Considerations When Treating Hepatitis C in a Cirrhotic Transplant Candidate

Area of Science:

• Hepatology
• Transplant Surgery
• Infectious Diseases

Background:

• Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver transplantation (LT).
• Direct-acting antiviral (DAA) therapies offer high cure rates for HCV but their optimal timing in LT candidates is debated.

Purpose of the Study:

• To review the complexities of deciding when to initiate DAA therapy for HCV-positive patients who are candidates for LT.
• To evaluate the impact of DAA treatment timing on liver function, transplant candidacy, and outcomes.

Main Methods:

• Literature review of studies investigating DAA therapy in liver transplant candidates.
• Analysis of patient outcomes based on disease severity (MELD score, Child-Pugh class) and treatment timing (pre- vs. post-LT).

Main Results:

• HCV cure with DAAs can improve liver function and potentially lead to delisting in some patients.
• For patients with significant hepatic impairment (MELD > 16-20), pre-LT DAA may offer reduced cure rates, increased decompensation risk, and fewer transplant opportunities.
• Post-LT DAA therapy is associated with better response, tolerability, and access to a wider donor pool, including HCV-positive organs.
• Preliminary data on increased hepatocellular carcinoma (HCC) recurrence post-DAA requires further investigation.

Conclusions:

• Patients with advanced liver disease (MELD > 16, CTP-B/C) and HCC awaiting LT may benefit more from post-LT DAA treatment.
• Timing of DAA therapy should be individualized based on MELD score, liver function, and transplant status.
• Further prospective studies are needed to clarify the association between DAAs and HCC recurrence.