Fewer
Viral Hepatitis Patients with End-stage Liver Disease
Are Awaiting Liver Transplants, Likely Due to Effective
Hepatitis B Treatment
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| SUMMARY:
Trends over time in the number of patients
registering for the liver transplant waiting
list show a decrease in the proportion with
end-stage liver disease (ESLD), while the
proportion with hepatocellular
carcinoma (HCC) has increased, researchers
reported in the November
2009 issue of Gastroenterology.
The decline in ESLD was especially pronounced
among patients
with hepatitis B, which the investigators
attributed to widespread use of effective
antiviral therapy. |
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By
Liz Highleyman
Over
years or decades, chronic hepatitis
B virus (HBV) and hepatitis
C virus (HCV) infection can progress to advanced
liver disease and are major reasons for liver transplants
in the U.S. Other indications include alcoholic hepatitis
and liver toxicity (for example, due to acetaminophen
or poisonous mushrooms).
There
has been significant progress in treating viral hepatitis
over the past decade, and infants are now routinely
vaccinated against HBV
(done as an adolescent if not received earlier). But
many people with HBV or HCV have not been diagnosed,
and a significant number of those who received treatment
do not achieve a sustained response, or "cure."
W.
Ray Kim from the Mayo Clinic College of Medicine and
colleagues investigated whether the widespread adoption
of antiviral therapies for hepatitis B and C has affected
liver transplant waiting list registration, analyzing
longitudinal trends for patients with hepatitis B
and C and those with non-viral liver disease.
The
researchers performed a retrospective analysis of
registry data from all U.S. liver transplant centers,
including all adult primary liver transplantation
candidates registered with the Organ Procurement and
Transplantation Network (OPTN) between 1985 and 2006.
Standardized
incidence rates were calculated according to underlying
disease (HBV, HCV, and other) and indication for transplantation
(fulminant liver disease, ESLD, and HCC).
Results
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Out
of 113,927 unique waiting list registrants, 4793
(4.2%) had HBV, 40,923 (35.9%) had HCV, and the
remaining 68,211 (59.9%) had neither virus. |
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The
3 groups were similar in age, but patients with
viral hepatitis (especially HBV) were more likely
to be male. |
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The
rate of waiting list registrations for ESLD and
fulminant liver disease decreased overall during
the study period. |
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The
decrease in registrations due to ESLD was most
pronounced. |
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The
decrease in registration for ESLD related to HCV
was significantly larger than that for ESLD related
to non-viral causes. |
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In
contrast, there was a persistent increase in waiting
list registrations for HCC. |
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The
HCC increase was least dramatic among registrants
with HBV. |
Based on these findings, the study authors concluded,
"The pattern of liver transplantation waiting
list registration among patients with hepatitis B
suggests that the widespread application of oral antiviral
therapy for HBV contributed to the decreased incidence
of decompensated liver disease."
In
their discussion, the researchers offered evidence
that the trends were not primarily attributable to
changes in the organ allocation system (which tended
to favor patients with HCC compared with other causes).
They
noted that another plausible explanation may be that
a decreasing proportion of patients are considered
suitable candidates for liver transplants, rather
than there being fewer people who develop ESLD.
In
the case of hepatitis C, other epidemiological data
do not suggest a decline in end-stage disease, so
it may be that more HCV patients with ESLD are considered
to be too old or to have unacceptable comorbid conditions
for liver transplantation.
"The
effect of anti-HCV therapy at the population level
is likely to have a much longer lag period compared
with that for HBV, because the regimens available
to date are not uniformly effective, especially in
patients with advanced fibrosis and contraindicated,
by and large, in those with decompensated liver disease,"
the authors suggested.
In
the case of hepatitis B, however, the parallel decrease
in mortality suggests a real decrease in the occurrence
of ESLD.
"The
evidence to link this trend to antiviral therapy [for
HBV] is indirect and circumstantial," they wrote,
"however, there are few other plausible explanations
for this trend other than a widespread application
of antiviral therapy."
Division
of Gastroenterology & Hepatology and Division
of Biostatistics, Mayo Clinic College of Medicine,
Rochester, MN; University of California at San Francisco,
San Francisco, CA; United Network for Organ Sharing,
Richmond, VA; Gilead Sciences, Inc, Foster City, CA.
12/11/09
Reference
W Ray Kim, NA Terrault, RA Pedersen, and others.
Trends in Waiting List Registration for Liver Transplantation
for Viral Hepatitis in the United States. Gastroenterology
137(5): 1680-1686 (Abstract).
November 2009.
