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HCV-positive liver transplant cost-effective in patients without HCV

Modelling results from a recent study showed that transplantation of hepatitis C-positive livers into uninfected patients with preemptive direct-acting antiviral therapy was a cost-effective strategy and could improve health outcomes, especially in those with higher MELD scores.

While current guidelines do not recommend the use of HCV-positive donor livers for uninfected patients, Emily D. Bethea, MD, from the Massachusetts General Hospital Institute for Technology Assessment, and colleagues note that the high success rate of DAA treatments represent a chance to revisit HCV-positive organ allocation policies.

“Hepatitis C virus (HCV)-infected donor organs are a potentially underutilized resource,” Bethea and colleagues wrote. “This is becoming increasingly recognized as persons who inject drugs emerge as the fastest-growing donor category, and HCV-positive organs begin to compromise a larger portion of the donor organ supply. With the advent of highly effective direct-acting antivirals (DAAs), the number of patients in need of liver transplantation as the result of HCV related liver disease is expected to decline, while an increasing number of HCV-uninfected patients, remain on the waitlist.”

The researchers used a Markov-based mathematical model to determine the clinical and economic benefit of an uninfected patient accepting an HCV-positive liver with preemptive DAA therapy dependent on MELD scores.

For patients with MELD scores of 22 or higher, accepting any liver was more cost-effective than waiting for an HCV-negative liver with an incremental cost-effectiveness ratio (ICER) of $56,100 vs. $91,700 per additional quality-adjusted life year (QALY).

For patients with MELD scores of 28 — the current median MELD at transplant in the U.S. — accepting any liver was deemed cost-effective with an ICER of $62,000 per additional QALY.

While patients with MELD scores between 18 and 20 had an ICER higher than the commonly accepted willingness to pay threshold of $100,000, accepting an HCV-positive liver was clinically beneficial. Also, patients with poor quality of life and low MELD scores that may not accurately reflect disease severity showed clinical benefit and an ICER that ranged from $57,000 to $66,000.

“Our current model evaluates preemptive DAA therapy, an approach that is likely to be uniformly agreed upon in NAT-positive donor organs exhibiting a universal rate of HCV transmission,” Bethea and colleagues wrote. “As opposed to preemptive therapy, there are potential cost-saving benefits to a reactive approach to DAA initiation in non-viremic donors. However, until additional studies can further evaluate the clinical outcomes associated with these high-risk organs, administration of preemptive therapy irrespective of NAT status is likely to minimize patient harm.” – by Talitha Bennett

Disclosure: Bethea reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures.