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EASL 2017: Hepatitis C Treatment Allows 1 in 4 to Come Off Liver Transplant Waiting List

Around a quarter of people with hepatitis C and decompensated cirrhosis came off liver transplant waiting lists in Europe after direct-acting antiviral (DAA) treatment, and very few had any subsequent liver-related problems during 15 months of follow-up, Luca Belli reported on behalf of the ELITA study investigators at the EASL International Liver Congress last month in Amsterdam.

[Produced in collaboration with infohep.org]

Decompensated cirrhosis leads almost invariably to end-stage liver disease without careful management of portal hypertension, varices, and ascites. The severity of cirrhosis is graded by the MELD score: patients with a MELD score of 10 or above should be considered for a liver transplant.

Direct-acting antiviral treatment is a double-edged sword for people with decompensated cirrhosis who are already on the transplant waiting list. For some, it might improve liver function sufficiently that they no longer need a transplant and experience improvement of symptoms.

But for others, the improvement in symptoms might take them off the transplant list when, in time, a liver transplant would turn out to be the best solution to their liver disease. Treatment would, therefore, have the effect of re-setting the clock on a liver transplant, sending patients back to join the queue once more.

European liver centers have been investigating this question for several years through a multicenter cohort study, ELITA, which looks at people with hepatitis C and decompensated cirrhosis on the transplant waiting list in Italy, Germany, Austria, France, and Spain.

Early findings from the study were presented at last year’s International Liver Congress, showing that about 1 in 5 patients had been taken off the transplant waiting list. Details of outcomes in an expanded cohort, with longer follow-up after treatment were presented at this year's meeting.

The cohort study recruited 142 consecutive hepatitis C patients with decompensated cirrhosis who were candidates for liver transplantation and who underwent direct-acting antiviral treatment between February 2014 and June 2015. Of these, 46% received treatment with sofosbuvir (Sovaldi) plus ribavirin, while the remainder were treated with either sofosbuvir plus daclatasvir (Daklinza) or sofosbuvir/ledipasvir (Harvoni).

Participants were followed for a median of 28 months, including their time on treatment, during which time half underwent a liver transplant.

There were 34 patients (24%) who were delisted. Of these, 1 died due to hepatocellular carcinoma that had probably been diagnosed late due to a missed ultrasound scan 6 months before. There were 2 patients who experienced improvement but subsequently developed decompensation again; 1 underwent a liver transplant and the other was successfully treated for ascites.

Delisting was strongly associated with a baseline MELD score below 16, although a small number of patients with higher MELD scores were delisted, in

most cases after at least 18 months of follow-up. Clinical improvement was also predicted by the degree of change in MELD score 12 weeks after starting DAA treatment.

Delisted patients experienced significant improvement in liver-related outcomes over time. Median follow-up after delisting was 58 weeks. Median MELD score declined significantly, from 14 at baseline to 9 at the last follow-up visit. The proportion of patients with any ascites fell from 82% at baseline to 24% at the last follow-up visit. Hepatic encephalopathy almost disappeared among these patients too: at baseline 29% experienced mild hepatic encephalopathy, but by the last follow-up visit only 3% were experiencing this condition.

Belli emphasized that delisting was good news not only for those who come off the transplant list -- delisting also frees up a liver for another transplant candidate, enabling them to receive a transplant more quickly.

5/1/17

Source

LS Belli, M Berenguer, PA Cortesi, et al. Delisting of liver transplant candidates with chronic hepatitis C virus infection after viral eradication: outcome after delisting, a European study. EASL International Liver Congress. Amsterdam, April 19-23, 2017. Abstract PS-063.