Reuters Health Information: Changing trends in liver transplant indications
Changing trends in liver transplant indications
Last Updated: 2017-01-23
By Will Boggs MD
NEW YORK (Reuters Health) - Hepatitis C virus (HCV)
infection is declining while nonalcoholic steatohepatitis (NASH)
and alcoholic liver disease (ALD) are increasing as indications
for liver transplant, according to U.S. data.
"The decrease in HCV among patients with chronic liver
failure (aka decompensated cirrhosis) was striking and likely
reflects the positive consequences of more efficacious and safe
therapies for HCV," said Dr. David Goldberg from Perelman School
of Medicine at the University of Pennsylvania, Philadelphia.
"However, the continued prevalence of HCV among patients
with hepatocellular carcinoma in the broader population, as well
as the transplant waitlist, demonstrates the continued risk of
HCC in patients with HCV cirrhosis, even after their HCV is
cured," he told Reuters Health by email.
For the last 20 years, HCV has been the most common
indication for liver transplantation in North America and
Western Europe, Dr. Goldberg and colleagues note in
Gastroenterology, online January 13. With the improved treatment
of HCV infection, nonalcoholic fatty liver disease has emerged
as an important indication for liver transplantation, they add.
The team used data from the National Health and Nutrition
Evaluation Survey (NHANES), the HealthCore Integrated Research
Database (HIRD) of commercially insured patients, and the Organ
Procurement and Transplantation Network/United Network for Organ
Sharing to evaluate temporal trends in the burden of liver
disease in the U.S.
Between 2006 and 2014, among patients with compensated
cirrhosis, there were decreases in the percentages with HCV and
ALD and increases in the percentage with NASH.
During the same interval, HCV and ALD decreased as causes of
chronic liver failure, while NASH nearly tripled in percentage,
passing HCV as the leading cause of chronic liver failure in
Among patients with hepatocellular carcinoma (HCC), there
were decreases in the percentage with HCV and ALD and a small
increase with NASH.
Liver transplant waitlist data followed a similar pattern.
The percentage of patients with chronic liver failure caused by
HCV was stable between 2004 and 2012 and dropped precipitously
over the next three calendar years. This was accompanied by a
progressive, continued increase in the percentage of patients
with ALD and NASH.
Between 2002 and 2014, the absolute number of patients added
to waitlists for HCC increased dramatically for patients with
HCV, but only modestly for other causes of liver disease.
According to Medicare data, the number of prescriptions for
direct-acting antiviral agents against HCV increased by a factor
of five between 2013 and 2015, the period during which there
were decreasing numbers of patients waitlisted and transplanted
for chronic liver failure in the setting of HCV.
"The rise in waitlistings and transplants in patients with
NASH and alcoholic liver disease requires better risk
stratification of patients with NASH and concomitant medical
co-morbidities (i.e., diabetes, cardiac disease) and alcoholic
liver disease at risk for alcohol relapses," Dr. Goldberg said.
"Despite the decreased prevalence of cirrhosis due to HCV,
and the lower rates of waitlisting for chronic liver failure due
to HCV, there still are millions of infected patients," he said.
"There is a continued need to broadly employ birth-cohort
screening to identify patients with HCV, and to strengthen
linkage-of-care to treat patients before cirrhosis develops, or
in those with cirrhosis, treat prior to liver decompensation."