Letter from Ireland

Letter from Ireland is the first in a series of correspondence which our Editors hope to present regularly from foreign lands. A group of corresponding editors has been contacted to supply news and information thought to be of interest to our readers. We are happy to begin the new year with this Irish contribution

Letter to the editors

Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Letter to the Editors

Page range: 181-18

Letter to the editors

We read with interest the study by Manzia et al. [1] onthe effect of maintenance of mycophenolate mofetil(MMF) monotherapy on progression of recurrent hepati-tis C virus (HCV) after liver transplantation.The authors concluded: MMF ''monotherapy may cur-rently represent the preferred immunosuppressive alterna-tive for the long-term management of liver transplantrecipients with HCV infection''. However, we believe thatthey should exert great caution in coming to this conclu-sion, as their results [1] have not been properly evaluatedwithin the context of the complete picture of the pub-lished literature on the subject.Our group recently published a review on the role ofMMF and azathioprine in liver transplantation withregard to acute rejection, renal dysfunction and HCVrecurrence [2]. Considering HCV recurrence, we showedthat between 2001 and 2007, 17 studies evaluated MMFand HCV recurrence; among these, only two studies [3,4]found a decreased severity of HCV recurrence with MMFand one of these had no multivariate analysis [3] – citedby Manzia et al. Nine studies (reported in reference 2)documented similar severity of HCV recurrence; however,six studies [5–10] showed increased severity of HCVrecurrence, but only one of these [10] was cited byManzia et al.Therefore, the study by Manzia et al. [1] representsonly the third study out of 18 (17%) showing a beneficialtherapeutic effect of MMF on HCV progression after livertransplantation, whereas 33% shows a deleterious effect.For this reason, in omitting to cite this literature, Maniaet al. have gone against the available evidence in statingthat MMF is the preferred immunosuppressive alternativefor long-term regimen in patients transplanted for HCV-related cirrhosis.Moreover, although Manzia et al. [1] showed in theirpatient cohort a positive association between a favorableeffect of MMF monotherapy on the progression of hepa-tic fibrosis in HCV liver transplant patients, there are sev-eral methodological issues. There was no multivariateanalysis evaluating MMF with respect to fibrosis progres-sion. This is especially important, as the study was retro-spective and nonrandomized and with only 15 patientsper arm. Although other studies have also been retrospec-tive and nonrandomized [2], several have included multi-variate analyses.Thus, overall, the current published evidence for MMFwith respect to the severity of fibrosis and HCV recur-rence does not suggest a beneficial effect. If anything, apotential adverse effect is shown as we pointed out in ourreview [2], although we acknowledged then, and now thatthe evidence is weak.Giacomo Germani