subjected to frequent tests for antibodies against hcv in the past but all were neagative.

[mikesimon]

From what I know steroids are not a good drug for a patient who is Hepatitis C positive. It could be argued that no immunosuppressive drug is good in an HCV setting but recently steroids are generally not recommended post liver transplant for HCV. I would guess that the same applies to kidney transplant recipients who are HCV positive but his physician should be better able to advise you.
It's not clear whether your Father had HCV before his kidney transplant or if he acquired it with his kidney transplant. I pasted an excerpt from a Medscape article which addresses your question but it appears not to definitively answer it. It suggests that acceptable liver histology (decent condition of the liver) pre-transplant bodes well for the liver. But then it seems to question this premise with reference to another study. I think I would want a clearer picture of your Father's liver condition.
I do not have any studies on hand but my recollection is that the standard treatment for HCV is not often recommended in kidney transplant recipients because of the increased risk of organ rejection.
For a lot more information on this issue see:
http://cjasn.asnjournals.org/cgi/content/full/2/3/563

"Impact of HCV in Kidney Recipients

Among kidney recipients, the prevalence of chronic HCV infection prior to transplantation is documented to be as high as 38%.[7] Although outcomes of kidney transplantation in this population are superior to those achieved with dialysis,[8] graft and patient survival in HCV+ patients is lower than that in HCV- recipients.[1,9] Initial studies suggested that decompensated liver disease contributed to the increased death rates in HCV+ kidney recipients.[8] However, many of these earlier studies examined outcomes in patients in whom a retrospective diagnosis of hepatitis C infection was made only after transplantation. This may have resulted in under-recognition of more advanced liver disease at the time of transplantation, accounting for the high rates of decompensated liver disease in their populations. Recent preliminary data suggest that HCV+ kidney recipients with acceptable pre-transplant liver histology have a low rate of progressive histologic liver injury on follow-up biopsy in the first 5 years after transplantation.[10] In another study where serial liver biopsies were performed into the second decade after kidney transplantation, the majority of HCV+ kidney recipients did not have progressive histological liver injury.[11] These data suggest that the deleterious effect of HCV status on patient and graft outcome in appropriately selected kidney recipients may not be related to severity of liver injury per se."

See: http://www.medscape.com/viewarticle/547370_3  
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Mike