Although recurrence of HCV after orthotopic liver transplantation (OLT) in patients with HCV mono-infection is common (48), the hepatic damage associated with this is usually mild, and long-term graft survival is not reduced (49). In those co-infected with HBV and HCV, virologic recurrence of HCV is less frequent, but histologic liver injury is thought to be possibly more severe. In one series, only 41% of patients with dual infection (vs 59% of patients with HCV mono-infection) had detectable HCV RNA by PCR in both serum and liver, during post-OLT follow-up. However, there was evidence of ongoing necroinflammatory activity, by histologic in some patients with negative serum HCV RNA (50). It was suggested that HBV may be masking the HCV, and the presence of both viruses led to more injury, and to development of a more severe liver disease. Two patients (5%) in this study had severe liver damage histologically, and both were co-infected with HBV and HCV (50).
Caccamo et al. (51) reported that HCV-related graft failure was more common in patients with HCV mono-infection, compared to those with dual infection. The occurrence of graft loss was 20% in those with monoinfection, which also happened relatively early during follow-up; none of those with dual infection had graft failure.
Rejection leading to graft loss was more frequent in dual HBV and HCV infection. This occurred in 21% of co-infected patients, compared to none in those with single infection with HBV (52). The underlying mechanism for this increased incidence of rejection, leading to graft failure, is unknown.
Post-OLT survival outcome of co-infected patients was significantly better, compared to those with HBV re-infection of the graft (i.e., 5-yr survival rate of 80 vs 30%, respectively) (52), and was similar to those with HCV re-infection (49). In the study by Huang et al. (52), there were two distinct histopathological patterns described in co-infected patients: One had predominantly HCV features, and the other one had predominantly HBV features. Rarely did they have a mixed histologic picture. It was suggested that the better outcome in co-infected patients may result from predominance of the HCV histopathological pattern, which is believed to have a more benign clinical course. Moreover, fibrosing cholestatic hepatitis, a histopathological entity described in recurrent HBV post-OLT associated with severe injury and poor outcome, was less frequent in the HBV and HCV dual-infection subgroup (52).
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