HCV management varies in transplant setting

BOSTON — Management of hepatitis C virus before and after transplantation varies in the United States, according to results of a survey of medical directors at US liver transplant programs.

Paul J. Gaglio, MD, from the department of medicine at Albert Einstein College of Medicine, and colleagues sent an electronic survey to medical directors of US liver transplantation programs to determine pre- and post-transplant treatment strategies for HCV around the country. The survey was administered before FDA approval of simeprevir (Olysio, Janssen Therapeutics) and sofosbuvir (Sovaldi, Gilead), Gaglio told HCV Next.

Thirty-seven of 110 medical directors responded to the survey.

Sixty-five percent of respondents reported routine treatment of HCV before transplantation in their program; 25% required negative HCV RNA levels before transplant.

Most respondents (95%) indicated willingness to use a liver from an HCV-positive donor for transplant in a recipient with HCV, and 93% would re-transplant if graft failure due to HCV occurred. However, most respondents suggested that a waiting period of 1 year was required before transplanting again.

Nearly two-thirds (62%) reported alternative immunosuppression strategies for patients with HCV in their program. The most common alternative strategies were a smaller postoperative steroid bolus and rapid steroid taper. Sixty-four percent of respondents reported using tacrolimus over cyclosporine for immunosuppression of patients with HCV, according to the study abstract.

Per-protocol biopsies at specific time points after transplantation were commonly performed (87%). Reasons for treating HCV varied among respondents. The most common trigger for treatment was fibrosis score of 2 or higher (97%), followed by cholestatic hepatitis (81%) and increased liver enzymes (19%), according to the abstract.

“We found a lot of heterogeneity in how clinicians behaved in treating these patients,” Gaglio said in an interview.

HCV treatment most often included antiviral therapy (97%), decreasing/discontinuing prednisone (35%) or mycophenolate (32%), or converting treatment from tacrolimus to cyclosporine (30%). More than 70% of respondents reported post-transplant antiviral therapy that included a protease inhibitor plus pegylated interferon and ribavirin, and 28% reported use of pegylated interferon and ribavirin.

If available at the time of the survey in the pre-transplant setting, 62% of respondents said they would have used sofosbuvir plus ribavirin, 32% would have used sofosbuvir plus pegylated interferon and ribavirin, and 8% would have used simeprevir plus pegylated interferon and ribavirin in a patient with HCV genotype 1 infection. Seventy-eight percent of respondents expressed willingness to use an all-oral direct-acting antiviral regimen, with 51% suggesting that they would use it before transplant and 19% suggesting that they would use it after transplant; 30% would use this therapy in patients with clinically significant HCV recurrence in the graft. – by Rob Volansky

For more information:

Gaglio PJ. Poster 708. Presented at: The Liver Meeting; Nov. 7-11, 2014; Boston.

Disclosure: The researchers report associations with companies including Boehringer Ingelheim, Bristol-Myers Squibb, Genentech, Gilead, Janssen Therapeutics, Merck, Otsuka, Salix and Vertex.