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Pre-LT DAAs do not increase waitlist drop-out rates due to HCC

Viral eradication with direct-acting antivirals does not appear associated with an increased risk for liver transplant waitlist drop-out due to hepatocellular carcinoma progression in patients with hepatitis C, according to a recently published study.

“Since HCV-HCC patients represent an important proportion of patients on LT waiting lists, it is crucial to understand any drug’s hypothetical effect on oncological progression leading to exclusion or drop-out from the waiting list,” the researchers wrote.

The researchers retrospectively reviewed patients listed for liver transplantation between January 2015 and May 2016 to analyze the rate of exclusion from the LT waitlist. They only included patients in the study if the indication for LT was HCC with HCV-related cirrhosis and detectable viremia at the time of listing.

The study comprised 46 patients: 23 who underwent antiviral treatment with DAAs during the follow-up period and 23 who were untreated during follow-up. Follow-up, defined as the time from listing to transplantation or drop-out, was a median of 10 months (range, 6-19 months) for the treated group and 7 months for the untreated group (range, 5-19 months).

Both groups had comparable patient age, sex, virological characteristics, median number of HCC nodules (2 vs. 2) and median alpha-fetoprotein levels (6 ng/mL vs. 12 ng/mL).

There was no significant difference between the two groups in radiological progression, though there was a positive trend in the treated group compared with the untreated patients (35% vs. 17%). There was no significant difference in drop-out rate between treated and untreated patients due to mortality (13% vs. 13%) or HCC progression. However, the treated patients had a significantly lower probability of being transplanted compared with the untreated patients (P = .04).

Nine treated patients and 14 untreated patients underwent LT. Between the treated patients and untreated patients, there were no significant differences in median total tumor volume of HCC nodules (14.2 cm³ vs. 11 cm³), grade 3 HCC tumor differentiation (12.5% vs. 14.3%) or cases of microvascular invasion (44% vs. 29%).

“Deferring HCV treatment until after LT in order to guarantee access to the expanded pool of HCV-positive donors has been proposed as the most cost-effective strategy for well-compensated HCV-infected cirrhotics listed for liver transplantation with HCC. However, this still depends on HCV epidemiology,” the researchers wrote. “Furthermore, HCV eradication in the pre-LT setting prevents recurrence of liver infection and has been associated to higher survival in patients transplanted for HCC. This finding, together with our results, should further encourage clinicians to treat HCV patients as early as possible, especially in HCC patients awaiting LT, who may be more likely to receive grafts from marginal donors, with the consequent higher risk of post-LT complications.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.