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DAAs Improve HCC Liver Transplant Survival - Outcomes of transplantation for HBV- vs. HCV-related HCC: impact of DAA HCV therapy in a national analysis of >18,000w patients: HCC Liver Transplant Survival No Longer Worse With HCV Than HBV
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AASLD The Liver Meeting Digital Experience, November 13-16, 2020
Mark Mascolini
With the arrival of direct-acting antivirals (DAAs) for HCV infection, survival after liver transplantation for hepatocellular carcinoma (HCC) is no longer worse for people with HCV than for those with HBV, according to results of a national US study [1]. Multivariate logistic regression no longer identified HCV status as a survival predictor in the DAA era.
HCV infection has led all causes of HCC-related liver transplantation for 30 years. Through much of that time, survival after transplantation in people with HCV significantly lagged survival in transplant recipients with HBV. Researchers from New York's Icahn School of Medicine at Mount Sinai conducted this national retrospective analysis to track posttransplant survival in people with HCV versus HBV from January 2003 to January 2019.
The Mount Sinai team culled data from the United Network for Organ Sharing OPTN/UNOS Registry for the study period. They called January 2003 through October 2013 the pre-DAA era and November 2013 through January 2019 the post-DAA era. Transplant recipients had to be at least 18 years old, have HCC, and undergo primary, single-organ, nonfulminant liver transplantation. The researchers used logistic regression to pinpoint predictors of survival after liver transplant in the two study eras.
Among 11,154 people who had an HCC-related transplant in the 2003-2013 pre-DAA era, 9814 (88%) had HCV and 1340 (12%) had HBV. Among 7561 people getting a liver transplant in the 2013-2019 post-DAA era, 6760 (89%) had HCV and 801 (11%) had HBV. Through 15 years of follow-up after liver transplant, 59% of the overall study group survived.
In the pre-DAA era, median age stood at 57 years in both the HCV group and the HBV group. The HCV group had a lower proportion of men (79% vs 83%, P = 0.001), a higher proportion of whites (68% vs 28.5%, P < 0.001), and a higher proportion within Milan status [2] at diagnosis of HCC (94% vs 91%, P < 0.001). Tumor size of the largest tumor at diagnosis was slightly but significantly smaller with HCV than HBV (2.5 vs 2.6 cm, P < 0.001). The HCV and HBV groups did not differ significantly in wait time for transplant or number of tumors at diagnosis.
In the post-DAA era, median age was slightly but significantly older in the HCV group than the HBV group (61 vs 60, P < 0.001). The HCV group included a larger proportion of men (85% vs 79%, P < 0.001) and a larger proportion of whites (66% vs 24%, P < 0.001). Compared with the HBV group, the HCV group had a shorter average wait time to transplantation (244 vs 290 days, P < 0.001). But the HCV and HBV groups did not differ significantly in proportion within Milan status at diagnosis, size of largest tumor at diagnosis, or number of tumors at diagnosis.
In the pre-DAA era posttransplant survival proved significantly shorter with HCV than HBV at 5 years (70.9% vs 80.4%) and 10 years (55.1% vs 69.5%, P < 0.001). In the post-DAA era, 5-year posttransplant survival did not differ significantly between people with HCV and HBV (78% and 83%, P = 0.12).
In the years before DAAs arrived, multivariate analysis identified 5 independent predictors of shorter posttransplant survival: HCV-positive status (P < 0.001), age over 50 (P < 0.001), MELD score [3] above 13 (P < 0.001), pretransplant alpha-fetoprotein above 20 ng/mL (P < 0.001), and outside Milan status at diagnosis (P = 0.03).
In the years after DAAs arrived, HCV-positive status no longer predicted shorter posttransplant survival (P = 0.09). Remaining predictors were age over 50 (P = 0.03), MELD score [3] above 13 (P = 0.006), vascular invasion by tumor (P < 0.001), and moderate or poor tumor differentiation (P < 0.001).
The Mount Sinai team concluded that arrival of DAAs to treat HCV infection significantly improved survival after liver transplantation for HCV-related HCC and that posttransplant survival is no longer significantly shorter with HCV than with HBV.
References
1. Tabrizian P, Saberi B, Holzner M, et al. Outcomes of transplantation for HBV- vs. HCV-related HCC: impact of DAA HCV therapy in a national analysis of >18,000w patients. AASLD The Liver Meeting Digital Experience, November 13-16, 2020. Abstract 138.
2. Milan criteria restrict liver transplantation for HCC to people with certain tumor characteristics. Meyers RL, Zimmermann A. Malignant liver tumors. Milan criteria. Science Direct. 2012. https://www.sciencedirect.com/topics/medicine-and-dentistry/milan-criteria
3. MELD (Model for End-stage Liver Disease) score predicts 3-month survival with serious liver disease. UPMC Transplant Service. https://www.upmc.com/services/transplant/liver/process/waiting-list/meld-score
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