Navigating Treatment Options for Liver Fibrosis in Kidney Transplant Patients

Q: Navigating Treatment Options for Liver Fibrosis in Kidney Transplant Patients

Mr. Andy： 1. Hepatitis C should be ruled out or treated before kidney transplantation. 2. In Taiwan, modern blood transfusions are filtered for Hepatitis C from donors. 3. It is indeed challenging to manage, and a biopsy is necessary for evaluation. Th

Treatment issues of liver fibrosis?

Dear Dr.
Chen,
I am a kidney transplant recipient and a hepatitis C patient, currently 57 years old.
Eight years ago, I underwent a successful kidney transplant surgery in mainland China, and since then, my post-operative condition has been good, with all indices normal (Cr: 0.89, BUN: 16).
I am currently taking a minimal amount of immunosuppressive medication (ciclosporin), which indicates a successful surgery.
However, six years ago, I had to take a heavier immunosuppressant (FK506), which led to immunosuppression and resulted in an Escherichia coli infection that progressed to sepsis.
I was hospitalized for over ten days before being discharged in recovery.
Unfortunately, during the treatment, I contracted hepatitis C due to a blood transfusion (platelets).
It was truly a devastating moment.
After the infection, my liver function remained elevated (GOT: 60-70, GPT: 80-120, T.Bili: 2.5-3.0) until last year when, possibly due to reduced work stress or dietary adjustments, all indices returned to normal.
Since then, apart from the medications for my kidneys, I have only been taking one liver-protective medication (silymarin) and undergoing regular check-ups, including blood tests and ultrasounds.
During outpatient visits, the hepatologist has repeatedly suggested that I undergo interferon treatment, but I have refrained due to concerns about the potential impact on my transplanted kidney.
(According to the physician, the cure rate for hepatitis C is only about 60%, but there is a high risk of losing kidney function—up to about 40%.
I have invested a lot of effort and money over the past eight years to maintain my kidney function, so giving it up is hard to accept.) Given that my liver function and ultrasound results have shown no abnormalities for over a year, two weeks ago, my doctor recommended that I pay out of pocket for a liver fibrosis scan.
To my surprise, the result was 13.9 kPa.
Some literature indicates that a value greater than 17.5 kPa suggests early cirrhosis (with values below 6.0 kPa considered normal).
Consequently, the hepatologist strongly recommended that I undergo interferon treatment again, stating that while the kidney can be dialyzed, the liver cannot.
However, when I discussed this with my kidney transplant physician, he responded very conservatively, seemingly not supportive of interferon treatment for kidney transplant patients, and mentioned that he has not seen any cases of hepatitis C patients receiving this treatment, as it could severely affect the function of the transplanted kidney or even lead to failure.
At this point, I find myself in a dilemma, as the decision to treat or not treat is a matter of life and death.
I am feeling anxious and restless; I have a history of anxiety disorder, and recently I have been unable to sleep and have lost my appetite.
I hope that Dr.
Chen can provide some advice and guidance on the best treatment options for me.
Additionally, could you inform me about the progression from a liver fibrosis index of 13.9 kPa to early cirrhosis and then to end-stage cirrhosis, and approximately how many years one might expect to sustain this condition? This information would be helpful for my decision-making.
Thank you for your guidance.
Sincerely,
Andy

Andy, 50~59 year old female. Ask Date: 2011/06/15

Dr. Chen Shidian reply Gastroenterology and Hepatology

Mr.
Andy: 1.
Hepatitis C should be ruled out or treated before kidney transplantation.
2.
In Taiwan, modern blood transfusions are filtered for Hepatitis C from donors.
3.
It is indeed challenging to manage, and a biopsy is necessary for evaluation.
The Department of Hepatobiliary Medicine at National Taiwan University Hospital has more experience with such patients, and you may consult with Dr.
Chen Shih-Tien at Changhua Hospital regarding your health.

Reply Date: 2011/06/15

More Info

Navigating treatment options for liver fibrosis in kidney transplant patients, particularly those with chronic hepatitis C, presents a complex challenge that requires careful consideration of both liver and kidney health. In your case, you have a history of kidney transplantation and have developed hepatitis C, which complicates the treatment landscape due to the potential impact on your transplanted kidney.

Understanding Your Condition
You mentioned that your liver fibrosis scan indicated a score of 13.9 Kpa, which suggests significant fibrosis but not yet cirrhosis (which is typically indicated by scores above 17.5 Kpa). The progression from fibrosis to cirrhosis can vary widely among individuals, influenced by factors such as the underlying cause of liver disease, overall health, and adherence to treatment. Generally, without intervention, significant fibrosis can progress to cirrhosis over several years, but this timeline can be highly variable.

Treatment Considerations
1. Antiviral Therapy for Hepatitis C: The primary goal in managing hepatitis C is to achieve a sustained virologic response (SVR), which means the virus is undetectable in the blood after treatment. Direct-acting antiviral (DAA) therapies have revolutionized hepatitis C treatment, offering high cure rates with fewer side effects compared to older treatments like interferon. Given your concerns about the impact of interferon on your transplanted kidney, discussing the possibility of DAA therapy with your hepatologist is crucial. These medications are generally well-tolerated and have a lower risk of adverse effects on kidney function.

2. Monitoring and Management of Liver Health: Regular monitoring of liver function tests, imaging studies, and possibly liver biopsies may be necessary to assess the progression of liver disease. Given your history of fluctuating liver enzymes, close follow-up with a hepatologist is essential to tailor your treatment plan based on your liver's response.

3. Kidney Function Considerations: Since you are on immunosuppressive therapy to prevent kidney rejection, it is vital to balance the need for antiviral treatment with the potential risks to kidney function. Your nephrologist should be involved in discussions about any changes to your immunosuppressive regimen, especially if you start antiviral therapy.

4. Psychological Support: The anxiety and uncertainty you are experiencing are understandable, given the stakes involved in your health decisions. Engaging with a mental health professional who specializes in chronic illness may provide you with coping strategies and support as you navigate these challenges.

The Dilemma of Treatment
You are in a difficult position, weighing the risks of treating hepatitis C against the potential impact on your kidney. It is essential to have a multidisciplinary team approach, involving both your hepatologist and nephrologist, to develop a comprehensive treatment plan that considers both your liver and kidney health.

Conclusion
In summary, while the prospect of treating hepatitis C in the context of kidney transplantation is complex, it is not insurmountable. Exploring DAA therapy, maintaining regular monitoring of liver and kidney function, and seeking psychological support are all critical components of your care. The decision to treat should be made collaboratively with your healthcare team, ensuring that both your liver and kidney health are prioritized. Remember, the goal is to achieve the best possible outcome for both organs while maintaining your overall quality of life.

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