Changing Population of Liver Transplant Recipients in the Era of Direct-acting Antiviral Therapy

Abstract

Background and Aims: With the availability of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection and changing liver disease etiology for liver transplantation (LT), data on the changes in LT recipient population in the DAA era are scanty. Methods: The United Network for Organ Sharing (UNOS) registry (01/2007 to 06/2018) was used to develop a retrospective cohort of LT recipients for HCV, alcohol-associated liver disease (ALD), and non-alcoholic steatohepatitis (NASH). LT recipients in the DAA era (2013-2018) were compared with those in the pre-DAA era (2007-2012) era for recipient characteristics. Chi-square and analysis of variance were the statistical tests used for categorical and continuous variables, respectively. Results: Of 40,309 LT recipients (21,110 HCV, 7586 NASH, and 11,713 ALD), the 21,790 in the DAA era (9432 HCV, 7240 ALD, and 5118 NASH) were more likely to be older, female, obese, diabetic, have acute-onchronic liver failure with a higher model for end-stage liver disease score, receive grafts with a lower donor risk index, and have waited on the LT list for a shorter period compared with their pre-DAA era counterparts. Specific to ALD, LT recipients with alcohol hepatitis were more likely to be younger at the time of LT. Of 9895 LT recipients with hepatocellular carcinoma, recipients in the DAA era were observed to have a higher proportion of HCV (43% vs. 32%, p<0.001), a lower proportion of ALD (9% vs. 12%, p<0.001), and no change for NASH (13% vs. 13%, p=0.9) compared with the pre-DAA era. Within the hepatocellular carcinoma population, LT recipients in the DAA era were older, diabetic, and waited on the LT list longer compared with their pre-DAA counterparts. Conclusions: Along with changing liver disease etiology in the DAA era, the LT recipient population demographics, comorbidities, liver disease severity, and graft quality are changing. These changes are relevant for future studies, immunosuppression, and post-transplant follow-up.

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization

“…This finding is in alignment to previous reports with NASH etiology as the fastest growing indication for use of SLK, likely due to concomitant comorbidities such as diabetes, hypertension, and obesity 20 . Among candidates listed for LT alone who have renal dysfunction at listing, ALD etiology was most strongly associated with receipt of LT, likely due to presence of concomitant alcoholic hepatitis with severe disease and younger age in this population 29,30 …”

“…20 Among candidates listed for LT alone who have renal dysfunction at listing, ALD etiology was most strongly associated with receipt of LT, likely due to presence of concomitant alcoholic hepatitis with severe disease and younger age in this population. 29,30 Analysis using the UNOS database with a large sample size is a strength of our study. Using extended data until June 2020, our study confirmed recently reported findings on SLK and use of kidney after LT alone.…”

The changing epidemiology of adult liver transplantation in the United States in 2013-2022: The dominance of metabolic dysfunction–associated steatotic liver disease and alcohol-associated liver disease

“…We believe this is most likely due to the wide availability of curative therapy for chronic HCV infection, which reduces the rates of HCC. 2 , 16 – 19 Notably, the proportion of those with HBV-HCC requiring a transplant remained low and decreased further over time, suggesting the positive impact of antiviral therapy and preventive HBV vaccination. 3 , 4 …”