Treatment strategies for patients with decompensated liver cirrhosis due to HCV infection – Antiviral treatment or liver transplantation first?

Question:

Since the availability of oral direct acting antivirals (DAA) chronic hepatitis C virus infection can be treated effectively in almost all patients. However, treatment of patients with decompensated cirrhosis remains difficult since clinical deterioration and the need for transplantation despite prior antiviral treatment have been reported. On the other hand antiviral treatment after transplantation leads to viral eradication with high certainty. Whether initiation of antiviral treatment in patients with decompensated cirrhosis and high MELD scores should be preferred to liver transplantation as a curative treatment strategy remains unclear. Therefore we analyzed treatment strategies of German liver transplantation centers retrospectively since introduction of DAA in August 2014 to compare clinical outcome based on treatment strategy (DAA vs. transplantation) for patients with high MELD scores.

Methods:

We performed a retrospective data analysis of patients with decompensated liver cirrhosis due to HCV infection being treated at five different DZIF affiliated transplantation centers in Germany. Patients with MELD scores of 15 or higher and positive HCV RNA who have not yet been listed for othotopic liver transplantation were included in this analysis. Treatment strategy (DAA first vs. transplantation first) and clinical data as well as overall outcome like SVR, MELD and death were compared to deduce general treatment recommendations based on MELD level for those patients.

Results:

So far 22 patients are enrolled in the study while data of one center is still pending. Preliminary results show a MELD score of 18 (/- 3.9) at first visit. 16 patients (72.7%) received DAA first (MELD 17.1/- 4.2, max 27, min 11) and 81% (n = 13) achieved SVR; 61.5% (n = 8) patients showed stable MELD, whereas 38.5% (n = 5) had an increase in MELD score leading to transplantation (n = 1) or death (n = 2). Six patients (27.3%) did not receive antiviral treatment (MELD 21.5/- 5.2, max 32, min 16) leading to three deaths (50%) with one on the waiting list, one transplantation with successful antiviral treatment afterwards and one patient still awaiting transplantation.

Conclusion:

So far preliminary results show a trend towards antiviral treatment prior to transplantation in patients with MELD scores below 20. Treated patients show relatively high rates of SVR and a majority developed stable MELD scores. Nevertheless one third of treated patients showed clinical deterioration after treatment. Definite results and possible treatment recommendations will be available after all data has been received and final analysis can be performed.