As direct‐acting antiviral (DAA) agents become more readily available for the treatment of chronic hepatitis C, it is important to understand real‐world treatment experiences. In order to assess the effectiveness of DAA regimens and factors that influence sustained virologic response (SVR) rates in the Veterans Affairs healthcare system, we retrospectively identified veterans with chronic hepatitis C who were treated with DAAs from January 2014 to June 2015. We determined SVR rates and collected data on demographics, genotype (GT), previous interferon‐based treatment, antiviral regimens, and co‐morbidities (HIV, prior solid organ transplant, haemodialysis) for analysis. Of 15 720 veterans, the majority were infected with genotype 1a (GT1a, 60.5%). Excluding the special populations, the overall cohort SVR rate was 92%. Compared to treatment‐experienced patients, treatment‐naïve patients had significantly higher SVR rates (90% vs 92%, P = .006). Subgroups associated with lower likelihood of achieving SVR‐included African Americans (OR 0.79, 95% CI 0.69‐0.91), GT3 (OR 0.65, CI 0.50‐0.86), and cirrhosis (OR 0.91, CI 0.84‐0.99) or decompensated cirrhosis (ascites: OR 0.78, CI 0.67‐0.91, variceal bleed: OR 0.75, CI 0.57‐0.99). The only treatment regimen independently associated with lower SVR rates was SOF+RBV+IFN (OR 0.65, CI 0.50‐0.84). Special populations achieved high SVR rates: HIV 92%, haemodialysis 93%, liver transplant 96% and renal transplant 94%. In conclusion, overall SVR rates were comparable to those reported in clinical trials and carried over to historically more difficult‐to‐treat patients. Several patient‐ and treatment‐related factors were identified as independent predictors of treatment failure and suggest subgroups to target for efforts to improve therapeutic strategies.

The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a validated interview tool to assess psychosocial well‐being in candidates for solid organ transplants, with higher scores indicating greater vulnerability. We hypothesized that patients with alcohol‐related liver disease (ALD) undergoing liver transplantation (LT) evaluation would have higher SIPAT scores than candidates with non‐ALD, but that only patients with ALD who have low scores would be selected. We analyzed retrospectively consecutive adults undergoing LT evaluation from June 2018 to December 2019. Comparisons between patients with ALD and patients with non‐ALD were made using the nonparametric Wilcoxon rank sum test plus a multivariate analysis to determine independent predictors for approval. In the study cohort of 358 patients, there were 199 (56%) patients with ALD with a mean age of 55 years, and 133 (67%) were men. There were 159 (44%) patients with non‐ALD with a mean age of 57 years, and 95 (60%) were men. Mean Model for End‐Stage Liver Disease–sodium scores were similar for selected versus not selected patients with ALD (25 versus 25.6) and selected versus not selected patients with non‐ALD (18.3 versus 17.4), although the ALD group had substantially higher Model for End‐Stage Liver Disease scores. Patients with ALD had higher mean SIPAT composite and individual domain scores compared with their non‐ALD counterparts. SIPAT scores were not affected by age or sex. Proportionately more candidates with non‐ALD were selected compared to candidates with ALD (68% versus 42%; P < 0.001; odds ratio for approval of non‐ALD versus ALD, 2.9; 95% confidence interval, 1.8‐4.7; P < 0.001). Composite SIPAT scores were lower in the selected versus nonselected in both ALD and non‐ALD groups, although the SIPAT scores were significantly higher in selected patients with ALD (median, 39) than selected patients with non‐ALD (median, 23; P = 0.001). Psychosocial assessment has a greater influence than acuity of liver failure on the selection of patients with ALD for LT listing, whereas psychosocial assessment has a minor influence on the selection of non‐ALD candidates.

A coordinated holistic approach that focuses on limiting immunosuppression, infection, risky behaviors, and CV risks, while screening for cancer, is needed to extend the healthy lives of LT recipients.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/10-3-reading-daniel.html a video presentation of this article