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Liver transplant indications changing, survival better in DAA era

The number of liver transplantations due to hepatitis C-related decompensated cirrhosis and hepatocellular carcinoma declined rapidly over the last 3 years while posttransplant survival has improved, according to data from the European Liver Transplant Registry .

“This study shows for the first time on a large scale the use of direct-acting antiviral drugs giving major improvement in HCV recipient survival,” Luca Saverio Belli, MD, from the Niguarda Hospital in Milan, Italy, and colleagues wrote. “This trend is expected to continue provided that current policies aiming to eradicate HCV infection in the population are maintained.”

To determine the effect of direct-acting antivirals on the rate of HCV-related liver transplants, Belli and colleagues analyzed the available data and defined three treatment eras: 2007 to 2010, when only interferon and ribavirin were available; 2011 to 2013, when pegylated interferon become available; and the DAA era from 2014 to 2017.

The researchers found data on 60,527 patients who underwent liver transplant between January 2007 and June 2017, of whom 20.6% had HCV. The indications for liver transplant were decompensated cirrhosis in 71.7% of patients and HCC in 28.3% of patients.

HCV-related disease as indication for liver transplant decreased from 22.8% in the interferon era to 17.4% in the DAA era (P < .0001), with a significant decline from 13.2% to 8% in HCV-related decompensated cirrhosis (P < .0001). The rate of HCV-related HCC as an indication remained stable from 9.5% to 9.4%.

In the DAA era, the researchers observed a significant decline of HCV as an indication for liver transplant from 21.1% in the first half of 2014 to 10.6% in the first half of 2017 (P < .0001).

Three-year survival improved in patients with HCV-related decompensated cirrhosis from 65.1% in the interferon era to 76.9% in the DAA era (P < .0001) and HCV recurrence as the cause of death or retransplant decreased from 6.37% to 1.27% between the same periods (P < .0001).

Similarly, HCV recurrence as cause of death or retransplant decreased among patients with HCV-related HCC from 5.89% in the interferon era to 0.6% in the DAA era (P < .0001).

“A positive result from decreased need of LT for HCV-related indication is greater availability of donor livers, at least 600 every year in Europe, which may be allocated to indications other than HCV,” the researchers noted. “How to best allocate this relatively ‘increased availability of grafts’ is a question that needs to be urgently addressed. It is not unreasonable to anticipate a new scenario where patients once excluded from many LT programs such as those with HCC beyond Milan criteria or those with alcoholic hepatitis are likely to be considered as candidates for LT in the near future.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.