Our Worst Problem
By Andrew Cameron, MD, PhD
In 2004 I lived in Southern California and was training in liver transplantation at the busiest center in the US. I was told almost daily by my boss who was an indefatigable, irrepressible dynamo, that there was one battle that we still could not win.
“Recurrent Hepatitis C after liver transplant is the number one problem in the field,” he would admit in a depressed voice.
No obvious solution or hope on the horizon. What I saw daily in the corridors of the hospital proved him right: Hep C (a surprisingly common virus: around 4 million in the US have it, most don’t know it) is the number one reason to need a liver transplant. Liver transplants are all too few and far between, and many die waiting (4 or 5 each day, actually). Those who do win the lottery and get a lifesaving liver transplant for Hep C have the clock reset on their liver dysfunction but the virus re-infects the new liver immediately: 100% reinfection rate. And in fact, viral levels in the blood are 10 times greater a few days after the surgery than they were before.
Turns out liver transplant doesn’t cure Hep C, it makes it worse. The virus then attacks the new liver with a greater ferocity than before the transplant, and patients who were waiting with Hep C infection for 20 to 30 years before their new liver now had recurrent cirrhosis just a couple of years after transplant. Or even after only a few months! We learned the hard way (it was harder for the patients and their families) that when Hep C came back after transplant in that virulent fashion, there was nothing that could be done. No retransplant, no medicines, no hope. We lost those battles and it was indeed “the number one problem in the field.”
Now we win.
After struggling for years with the ineffective and toxic combinations of interferon and ribavirin for Hep C, we were given Harvoni about a year ago. “Harvoni” (which is a pill containing the antiviral drugs ledipasvir and sofosbuvir) was introduced clinically in October of 2014. One pill, once a day, for three months. Really no side effects. Cures Hep C in somewhere around 95% of patients. We win. At first, we gave Harvoni, when we could get it, to our patients with bad recurrent Hep C after a transplant. Beautiful transplant, doing great, turned yellow, progressed to near death, so much for winning the lottery. Gave them Harvoni and it was like watching a movie in which the hero gets the antidote for the deadly poison in the nick of time. A day after the first pill, they are a little less yellow. Each day a little better. Two weeks later, they get up, grab their suitcase and walk out the front door of the hospital. We now win every time.
I imagine that this is what it must have been like to be there when penicillin was discovered. Or maybe when HIV medicines got better and started really working. It’s miraculous to behold. Such a terrible disease now tamed. By the way, it’s not expensive. It’s cheap, all things considered.
Guess we need to find a new worst problem in liver transplantation.