1. Recurrent Hepatitis C Post OLT for HCC and Cirrhosis

2. History
76 year old white female with chronic hepatitis C (genotype 1b) acquired in 1975 through blood transfusion
HCV cirrhosis
H/O varices
No encephalopathy
No ascites

3. Hepatitis C Biopsy G-4 S-3 (June 1999)
Interferon (standard) and RBV in 1999 – 2000 (6 months)
Virological and biochemical remission
Stopped after 6 months due to
Profound anemia
Erythema nodosum
Pegylated interferon (40mcg) + RBV (800mg) in Stopped after 3 months due to severe anemia despite GF supplementation.
Cirrhosis of liver documented on biopsy in 2002 (grade 4 and stage 4)

4. Clinical Course AFP high 25.5 in March 2003 but U/S negative
Development of pedal edema (03) and ascites (April 04) – MELD of 9 (August 04)
Secondary iron overload with ferritin of 1417, iron 235
MRI showed nodules (Siderotic?)
HFE phenotype is negative
Phlebotomy 250 cc/month
EGD showed esophageal varices (grade 2–3), never bled, on nadolol

5. Clinical Course Decompensated cirrhosis with a MELD score of 10
AFP 14 (4/06)
US in 4/06 showed 3 lesions in the right lobe measuring 1.2x1.2x1.3cm, 2.7x3.2x3.3 cm and 1.8x1.4X2 cm

9. Liver Transplantation
Roux-en-Y liver transplant on 7/9/06 for decompensated cirrhosis and HCC (within Milan criteria)
CMV +D/–R
Explant pathology
Well to moderately differentiated multifocal HCC
Total 5 lesions, largest 2.5cm (necrotic)

10. Post Transplant Course
Recurrent HCV infection on biopsy (grade 3 and stage 1 with mild ACR)
Treated for rejection episode
Malnutrition and anemia
CMV positive by PCR and CMV positive on liver biopsy. Treated with gancyclovir
Episode of rejection when CMV positive
Most recently on Rapa and steroid

11. Follow-up AFP within 2–3 range since transplanted (6 years)
No HCC recurrence
Recurrent HCV not treated after the OLT due to severe adverse effects in the past

12. Follow-up triple phase CT at one year

13. Follow-up triple phase CT (one year)
Follow-up triple phase CT at two years