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Liver waitlist outcomes for patients with HCV improving in recent years

In recent years, mortality rates and progression of disease severity has decreased among patients with hepatitis C on the liver transplant waitlist, according to recently published data.

“The improvement in survival and disease progression in this population could be attributed to improvement in the management of cirrhosis complications, advances in the quality of medical care in general, access to LT, or perhaps a difference in the selection of patients referred and listed for LT; however, the difference between HCV and non-HCV patients points to factors that are specific to HCV,” Allison Kwong, MD, from the Stanford University School of Medicine, California, and colleagues wrote.

To determine trends in waitlist outcomes, the researchers gathered data on patients from the liver transplant waitlist over three periods: cohort 1 included patients waiting as of Jan. 1, 2004 (n = 6,000); cohort 2 included those waiting as of Jan. 1, 2009 (n = 6,566)); and cohort 3 included those waiting as of Jan. 1, 2014 (n = 8,809).

The study comprised a total of 7,627 patients with HCV and 13,748 patients without HCV on the liver transplant waitlist.

Although there was no apparent difference in 1-year mortality rates among the three cohorts (63% to 65%), the proportion of patients who underwent liver transplantation decreased over time from approximately 21% in cohort 1 and 2 among both patients with HCV and those without HCV to 18.9% for patients with HCV and 17% for those without HCV in cohort 3.

The proportion of patients withdrawn from the waitlist, however, increased at a higher rate among patients with HCV compared with those without.

Compared with patients in cohort 2, patients with HCV in cohort 3 had 21% lower risk for death on the waitlist (HR = 0.79; 95% CI, 0.67-0.93). The researchers observed no significant decrease in waitlist mortality among patients without HCV from cohort 2 to cohort 3.

The mean delta-MELD score increased in patients with HCV from cohort 1 (2.07 per year) to cohort 2 (2.35 per year) but decreased from cohort 2 to cohort 3 (1.9 per year). The trend was less significant among those without HCV.

The rate of liver transplantation declined overall from 26.6 transplants per 100 waitlist years in cohort 1 (95% CI, 25.1-28) to 21.6 per 100 waitlist years in cohort 3 (95% CI, 20.6-22.7).

Although the researchers were unable to associate the improved waitlist outcomes directly with the “direct-acting antiviral era,” they noted that effective DAA-treatment may lead to reduced portal hypertension and overall clinical improvement, which may correlate with the recent improved outcomes.

“One possible alternate hypothesis for the improved waitlist outcomes among HCV positive LT candidates is the increased utilization of HCV-positive donors,” the researchers wrote. “Increased usage of those organs signals increasing confidence in the effectiveness of DAA therapy after LT. The addition of HCV-positive organs to the donor pool may shorten waiting times and increase access to transplantation, especially for HCV patients.” – by Talitha Bennett

Disclosure: The authors report that the study was supported in part by a grant from the National Institute of Diabetes, Digestive and Kidney Disease.