IMPLICATIONS OF CHRONIC HEPATITIS-B OR HEPATITIS-C INFECTION FOR RENAL-TRANSPLANT CANDIDATES

Hepatic cirrhosis and clinically active hepatitis due to HBV or HCV infection clearly contraindicate kidney transplantation. More controversial is the attitude to be adopted towards candidates with clinically quiescent chronic HBV or HCV infection. The presence of the HBs antigen does not adversely affect survival or increase morbidity on maintenance haemodialysis, at least during the first decade. After transplantation, by contrast, the long-term outcome of HBV infection is undoubtedly worse than on haemodialysis: more patients develop chronic hepatitis and eventually die from liver disease. The risk of fatal liver disease after transplantation is greater in patients with markers of active viral replication before transplant and in those with severe histological liver lesions, Pretransplant candidates should be warned of this significant risk factor. Comparison of survival of HCV-infected patients on haemodialysis and after transplantation is not yet possible. The outcome of HCV infection after transplantation appears less severe than that of HBV infection: the survival of anti-HCV-positive patients is similar to that of anti-HCV-negative patients, at least during the first decade after transplantation. Liver biochemical abnormalities, serological markers and detection of HCV RNA are of little value to identify patients at greater risk of poor outcome after transplantation. Only liver biopsy might help identify such patients. Both efficacy and risks of antiviral therapies are yet to be properly assessed during haemodialysis. Preliminary evidence suggests that interferon therapy given after transplantation entails an unacceptable rate of deterioration in graft function. At the present time, positive HBs antigen with negative HBe antigen as well as anti-HCV-positive patients with clinically quiescent infection should not be denied kidney transplantation.