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J Hepatol. 2018 Oct;69(4):810-817. doi: 10.1016/j.jhep.2018.06.010. Epub 2018 Jun 27.

Impact of DAAs on liver transplantation: Major effects on the evolution of indications and results. An ELITA study based on the ELTR registry.

Author information

1
Gastroenterology and Hepatology, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy. Electronic address: luca.belli@ospedaleniguarda.it.
2
Gastroenterology and Hepatology, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
3
Centre Hépatobiliaire, Université Paris-Sud, Hôpital Paul Brousse, F-94804 Villejuif, France.
4
Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy.
5
Yale University Liver Center, Department of Medicine New Haven, USA.
6
Centro trapianti di fegato, AO San Giovanni Battista, Torino, Italy.
7
Hospital Universitario y Politecnico La Fe, Unidad de Chirurgia HPB y TX, Valencia, Spain.
8
Hospital Clinic de Barcelona, Dep. of Surgery, University of Barcelona Villaroel, Barcelona, Spain.
9
Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.
10
Liver and Multiorgan Transplantation, Policlinico Sant'Orsola-Malpighi, Bologna, Italy.
11
Hospital Universitari de Bellvitge, Unidad de Transplante Hepatico, Barcelona, Spain.
12
Institute of Liver Diseases, King's College Hospital, Liver Unit, London, UK.
13
Hospital 12 de Octubre, Servicio de Transplante de Oraganos Abdominales, Madrid, Spain.
14
Hospital Universitario Vall D Hebron HBP, Surgery & Transplant Department, Barcelona, Spain.
15
Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland.
16
Chirurgia generale 2 e Trapianti, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy.
17
Department of Hepatology and Liver Transplant Unit, Henri Mondor Hospital, AssistancePublique-Hôpitaux de Paris, Paris-Est University, Creteil, France.

Abstract

BACKGROUND & AIMS:

Direct-acting antivirals (DAAs) have dramatically improved the outcome of patients with hepatitis C virus (HCV) infection including those with decompensated cirrhosis (DC). We analyzed the evolution of indications and results of liver transplantation (LT) in the past 10 years in Europe, focusing on the changes induced by the advent of DAAs.

METHODS:

This is a cohort study based on data from the European Liver Transplant Registry (ELTR). Data of adult LTs performed between January 2007 to June 2017 for HCV, hepatitis B virus (HBV), alcohol (EtOH) and non-alcoholic steatohepatitis (NASH) were analyzed. The period was divided into different eras: interferon (IFN/RBV; 2007-2010), protease inhibitor (PI; 2011-2013) and second generation DAA (DAA; 2014-June 2017).

RESULTS:

Out of a total number of 60,527 LTs, 36,382 were performed in patients with HCV, HBV, EtOH and NASH. The percentage of LTs due to HCV-related liver disease varied significantly over time (p <0.0001), decreasing from 22.8% in the IFN/RBV era to 17.4% in the DAA era, while those performed for NASH increased significantly (p <0.0001). In the DAA era, the percentage of LTs for HCV decreased significantly (p <0.0001) from 21.1% (first semester 2014) to 10.6% (first semester 2017). This decline was more evident in patients with DC (HCV-DC, -58.0%) than in those with hepatocellular carcinoma (HCC) associated with HCV (HCV-HCC, -41.2%). Conversely, three-year survival of LT recipients with HCV-related liver disease improved from 65.1% in the IFN/RBV era to 76.9% in the DAA era, and is now comparable to the survival of recipients with HBV infection (p = 0.3807).

CONCLUSIONS:

In Europe, the number of LTs due to HCV infection is rapidly declining for both HCV-DC and HCV-HCC indications and post-LT survival has dramatically improved over the last three years. This is the first comprehensive study of the overall impact of DAA treatment for HCV on liver transplantation in Europe.

LAY SUMMARY:

After the advent of direct-acting antivirals in 2014, a dramatic decline was observed in the number of liver transplants performed both in patients with decompensated cirrhosis due to hepatitis C virus (HCV), minus 60%, and in those with hepatocellular carcinoma associated with HCV, minus 41%. Furthermore, this is the first large-scale study demonstrating that the survival of liver transplant recipients with HCV-related liver disease has dramatically improved over the last three years and is now comparable to the survival of recipients with hepatitis B virus infection. The reduction in HCV-related indications for LT means that there is a greater availability of livers, at least 600 every year, which can be allocated to patients with indications other than HCV.

KEYWORDS:

EtOH; HBV; HCV; Liver Transplantation; NASH; Waiting list

PMID:
29940268
DOI:
10.1016/j.jhep.2018.06.010

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