Treatment with direct-acting antivirals (DAAs) before liver transplantation is associated with improved outcome and appears to be safe in patients with decompensated hepatitis C (HCV)-related cirrhosis, according to a retrospective data analysis published in the European Journal of Gastroenterology & Hepatology.1
DAA combinations are associated with high rates of virologic response, even in patients previously considered difficult to treat, such as patients with compensated cirrhosis,2-6 which may lead to the recovery of liver function and the avoidance of liver transplantation. However, clinical deterioration during DAA treatment has been reported.7,8 In addition, the possibility of “Model for End-Stage Liver Disease (MELD) purgatory” or lowering a patient’s position on the waiting list even though the patient’s overall health and quality of life remain impaired as a result of DAA treatment before liver transplant has been debated.9 Therefore, researchers in Germany performed a multicenter national study of 35 patients with liver cirrhosis related to HCV infection, high MELD scores (≥15), and no contraindications to liver transplantation to evaluate treatment strategies (DAA first vs transplantation first) and clinical outcome.1
Researchers found that in the majority of patients (85.7%), DAA therapy was initiated before liver transplantation and survival rates (82.1 vs 40%, P =.078) and change in MELD (−2.68±6.2 vs 5.8±14.4, P=.157) were numerically better in this group compared with patients from whom DAA therapy was withheld. In addition, DAA treatment was more often initiated in patients with better liver function. Of the patients, 3 discontinued DAA treatment because of clinical deterioration (all had MELD scores >20 at the start of therapy).
The study authors concluded that, “At liver transplant centers in Germany DAA before LT [liver transplant] is attempted in the majority of cases. It appears to be associated with an improved outcome and seems safe at least in individuals with MELD below or equal to 20.”1
- Sandmann L, Dörge P, Wranke A, et al. Treatment strategies for patients with decompensated liver cirrhosis due to hepatitis C virus infection eligible for liver transplantation: real-life data from five German transplant centers [published online February 21, 2019]. Eur J Gastroenterol Hepatol. doi:10.1097/MEG.0000000000001386
- Afdhal N, Reddy KR, Nelson DR, et al. Ledipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl J Med. 2014;370:1483-1493.
- Afdhal N, Zeuzem S, Kwo P, et al. Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. N Engl J Med. 2014;370:1889-1898.
- Feld JJ, Jacobson IM, Hezode C, et al. Sofosbuvir and velpatasvir for HCV genotype 1, 2, 4, 5, and 6 infection. N Engl J Med. 2015;373:2599-2607.
- Foster GR, Afdhal N, Roberts SK, et al. Sofosbuvir and velpatasvir for HCV genotype 2 and 3 infection. N Engl J Med. 2015;373:2608-2617.
- Zeuzem S, Foster GR, Wang S, et al. Glecaprevir–pibrentasvir for 8 or 12 weeks in HCV genotype 1 or 3 infection. N Engl J Med. 2018;378:354-369.
- Welker MW, Luhne S, Lange CM, et al. Lactic acidosis in patients with hepatitis C virus cirrhosis and combined ribavirin/sofosbuvir treatment. J Hepatol. 2016;64:790-799.
- Dyson JK, Hutchinson J, Harrison L, et al. Liver toxicity associated with sofosbuvir, an NS5A inhibitor and ribavirin use. J Hepatol. 2016;64:234-238.
- Carrion AF, Khaderi SA, Sussman NL. Model for end-stage liver disease limbo, model for end-stage liver disease purgatory, and the dilemma of treating hepatitis C in patients awaiting liver transplantation. Liver Transpl. 2016;22:279-280.