Impact of Hepatitis C Virus (HCV) Antiviral Treatment on the Need for Liver Transplantation (LT)

Esteban Sáez-González; Carmen Vinaixa; Fernando San Juan; Vanesa Hontangas; Salvador Benlloch; Victoria Aguilera; Angel Rubín; María García; Martín Prieto; Rafa López-Andujar; Marina Berenguer

Disclosures

Liver International. 2018;38(6):1022-1027. 

In This Article

Results

Inclusion in the Waiting List

From January 1997 to December 2016, 2379 patients were listed for LT. Of these, 1113 (47%) were listed for HCV cirrhosis ± HCC. Median age of patients with HCV cirrhosis included in the WL for LT was 54 years (IQR 71–45). The median MELD score at listing was 17 (IQR 11–40) and the median Body mass index was 26 kg/m2 (IQR 38–17) (Table 1).

The percentage of patients waitlisted for HCV cirrhosis ± HCC varied significantly over time, declining from 48.8% in the 1997–2009 period to 33% in the final period of 2014–2016 (P = .030) (Table 2 and Figure 1).

Figure 1.

Prevalence of wait–listing for liver transplantation due to HCV cirrhosis ± hepatocellular carcinoma in the last 20 years. Era of antiviral therapy. DAA, direct antiviral agents

In contrast, the percentage of HCV–infected patients who were included in the WL for HCC has significantly increased overtime (P = .0001).

In addition, among HCV–positive decompensated patients without HCC waitlisted for LT, those with an HCV–alcohol mixed etiology have also increased significantly over these years (P = .001).

Overall, from the approval of all oral DAAs regimens in 2014, there has been a 15.8% decrease in the rate of HCV patients included in the WL with respect to the IFN–based regimens era (P = .030). While adjusted incidence of WL inclusion for decompensated HCV cirrhosis decreased by 21% in the DAA era compared to the IFN era, that of HCC in the HCV–patients increased by 15%.

Delisting From the Waiting List

Of 1113 waitlisted HCV–positive patients, 203 (18%) were removed from the list during the study period (20 years). Of these, 77 (38%) patients were delisted due to clinical improvement. During the 1997–2009 period (IFN–based regimens), only 5.6% of 795 waitlisted HCV–positive patients were removed. In the 2010–2013 period (first–generation protease inhibitors), 8% of total waitlisted HCV–positive patients were removed. In the last 2014–2016 period (DAA oral regimens), 17% of total waitlisted HCV–positive patients were removed. These incremental differences were statistically significant (P = .026). Of the last 49 delisted cases, 14 removals from the WL occurred during the last 2014–2016 DAA years (Table 2 and Figure 2).

Figure 2.

Prevalence of HCV–positive patients delisted due to clinical improvement in the last 20 years. DAA, direct antiviral agents Mortality in the WL also decreased in the most recent era but without reaching statistical significance (10.7% vs 13.1% vs 6.5% in the three cohorts).

Mortality in the WL also decreased in the most recent era but without reaching statistical significance (10.7% vs 13.1% vs 6.5% in the three cohorts).

Liver Transplantation

An overall lower rate of LT among HCV waitlisted patients occurred in the DAA era (2014–2016 period) compared to the pre–DAA era (2007–2013 period): 46% vs 48%, without reaching statistical significance. Interestingly, when we analyzed specifically the DAA era (2014–2016 period), we observed a decrease in the rate of LT among HCV waitlisted patients, from 58.8% in 2014 to 41.7% in 2016 (Table 3).

Furthermore, the proportion of waitlisted patients without HCC who underwent LT decreased from 22.7% in the period 2011–2013 to 16.2% in the 2014–2016 all oral DAA period. In contrast, the proportion of waitlisted patients with HCC who underwent LT increased from 23.5% to 30.4% over the same time periods (Table 3).

Median waiting–list times did not decrease over time; in fact, an increase was observed without reaching statistical significance (78 days [range 0–747] vs 138 days[0–1182] vs 184[1–1485]).

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....