Transplant issues related to HCV are an active area of research and inquiry, particularly with regard to the use of infected organs. We sat down with transplant expert Gregory T. Everson, MD, to review recent findings and the current state of research. Dr. Everson recently retired from his role as Director of the Section of Hepatology at the University of Colorado. He is now focused on his current passion, liver function tests, as CEO of HepQuant, a company he founded in 2007. Here are some highlights of the interview with Dr. Everson.
Some studies are showing that up to one-third of HCV-infected liver transplant candidates can be removed from the waiting list due to substantial improvement in liver function after treatment with direct-acting antiviral (DAA) therapy. What are the long-term implications of delisting these individuals?
Dr Everson: Most of these patients who have cirrhosis will experience the long-term benefit of improvement in liver function and experience a slow sustained improvement in liver-related health. Those with significant improvement in liver health are candidates for delisting. However, the big concern is whether they will remain free from risk of liver cancer, since liver cancer is a consequence of cirrhosis.
A recent European study highlighted this potential problem. The study showed that, two years after cure of the HCV and delisting, some of these patients developed liver cancer. This raises the question of whether we should delist these patients at all, because we don't know who's going to get the liver cancer. Perhaps most importantly, if a liver transplant program decides to delist a patient, it behooves the program to continue very careful surveillance for liver cancer--you can't just tell these people, "You're out of the woods and you're going to get better."
"The study showed that, two years after cure of the HCV and delisting, some of these patients developed liver cancer. This raises the question of whether we should delist these patients at all..."
The main study on delisting was a European study, and the US experience may be different. For example, in the European study the mean MELD (model for end-state liver disease) score of delisted patients was 9; typically in the United States, listing for transplant would not occur until MELD score has risen to 15 or higher. Patients with HCV cirrhosis and MELD 9 would be treated with DAAs but would not be listed. Due to this practice, the number of patients listed for liver transplant for HCV cirrhosis has dramatically declined. The current US recommendation after curing HCV in cirrhosis is to maintain surveillance for liver cancer—imaging the liver by ultrasonography or CT or MRI at least annually.