No evidence to support use of antiviral drugs in patients with recurrent hepatitis C infection after liver transplantation

Antiviral therapy to treat recurrent hepatitis C infection after liver transplantation is controversial due to unresolved balance between benefits and harms. This systematic review of randomised clinical trials was performed to compare the benefits and harms of different antiviral therapies in patients with hepatitis C re-infected grafts after liver transplantation. A total of 425 liver transplant recipients with proven hepatitis C recurrence were randomised in 12 trials to various interventions and controls (including single drug regimen or multidrug regimen of interferon, ribavirin, and amantadine). Nine trials reported the proportion of patients belonging to genotype I (a subtype, which is more difficult to treat than other subtypes). More than three-quarters of the patients belonged to genotype I in these nine trials. Only one or two trials were included under each comparison. All the trials were of high risk of bias (risk of systematic error due to inadequate methodological quality) and high risk of play of chance (risk of random error due to few patients randomised). There were no significant differences in the mortality, graft rejection, or in re-transplantation between intervention and control in any of the comparisons that reported these outcomes. None of the trials reported liver decompensation or quality of life. Life threatening adverse effects were not reported in either group in any of the comparisons. Up to 87.5% of patients required reduction in dose and up to 42.9% of patients required cessation of treatment in the various comparisons because of adverse effects or because of patient's choice to stop treatment. Further randomised clinical trials at low risk of systematic errors or random errors are necessary to assess the long-term survival benefits for various treatment options, particularly combination pegylated interferon and ribavirin therapy with or without the use of granulocyte colony-stimulating-factor and synthetic erythropoietin, which may be helpful in treating the adverse effects of the therapies without reducing the dosage.