Tailoring immunosuppressants to hepatitis C virus–infected transplant patients

Hepatitis C virus (HCV) is the leading indication for liver transplant in the world. After transplantation, patients remain infected with HCV and are at high risk for recurrent end-stage liver disease. We will review retrospective and prospective studies, which suggest that specific immunosuppressive cocktails are more associated with severe recurrent HCV and relate these studies to in vitro analysis of the effect of immunosuppressants on HCV in vitro. Immunosuppressive antibodies and high-dose steroids have been associated with increased viral replication in the short term, and data also suggest worsening liver disease in the long term. On the other hand, mycophenolate mofetil, azathioprine, and cyclosporine have all been shown to have antiviral properties against HCV in in vitro studies. Although future research is desperately needed, a picture of how the risks and benefits of immunosuppressive regimens in HCV-infected patients differ from non–HCV-infected patients is emerging, and possible recipes for immunosuppressant cocktails tailored to limit HCV while still preventing graft rejection are contemplated.