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PARIS -- Since use of direct acting antiviral combination therapies for hepatitis C virus (HCV) infection became widespread, the need for liver transplantation for patients with the infection has plummeted, researchers reported here.

In 2007, HCV infection was listed as the reason for 23.87% of all liver transplants in Europe, and that remained constant through 2014 when the impact of direct acting antiviral medications began to hit, said Chiara Mazzarelli, MD, of A.O. Ospedale Niguarda Ca'Granda, Milan, Italy.

After that, the proportion dropped sharply each year, to the point that in 2017 about 10.6% of transplants were performed for HCV (P<0.0001).

"In contrast, the demand for livers for patients with NASH (nonalcoholic steatohepatitis) is increasing," Mazzarelli said in her late-breaker presentation at the International Liver Conference, sponsored by the European Association for the Study of the Liver. Liver transplantation for alcohol-related cirrhosis and for hepatitis B infection has remained consistent across the 11-year study period, she said.

She indicated that the reduction in transplantation observed among European patients would likely be similar in the United States and North America.

"In Europe the percentage of liver transplantations performed because of hepatitis C virus infection is rapidly declining," Mazzarelli said at a press conference. "This trend is expected to continue with the increasing access to direct acting antiviral therapy. For the first time after many years, survival of hepatitis C virus transplant recipients is improving thanks to the advent of direct acting antivirals."

"This important study does put into perspective the impact of treatment and shows that treatment can result in really relevant outcomes," said press conference moderator Markus Cornberg, MD, of Hannover Medical School in Germany.

Mazzarelli scrutinized data from the European Liver Transplant Registry, identifying 36,382 adult liver transplantations which were performed between January 2007 and June 2017 due to hepatitis C, hepatitis B, alcohol and NASH.

The researchers stratified time periods based on treatment options for hepatitis C, with the period from 2007 to 2010 identified as the interferon era; the period from 2011 to 2013 as the protease inhibitor era, and the period from 2014 to 2017 as the direct acting antiviral era. During the first two periods, the numbers of liver transplantations in Europe ranged from about 2,600 to around 3,000 a year. That number fell to 2,271 in the first half of 2017, driven mainly by the precipitous drop in HCV infection etiology for transplant, she said.

A similar fall was observed for patients with decompensated liver disease as a result of HCV, and a mirroring fall in cases of transplant needed for patients who developed primary hepatocellular carcinoma secondary to hepatitis C.

Mazzarelli said that the decline in the need for a liver transplant was more evident in patients with HCV-related decompensation – a reduction of more 68.8% – than in those patients who were diagnosed with hepatocellular carcinoma associated with HCV where the reduction was about 34%.

Patients who underwent liver transplantation in the direct acting antiviral era also had significantly better survival after transplant when compared with the other periods. About 76.9% of patients in the direct acting antiviral period lived at least 3 years compared with about 70% of patients in the protease era and 65.1% of those who were transplanted during the interferon era (P<0.0001).

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