Cost-Effectiveness of Direct-Acting Antiviral Treatment in Hepatitis C–Infected Liver Transplant Candidates With Compensated Cirrhosis and Hepatocellular Carcinoma

Abstract

Background HCV(+) donors represent an effective strategy to increase liver donor availability to HCV-infected recipients. However, many HCV(+) transplant candidates are now receiving treatment with direct acting anti-virals (DAA) that lower the risk of posttransplant HCV recurrence but could make the patient ineligible for HCV(+) livers. Methods We compared pretransplant DAA treatment versus deferred DAA treatment using a cost-effectiveness decision analysis model to estimate incremental cost-effectiveness ratios (ICERs; cost per quality-adjusted life year [QALY] gained) from the societal perspective across a range of HCV(+) liver availability rates. For practical considerations, the population modelled was restricted to well-compensated HCV(+) cirrhotics listed for liver transplantation with HCC MELD exception points. Results Under base case conditions, the deferred DAA treatment strategy was found to be the “dominant” strategy. That is, it provided superior health outcomes at cost savings compared to the pretransplant DAA treatment strategy. The pretransplant DAA treatment strategy trended towards cost-effectiveness as HCV(+) donor liver availability declined. However, only in 1 scenario that was highly optimized for favorable outcomes in the pretransplant DAA treatment arm (low availability of HCV(+) organs, low cost of DAA treatment, high cost of HCV recurrence) was the ICER associated with HCV DAA treatment before transplant <$150,000/QALY gained. Conclusions Deferring HCV treatment until after liver transplant and maintaining access to the expanded pool of HCV(+) donors appears to be the most cost-effective strategy for well-compensated HCV-infected cirrhotics listed for liver transplantation with HCC, even in geographic areas of relatively low HCV(+) donor availability.

Hepatitis C virus–infected kidney waitlist patients: Treat now or treat later?

“…There are exceptions in liver disease cohorts. Patients with hepatocellular carcinoma and relatively low Model for End‐Stage Liver Disease (MELD) scores did better with deferred therapy with the option of receiving an HCV viremic organ earlier . Although not modeled specifically, kidney disease patients with significant residual function not yet on dialysis should have reduced rates of progression to ESRD with DAA treatment and may potentially benefit more from early intervention …”

Dropout rate from the liver transplant waiting list because of hepatocellular carcinoma progression in hepatitis C virus–infected patients treated with direct‐acting antivirals

“…Deferring HCV treatment until after LT in order to guarantee access to the expanded pool of HCV-positive donors has been proposed as the most cost-effective strategy for well-compensated HCV-infected patients with cirrhosis listed for LT with HCC. (44) However, this still depends on HCV epidemiology. Furthermore, HCV eradication in the pre-LT setting prevents recurrence of liver infection (45) and has been associated with higher survival in patients transplanted for HCC.…”

Con: Treating hepatitis C virus With direct‐acting antivirals: Fear not the perceived threat of hepatocellular carcinoma

“…In this context, HCC should be controlled with LRT first before treating HCV with DAAs, and this may result in disease stabilization and even reduction in liver‐related death on the waiting list. The decision regarding DAA treatment before versus after LT is complex, but it should take into account the degree of hepatic decompensation and availability of regional HCV‐positive donor livers …”

“…The decision regarding DAA treatment before versus after LT is complex, but it should take into account the degree of hepatic decompensation and availability of regional HCV-positive donor livers. (28) For LT recipients for HCC who received DAAs, data assessing the impact of DAAs on the risk of HCC recurrence after LT are scant. Yang et al (29) reported a 27% (5/18) HCC recurrence rate after DAA therapy followed by LT versus 9.5% (6/63; P 5 0.06) in those who did not receive DAAs prior to LT.…”