The New Era of Hepatitis C: Therapy in Liver Transplant Recipients

Revolution in the diagnosis and management of hepatitis C virus infection in current era

Chronic hepatitis C virus (HCV) infection is a major global public health problem, particularly in developing part of the world. Significant advances have been made in the early diagnosis and treatment of the disease. Its management has been particularly revolutionized during the past two decades. In this review, we summarize the major advances in the diagnostic and management armamentarium for chronic HCV infection. The focus of the present review is on the newer directly acting anti-viral agents, which have revolutionized the management of chronic HCV infection. Management of uncomplicated chronic HCV infection and of specific complications and special at-risk populations of patients will be covered in detail. Despite the advent and approval of highly effective and well tolerable oral agents, still many challenges remain, particularly the affordability, the equitable distribution and access to later drugs. The World Health Organization aims to eliminate viral hepatitis including HCV by 2030 since its poses a major public health threat. There is an urgent need to ensure uniform and early access to diagnostic and therapeutic facilities throughout the world if the later goal has to be realized.

Delisting and clinical outcomes of liver transplant candidates after hepatitis C virus eradication: A long-term single-center experience

BACKGROUND

Previous short-term studies have reported on liver function improvements and delisting among liver transplantation (LT) candidates with hepatitis C virus (HCV) and decompensated liver cirrhosis after successful antiviral therapy. This study aimed to evaluate the long-term impact of HCV eradication on liver function, portal hypertension, probability of delisting, and clinical outcomes in patients awaiting LT.

METHODS

Forty-five LT candidates with decompensated HCV cirrhosis were prospectively observed after HCV eradication by direct-acting antiviral therapy. The median follow-up (FU) time was 24 months.

RESULTS

Twenty-six (57.8%) patients were delisted due to clinical improvement. Multivariate analysis revealed male gender (hazard ratio (HR) 3.28; p = 0.022), baseline Child - Turcotte - Pugh class C (HR 4.81; p = 0.003), and delta prothrombin index <2% between baseline and the time of sustained virological response (HR 3.82; p = 0.01) as independent risk factors for non-delisting. During a median FU of 21 months after delisting, hepatocellular carcinoma (HCC) developed in 2 (7.7%) patients. Among non-delisted patients, HCC developed in 6 (31.6%) cases, variceal bleeding developed in 3 (15.8%) patients, and spontaneous bacterial peritonitis developed in 2 (10.5%) patients.

CONCLUSION

HCV eradication lead to the delisting of more than 50% of patients, but did not eliminate the HCC risk, and close monitoring of patients should continue after the end of treatment.

Recent advances in liver transplantation with HCV seropositive donors

The paradigm shift from interferon-based to direct-acting antiviral (DAA) therapy for the treatment of hepatitis C virus (HCV) infection has revolutionized the field of liver transplantation. These advances in effective HCV treatment, along with the persistent shortage in available liver grafts, have encouraged investigators to assess the need for adopting more inclusive donor policies. Owing to the poor outcomes following liver transplantation with recurrent HCV infection, liver transplantation using HCV seropositive donors (non-viremic and viremic) had been restricted. However, as a result of the growing supply of HCV seropositive donors from the recent opioid epidemic along with the advent of efficacious DAA therapy to treat HCV recurrence, there has been an increasing trend to use HCV seropositive donors for both HCV seropositive and seronegative recipients. The review aims to discuss recent advances and associated outcomes related to the use of HCV seropositive grafts for liver transplantation.

Changes in practice and perception of hepatitis C and liver transplantation: Results of a national survey

With new practice guidelines, it is important to understand how liver transplant (LT) centers have incorporated direct-acting antivirals (DAAs) into the management of hepatitis C virus-infected (HCV+) candidates and recipients. To explore how DAAs have affected LT centers' willingness to treat HCV+ candidates and recipients and to use HCV+ donors, we surveyed high volume US LT centers (11/2014-12/2015) regarding practices for HCV+ candidates, recipients, and donors, before vs after DAAs. We used the Scientific Registry of Transplant Recipients to compare centers' number of LTs, HCV+ recipients, and HCV+ donors in the years before (1/1/2012-12/31/2013) and after (1/1/2016-12/31/2017) survey administration. Of 80 centers contacted, 57 (71.3%) responded, representing 69.0% of the total volume of LTs in 2013. After DAAs, most centers increased treating candidates with low (≤15) model for end-stage liver disease (MELD) (85.2%), intermediate/high (>15) MELD (92.6%), and hepatocellular carcinoma (79.6%). There was consensus to treat low MELD candidates (90.8% "most of the time/always"), but less certainty for intermediate/high MELD candidates (48.2% "sometimes"). Universal post-LT HCV treatment increased (7.4% vs 57.4%). After DAAs, 42.6% were more willing to use HCV+ donors for HCV+ candidates, and 38.9% were willing to consider using HCV+ donors for HCV- candidates. Overall, with DAAs, centers were more willing to treat HCV+ candidates and recipients and to use HCV+ donors; recent recommendations may help to guide treatment decisions for intermediate/high MELD candidates.