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The future of liver transplantation for viral hepatitis
François Durand1, Claire Francoz1
1Hepatology and Liver Intensive Care, Hospital Beaujon, INSERM U1149, University Paris Diderot, Clichy, France.
Insights
Direct antiviral agents are curing hepatitis C virus (HCV) infections, reducing liver transplantations for HCV-related cirrhosis. However, hepatocellular carcinoma (HCC) risk persists, and non-alcoholic steatohepatitis (NASH) is a growing indication for transplants.
Area of Science:
- Hepatology and Transplantation
- Virology
- Oncology
Background:
- Hepatitis C virus (HCV) and hepatitis B virus (HBV) infections have been major indications for liver transplantation.
- Direct antiviral agents (DAAs) have revolutionized HCV treatment, significantly reducing HCV-related liver disease.
- Nucleos(t)ide analogues (NUCs) are effective in managing HBV, but post-transplant recurrence remains a concern.
Purpose of the Study:
- To analyze the evolving landscape of liver transplantation indications due to viral hepatitis.
- To project the future impact of antiviral therapies on transplantation rates for HCV and HBV.
- To highlight emerging indications like non-alcoholic steatohepatitis (NASH) and ongoing challenges in HBV management.
Main Methods:
- Review of transplantation data and trends in Europe and North America.
- Analysis of the efficacy of DAAs for HCV and NUCs for HBV.
- Discussion of the long-term risks of hepatocellular carcinoma (HCC) in patients with resolved viral hepatitis.
Main Results:
- HCV is projected to account for a decreasing proportion of liver transplant indications.
- Hepatocellular carcinoma (HCC) will remain a significant indication for transplantation, even after HCV cure.
- Non-alcoholic steatohepatitis (NASH) is emerging as a rapidly growing indication for liver transplantation.
- HBV-related cirrhosis is now uncommon, but HCC is the leading indication in HBV patients; post-transplant HBV recurrence is managed but requires continuous prophylaxis.
Conclusions:
- The decreasing incidence of HCV-related cirrhosis will lower HCV's proportion of transplant indications, though HCC risk persists.
- Antiviral therapies have transformed viral hepatitis management, but challenges remain, particularly in preventing HBV recurrence and eliminating residual HBV.
- The overall volume of liver transplantation is unlikely to decrease significantly due to the growing burden of other conditions like NASH and the persistent risk of HCC.
Abstract:
In hepatitis C virus (HCV)-infected patients, transplantation can be justified by decompensated cirrhosis, hepatocellular carcinoma (HCC) or both. During the last decade, HCV infection accounted for about 30% of the indications for transplantation in Europe and North America. Direct antiviral agents (DAAs) are highly effective at curing HCV, even in patients with end-stage cirrhosis. In the future, the incidence of HCV-related decompensated cirrhosis will continue to decrease. The incidence of HCC will also decrease, but a large cohort of patients with cirrhosis will still be at risk of developing HCC even after HCV has been cured. They will continue to represent potential candidates for transplantation. Overall, HCV will account for a significantly lower proportion of indications for transplantation in the future. However, generalization of DAAs is unlikely to affect the total transplantation volume as the gap between donors and potential recipients markedly exceeds 30%. In addition, non-alcoholic steatohepatitis (NASH) is a rapidly growing indication for transplantation. The high barrier to resistance nucleos(t)ide analogues (NUCs) have been used for several years to treat hepatitis B virus (HBV) infection. Decompensated HBV cirrhosis now represents a very uncommon indication for transplantation. HCC remains the leading indication in HBV-infected patients awaiting transplantation. NUCs plus anti-HBs immune globulins or NUCs alone are highly effective at preventing post-transplant HBV recurrence. However, continuous prophylaxis is still needed as extrahepatic HBV particles persist with a potential for recurrence. Post-transplant immunosuppression facilitates recurrence. In the future, an important challenge will be to cure HBV by eliminating residual HBV particles.
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