From the Guidelines
Patients with Hepatitis C awaiting liver transplantation should ideally be treated before transplantation whenever possible, as this approach improves liver function, potentially removing the need for transplantation in some cases, and prevents HCV recurrence in the new liver, according to the most recent European guidelines 1. The preferred approach is to achieve sustained virological response (SVR) prior to transplantation.
- The recommended regimens include direct-acting antivirals (DAAs) such as sofosbuvir/velpatasvir, glecaprevir/pibrentasvir, or sofosbuvir/ledipasvir, typically for 12 weeks, with specific regimens depending on the patient's HCV genotype, cirrhosis status, and previous treatment history.
- For patients with decompensated cirrhosis, ribavirin-free regimens are preferred.
- If treatment before transplantation is not feasible due to advanced liver disease or other factors, post-transplant treatment should begin early, usually within the first month after transplantation when the patient is stable. This approach is effective in preventing severe HCV recurrence and graft damage, as supported by the European guidelines 1. The timing decision should be individualized based on the patient's MELD score, expected waiting time for transplantation, renal function, and other comorbidities, with consideration of the potential benefits and risks of pre-transplant treatment, including the risk of death on the waiting list and the likelihood of transplantation 1.
From the FDA Drug Label
Patients with Hepatocellular Carcinoma Awaiting Liver Transplantation Administer SOVALDI in combination with ribavirin for up to 48 weeks or until the time of liver transplantation, whichever occurs first, to prevent post-transplant HCV reinfection [see Use in Specific Populations (8.8)] .
The European guidelines are not directly mentioned in the provided drug labels. However, based on the information provided, treatment before transplant is recommended for patients with hepatocellular carcinoma awaiting liver transplantation, to prevent post-transplant HCV reinfection. The recommended treatment regimen is sofosbuvir in combination with ribavirin for up to 48 weeks or until the time of liver transplantation, whichever occurs first 2.
From the Research
European Guidelines for Treating Hepatitis C in Patients Awaiting Liver Transplant
- The European guidelines suggest that patients with chronic hepatitis C virus (HCV) infections can and should be treated, either before or after liver transplantation 3.
- The decision on the timing of treatment depends on various factors, including the patient's model for end-stage liver disease (MELD) score, the presence of hepatocellular carcinoma, and the potential for improving liver function and reducing the risk of death and transplantation 3, 4.
- Direct-acting antiviral (DAA) therapies have dramatically increased the chances of curative treatment for the transplant population, and the debate about the best time for treating the infection is still open 4, 5.
- Some studies suggest that treating HCV before liver transplantation can improve liver function, delist some patients, and prevent graft infection 4, 6.
- However, other studies suggest that treating HCV after liver transplantation can also be effective in eradicating the infection and normalizing liver function tests 7, 5.
- The use of HCV-positive donors may represent a potential approach to safely expanding the donor pool, and the trend for liver transplantation for HCV is expected to decrease in the future 4.
- The ideal regimen and treatment duration for HCV treatment in patients on the liver transplant waiting list have yet to be determined, and additional data on the safety and efficacy of DAA regimens are needed 6, 5.