Changing Trends in Liver Transplant Indications

By Will Boggs MD

January 24, 2017

NEW YORK (Reuters Health) - Hepatitis C virus (HCV) infection is declining while nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD) are increasing as indications for liver transplant, according to U.S. data.

"The decrease in HCV among patients with chronic liver failure (aka decompensated cirrhosis) was striking and likely reflects the positive consequences of more efficacious and safe therapies for HCV," said Dr. David Goldberg from Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

"However, the continued prevalence of HCV among patients with hepatocellular carcinoma in the broader population, as well as the transplant waitlist, demonstrates the continued risk of HCC in patients with HCV cirrhosis, even after their HCV is cured," he told Reuters Health by email.

For the last 20 years, HCV has been the most common indication for liver transplantation in North America and Western Europe, Dr. Goldberg and colleagues note in Gastroenterology, online January 13. With the improved treatment of HCV infection, nonalcoholic fatty liver disease has emerged as an important indication for liver transplantation, they add.

The team used data from the National Health and Nutrition Evaluation Survey (NHANES), the HealthCore Integrated Research Database (HIRD) of commercially insured patients, and the Organ Procurement and Transplantation Network/United Network for Organ Sharing to evaluate temporal trends in the burden of liver disease in the U.S.

Between 2006 and 2014, among patients with compensated cirrhosis, there were decreases in the percentages with HCV and ALD and increases in the percentage with NASH.

During the same interval, HCV and ALD decreased as causes of chronic liver failure, while NASH nearly tripled in percentage, passing HCV as the leading cause of chronic liver failure in 2014.

Among patients with hepatocellular carcinoma (HCC), there were decreases in the percentage with HCV and ALD and a small increase with NASH.

Liver transplant waitlist data followed a similar pattern. The percentage of patients with chronic liver failure caused by HCV was stable between 2004 and 2012 and dropped precipitously over the next three calendar years. This was accompanied by a progressive, continued increase in the percentage of patients with ALD and NASH.

Between 2002 and 2014, the absolute number of patients added to waitlists for HCC increased dramatically for patients with HCV, but only modestly for other causes of liver disease.

According to Medicare data, the number of prescriptions for direct-acting antiviral agents against HCV increased by a factor of five between 2013 and 2015, the period during which there were decreasing numbers of patients waitlisted and transplanted for chronic liver failure in the setting of HCV.

"The rise in waitlistings and transplants in patients with NASH and alcoholic liver disease requires better risk stratification of patients with NASH and concomitant medical co-morbidities (i.e., diabetes, cardiac disease) and alcoholic liver disease at risk for alcohol relapses," Dr. Goldberg said.

"Despite the decreased prevalence of cirrhosis due to HCV, and the lower rates of waitlisting for chronic liver failure due to HCV, there still are millions of infected patients," he said. "There is a continued need to broadly employ birth-cohort screening to identify patients with HCV, and to strengthen linkage-of-care to treat patients before cirrhosis develops, or in those with cirrhosis, treat prior to liver decompensation."


Gastroenterology 2017.