People with end-stage liver disease (also called decompensated cirrhosis) need a liver transplant.

Treating hepatitis C at this stage is usually not recommended because of severe side effects—including life-threatening bacterial infections, low platelets and anemia—and the possibility that liver function may actually worsen during HCV treatment.

Sometimes, pegylated interferon and ribavirin are started at a low dose, which is gradually increased if tolerated. If treatment is working, and hepatitis C viral load becomes undetectable and stays that way until transplantation, HCV can be cured and re-infection of the new liver is avoided.

HCV protease inhibitors have not been studied in liver transplant candidates.

Liver transplant recipients

Hepatitis C always comes back after liver transplantation if treatment wasn't successful before surgery. This is because the virus is in the bloodstream as well as the liver. Medications that prevent the immune system from rejecting the new liver may also lead to faster hepatitis C.

Hepatitis C can be treated after liver transplantation, but side effects can be severe. Cure rates among transplant recipients with HCV genotype 1 are approximately 25 percent, even when full-dose pegylated interferon and ribavirin are used; they are higher for people with HCV genotypes 2 and 3.

HCV protease inhibitors have not been studied in liver transplant recipients.