The challenging patient: HCV and alcoholic liver disease.
The Challenging Patient: HCV and Alcoholic
Michael R. Lucey1and John R. Lake2
1Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, WI
2Division of Gastroenterology, Hepatology & Nutrition, University of Minnesota, Minneapolis, MN
A 54-year-old man first learned that he had liver dis-
ease 5 years ago. He was complaining of aches and
pains when his wife noticed that his eyes had turned
yellow. He presented to the emergency room and was
referred to the transplant evaluation clinic. Liver trans-
plantation evaluation confirmed that the patient was
infected with hepatitis C virus (HCV) genotype 1a. The
viral copy number was 1.4 million copies/mL HCV
RNA. In addition to jaundice, he had ascites and mild
He had been married for 25 years with 2 children. In
the past he worked in construction, but he had not been
able to work for 2 years before his initial presentation
because of chronic back pain. Before recognition of liver
disease, his normal pattern was to drink 2-4 beers a
day. He answered negatively to all 4 CAGE questions.
He stopped all alcohol when he was given the advice to
stop on account of liver disease. He had no reaction to
stopping alcohol. He had a history of one conviction for
driving while impaired 25 years ago. He went to drivers
education classes to get his license back. He agreed
that he had “experimented” with intravenous drugs
when he was a teenager. He was also tattooed when he
was 18. There is a history of probable alcoholism affect-
ing his mother.
Antiviral therapy was not attempted, and the patient
was placed on the transplant waiting list. Four years
ago, he underwent orthotopic liver transplantation.
Histopathological examination of the explanted liver re-
vealed micronodular cirrhosis without neoplasm. He
received posttransplantation immunosuppression with
tacrolimus, mycophenolate mofetil, and prednisone. He
had no episodes of acute cellular rejection.
Fifteen months after the transplant, when his immu-
nosuppression had been reduced to just tacrolimus, he
was treated with pegylated interferon alfa-2a and riba-
virin. He was unable to tolerate this because of depres-
sion and because of “feeling terrible.” It was stopped
after 8 weeks.
Two years ago, results of a percutaneous liver biopsy
showed one core of hepatic tissue with 14 portal tracts.
The portal tracts contained moderate inflammation,
comprising mostly lymphocytes and plasma cells, with
occasional eosinophils and neutrophils. A few nodular
lymphoid aggregates were also seen. There was mild
interface hepatitis. One to 3 necroinflammatory foci
were found per lobule. Occasional ballooned hepato-
cytes and acidophil bodies were seen. The parenchyma
was negative for marked steatosis, Mallory hyaline,
cholestasis, alpha-1 antitrypsin-like globules, and iron
deposits. A Trichrome-stained slide showed portoportal
fibrous bridging with rare portocentral fibrous bridging.
There was mild pericellular fibrosis. In summary, these
histopathological appearances were characterized as
chronic HCV, grade 2, stage III, with mild pericellular
For the past year, his main problem has been recur-
rent persistent intractable ascites. He underwent a
transjugular intrahepatic portosystemic shunt place-
ment 3 months ago. He was admitted to the hospital 2
months ago with encephalopathy. He was treated with
increased lactulose, and although the symptoms im-
proved, they did not resolve completely.
He says, “I feel lousy.” He has no energy. It takes him
until 3:00 PM to get going. He is monitoring his re-
sponse to lactulose carefully and having at least 4 bowel
movements a day. He has chronic back pain. There is
Abbreviation: HCV, hepatitis C virus.
Published online in Wiley InterScience (www.interscience.wiley.com).
LIVER TRANSPLANTATION 13:S87-S88, 2007
Liver Transplantation, Vol 13, No 11, Suppl 2 (November), 2007: pp S87-S88
no shortness of breath. There is no peripheral edema,
and his ascites is much improved.
He lives at home with his wife. He is on disabil-
ity. He does not smoke cigarettes. He does not drink
alcohol. He uses oxycodone (OxyContin) 3 times
daily, prescribed by the pain clinic, to control his
back pain. He is smoking marijuana 3 or 4 times
daily, which he says calms him and makes the pain
His laboratory values are as follows: international
normalized ratio of prothrombin time 1.7, creatinine
1.7, total bilirubin 2.8, leading to a calculated Model for
End-Stage Liver Disease score of 21. His serum HCV
RNA measured by reverse transcriptase–polymerase
chain reaction is 1,288,000 IU/mL.
Questions are as follows: (1) What is this patient’s
prognosis without retransplantation? (2) Is he a suit-
able candidate for retransplantation? (3) How does
his use of oxycodone (OxyContin) affect his suitability
for transplantation? (4) How does his use of mari-
juana affect his suitability for transplantation?
This case will be discussed by Dr. Lake during the Case Presentations of the AASLD ILTS Transplant Course.
S88 LUCEY AND LALE
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases