Decreasing Mortality and Disease
Severity in Hepatitis C Patients Awaiting
Liver Transplantation in the United States
Allison Kwong ,
W. Ray Kim,
and Donghee Kim
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA; and
Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
Hepatitis C virus (HCV) infection has been the leading indication for liver transplantation (LT) in the United States.
Since 2013, interferon-free antiviral therapy has led to sustained virological response in many LT candidates. We com-
pared the wait-list mortality of HCV patients with that of patients with other chronic liver diseases. Data for primary
LT candidates were obtained from the Organ Procurement and Transplantation Network database. Adult wait-list
registrants were divided into 3 cohorts: cohort 1 included patients on the waiting list as of January 1, 2004; cohort 2 as
of January 1, 2009; and cohort 3 as of January 1, 2014. The primary outcome was wait-list mortality, and the second-
ary outcome was the rate of change in Model for End-Stage Liver Disease (MELD). Multivariate Cox proportional
hazards analysis was performed to evaluate 12-month wait-list mortality. The cohorts included 7627 LT candidates
with HCV and 13,748 patients without HCV. Compared with cohort 2, HCV patients in cohort 3 had a 21% lower
risk of death (hazard ratio [HR], 0.79; 95% conﬁdence interval [CI], 0.67-0.93). Among patients with non-HCV liver
disease, no difference in mortality was seen between cohorts 2 and 3 (HR, 0.97; 95% CI, 0.86-1.09). Among HCV
patients, the mean rate of change in MELD decreased from 2.35 per year for cohort 2 to 1.90 per year for cohort 3,
compared with 1.90 and 1.66 in cohorts 2 and 3, respectively, among non-HCV patients. In this population-based
study, wait-list mortality and progression of disease severity decreased in recent HCV patients for whom direct-acting
Liver Transplantation 24 735–743 2018 AASLD.
Received June 30, 2017; accepted October 13, 2017.
SEE EDITORIAL ON PAGE 727
According to the World Health Organization, approx-
imately 3% of people worldwide (more than 170 mil-
lion people) have been infected with hepatitis C virus
In the United States, the prevalence of
HCV infection is estimated to be 2.7-5.2 million, with
up to 20% having developed cirrhosis.
HCV population ages, the number of patients with
complications of liver cirrhosis including hepatocellular
carcinoma (HCC) has increased, a trend projected to
continue in the foreseeable future.
disease due to HCV infection has been the most com-
mon indication for liver transplantation (LT) in the
LT candidates with HCV may beneﬁt from effec-
tive antiviral therapy. Sustained virological response
(SVR) in LT candidates eliminates the risk of post-LT
HCV recurrence and can potentially prevent further
clinical deterioration on the waiting list.
interferon era, HCV treatment in patients with
decompensated cirrhosis was not only ineffective, but
In late 2013, approval of sofosbuvir, a
potent and safe direct-acting antiviral (DAA), her-
alded a revolutionary era in the treatment of chronic
HCV. The efﬁcacy and safety of sofosbuvir-based
therapy in patients with decompensated cirrhosis have
been demonstrated, with most patients exhibiting
improved Model for End-Stage Liver Disease
(MELD) scores after treatment.
Given the high
achievable rate of SVR and tolerability in patients with
Abbreviations: BMI, body mass index; CI, conﬁdence interval; DAA,
direct-acting antiviral; HCC, hepatocellular carcinoma; HCV, hepa-
titis C virus; HR, hazard ratio; INR, international normalized
ratio; IQR, interquartile range; LT, liver transplantation; MELD,
Model for End-Stage Liver Disease; OPTN, Organ Procurement
and Transplantation Network; SD, standard deviation; SVR, sus-
tained virological response.
KWONG ET AL.