Victory and defeat at Heraclea - treating hepatitis C infection following liver transplantation with telaprevir and boceprevir.

HCV associated liver disease continues to be the most common indication for liver transplantation in the West. Although the impact of HCV infection varies substantially between recipients, allograft failure secondary to recurrence of HCV infection is the most frequent cause of death and graft failure in HCV infected recipients. Attenuating the impact of HCV on posttransplant patient and graft survival has been a critical priority for transplant physicians and their patients. In this edition of the Journal of Hepatology Duclos-Vallée et al., report the results of a multicenter study of 37 liver transplant recipients (male: 92%, age 57 ± 11 years), who were treated with PEG interferon, ribavirin and boceprevir (n = 18) or telaprevir (n = 19) for recurrence of HCV infection following liver transplantation. The indication for therapy was progressive HCV recurrence (fibrosis stage PF2 (83%) or fibrosing cholestatic hepatitis (16%)). Eighteen patients were treatment-naive, five were relapsers and 14 were nonresponders to prior dual therapy after LT. The patient population was, by and large, typical of recipients with post-LT HCV infection who are considered for boceprevir and telaprevir based antiviral therapy. The main finding of the study by Duclos-Vallée et al., is that a sustained virological response (SVR) at 12 weeks after treatment discontinuation was observed in 20% and 71% of patients in the telaprevir (TVR) and boceprevir (BOC) groups, respectively, for an overall SVR rate of 50%. While a study with an n of 37 may seem unimportant, to dismiss the results of this study would be to miss an opportunity to gain insights into the opportunities and challenges of treating posttransplant HCV infection. The report by Duclos-Vallée et al., which is thoughtful in design and presentation, is not without limitations, including small sample size, lack of randomization and absence of a prospective antiviral treatment protocol. To focus on the shortcomings would, however, be a disservice to the field and the authors. There are important lessons to be had. The first and most obvious lessons are that boceprevir and telaprevir are neither particularly effective nor safe in this patient population. While