title: Reduction in liver transplant wait-listing in the era of direct-acting antiviral therapy.
abstract: Direct-acting antiviral (DAA) therapy, recently approved for patients with decompensated cirrhosis (DC) secondary to hepatitis C virus (HCV), is associated with improved hepatic function. We analyzed trends in liver transplant (LT) wait-listing (WL) to explore potential impact of effective medical therapy on WL registration. This is a cohort study using the Scientific Registry of Transplant Recipients database from 2003 to 2015. A total of 47,591 adults wait-listed for LT from HCV, hepatitis B virus (HBV), and nonalcoholic steatohepatitis (NASH) were identified. LT indication was defined as DC if the Model for End-Stage Liver Disease (MELD) at WL was ≥15 or hepatocellular carcinoma (HCC). Era of listing was divided into interferon (IFN; 2003-2010), protease inhibitor (PI; 2011-2013), and direct-acting antiviral (DAA; 2014-2015). Annual standardized incidence rates of WL were analyzed using Poisson regression. Adjusted incidences of LT WL for DC in HCV patients decreased by 5% in the PI era (P = 0.004) and 32% in the DAA era (P < 0.001) compared to the IFN era. Listing for DC in HBV also decreased in the PI (-17%; P = 0.002) and DAA eras (-24%; P < 0.001). Conversely, WL for DC in NASH increased by 41% in the PI era (P < 0.001) and 81% in the DAA era (P < 0.001). WL for HCC in both the HCV and NASH populations increased in both the PI and DAA eras (P < 0.001 for all) whereas HCC WL in HBV remained stable (P > 0.05 for all).
  
  
  
  The rate of LT WL for HCV complicated by DC has decreased by over 30% in the era of DAA therapy. Further reductions in WL are anticipated with increased testing, linkage to care, and access to DAA therapy. (Hepatology 2017;65:804-812).
authors.affiliation: Departments of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Flemming
authors.affiliation: Department of Medicine, Stanford University, Palo Alto, CA.
authors.forename: W Ray
authors.initials: WR
authors.lastname: Kim
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA.
authors.forename: Carol L
authors.initials: CL
authors.lastname: Brosgart
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA.
authors.forename: Norah A
authors.initials: NA
authors.lastname: Terrault
mesh_terms: D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use; D015331:Cohort Studies; D016048:Dideoxyadenosine / Q000627:therapeutic use*; D058625:End Stage Liver Disease / Q000209:etiology* / Q000473:pathology / Q000601:surgery* / Q000821:virology; D005260:Female; D006509:Hepatitis B / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy; D019698:Hepatitis C, Chronic / Q000150:complications / Q000188:drug therapy / Q000473:pathology; D006801:Humans; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000150:complications / Q000188:drug therapy / Q000473:pathology; D011300:Preoperative Care / Q000379:methods; D058996:Quality Improvement; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014850:Waiting Lists
chemical_list: D000998:Antiviral Agents; D016048:Dideoxyadenosine