**Clinical Management of Viral Infection**

**1** 

*Pakistan* 

**Antiviral Therapy in HCV-Infected** 

**What we are dealing with:** Hepatitis C virus (HCV) infection is the commonest blood-borne infection, one of the commonest cause of chronic liver disease (CLD) & hepatocellular carcinoma (HCC) and one of the commonest reason for liver transplantation (LT) the world

**What is the meaning of decompensation**: Fibrosis is the histopathological hallmark of chronic hepatitis causing progressive derangement of normal liver architecture with consequent reduction in hepatic synthetic function. CLD is said to be decompensated when one or the other complication of CLD has developed - ascites, variceal bleeding (secondary to portal hypertension), impaired hepatic synthetic function (hypoalbuminemia), jaundice, and/or hepatic encephalopathy. Five years survival rate in decompensated cirrhotics is

**Decompensated cirrhosis is NOT a contraindication to antiviral therapy:**  Decompensated cirrhosis has traditionally been considered a contraindication to interferon and ribavirin therapy. Whereas, the same may be true for advanced cirrhosis (which is only successfully amenable to LT), there are reports in the literature in which antiviral therapy was given *successfully* in selected cases of *early* hepatic decompensation with an aim to attain sustained viral clearance (SVR), halt disease progression and expect potential (though often partial) recovery of hepatic metabolic function. Antiviral therapy may also be instituted to prevent hepatitis C recurrence post-transplantation. If HCV is not eradicated pre-transplantation, reinfection with HCV occurs in *all* transplant recipients *as a rule*, with secondary cirrhosis developing in approximately 30% of cases within 5 years.2 Pre-transplantation HCV eradication is however associated with less likelihood of reinfection and this forms the rationale for treating decompensated cirrhotics awaiting LT with antiviral therapy.3 Initiating pre-emptive post-transplantation antiviral therapy, and treating established post-transplant HCV hepatitis are other options in LT patients. The aim of instituting pre-transplantation antiviral therapy is either to attain a sustained virological response (SVR) at transplantation, or an *on-treatment* HCV RNA clearance at transplantation. Mere reduction of viral load should *not* be the aim because, unlike HBV cirrhotics, this has not been shown to decrease the rate &/or severity of post-

**1. Introduction** 

estimated to be 50%.1

transplant HCV recurrence.

over.

**Decompensated Cirrhotics** 

Fazal-I-Akbar Danish

*Quaid-e-Azam University, Islamabad,* 
