C URRENT O PINION Hepatitis C following liver transplantation: current approach and future research opportunities Arif M. Cosar a , Christine M. Durand b , Andrew M. Cameron c , and Ahmet Gurakar a Purpose of review The treatment of hepatitis C virus infection (HCV) in liver transplant recipients was very limited until direct- acting antivirals became widely available. We review the current approach to HCV treatment following liver transplantation and future research opportunities. Recent findings Current treatment of HCV infection with all oral new direct-acting antivirals in the postliver transplant setting is easier, shorter, tolerable, and more effective with high-sustained virological response rates. However, some challenges remain, including the optimal timing of therapy, drug–drug interactions, renal insufficiency, and HIV coinfection. Summary Patients with recurrent HCV following liver transplant will significantly benefit from all oral new direct acting antivirals. Ongoing studies will determine the optimal timing and combination in this unique population. Keywords current treatment, hepatitis C, liver transplant INTRODUCTION Liver transplantation is curative treatment for end-stage liver disease because of different causes and for hepatocellular carcinoma (HCC) [1]. These patients are considered to be more susceptible to infections as well. Additionally, immunosuppres- sive drugs have important drug–drug interactions (DDIs). Some medications such as interferon, which was previously the backbone of HCV treatment, are also considered to be more harmful in the posttrans- plant setting. Hepatitis C virus (HCV) potentially has an immunosuppressive effect on the host and also suppresses cytochrome P450 function [2]. Therefore, posttransplant HCV clearance has important consequences on postliver transplan- tation course and outcomes [3]. HCV infection is one of the most common causes of chronic and end-stage liver diseases. HCV-related end-stage liver disease and HCC are also the major causes of liver transplantation, especially in the developed countries [4–9]. In patients with detectable HCV RNA levels at the time of liver transplantation, recurrence of HCV infec- tion is universal after transplant and has an accel- erated course [10–12]. Recurrence of HCV infection can occur within hours following the transplan- tation. In a study by Gane et al. [13], acute lobular hepatitis was reported in 62%. Recurrent HCV infec- tion is associated with rapid progression to cirrhosis (approximately 20–40% in 5 years after liver trans- plantation), allograft loss, and even death [8,10,14 – 16]. In comparison with other causes, patient and allograft survival rates are lower because of progress- ive fibrosis attributable to HCV [13,17,18]. In the postliver transplantation setting, after establish- ment of cirrhosis because of recurrence of HCV infection in allograft, more than 40% of liver trans- plant recipients progress to decompensated disease in 1 year. In contrast, this decompensation rate a Johns Hopkins University School of Medicine, Division of Gastroenter- ology and Hepatology – Transplant Hepatology, b Johns Hopkins University School of Medicine, Division of Infectious Diseases and c Johns Johns Hopkins University School of Medicine, Liver Transplant Surgery, Baltimore, Maryland, USA Correspondence to Ahmet Gurakar, MD, Section of Gastroenterology/ Hepatology, 720 Rutland Avenue, Ross Research Building, Suite #918, Baltimore, MD 21205, USA. Tel: +1 410 614 3369; fax: +1 410 614 9612; e-mail: aguraka1@jhmi.edu Curr Opin Infect Dis 2016, 29:000–000 DOI:10.1097/QCO.0000000000000274 0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-infectiousdiseases.com REVIEW Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.