title: Pre- Versus Posttransplant Treatment of Hepatitis C Virus With Direct-Acting Antivirals in Liver Transplant Recipients: More Issues to be Solved.
abstract: OBJECTIVE
  Our goal was to investigate wait times related to hepatitis C virus treatment with direct acting antivirals before versus after liver transplant at a single center as well as wait times for insurance approval for preemptive treatment with these agents after liver transplant.
  
  
  METHODS
  We retrospectively evaluated hepatitis C virus infections in transplant recipients of deceased liver donations in 2014 and 2015. Demographics, hepatocellular carcinoma incidence, Model for End-Stage Liver Disease scores, and transplant wait times were compared between patients treated before or after liver transplant. Wait times to approval of direct-acting antiviral treatment were evaluated in those untreated before transplant.
  
  
  RESULTS
  During our study period, of 67 deceased-donor liver transplants, 21 patients received hepatitis C virus treatment pretransplant (treated group) and 46 patients were not treated pretransplant (untreated group). Twenty-five patients in the untreated group received hepatitis C virus-positive donations, with all in this group treated with direct-acting antivirals. We found no statistically significant differences regarding age, sex, race, donation after cardiac death, or incidence of hepatocellular carcinoma between groups. The treated group had a longer median wait time (287 vs 172 days; P = .02). Twelve of the 46 untreated patients (26.1%) developed biopsy-proven hepatitis C virus-related relapse (median 87 days; range, 55-383 days). Preemptive direct-acting antiviral therapy was initiated at a median of 81 days in the untreated group.
  
  
  CONCLUSIONS
  Although treatment of hepatitis C virus before liver transplant is an attractive option to eliminate the risk of complications, it can limit the donor pool for recipients to uninfected donors, significantly increasing wait times in regions with large hepatitis C virus-positive donor pools. Allocation of Model for End-Stage Liver Disease score was not different between the treated and untreated groups. Insurance companies should revise their policies for rapid approval of preemptive direct-acting antiviral treatment after liver transplant.
authors.affiliation: Division of Internal Medicine, Medstar Franklin Square Hospital, Baltimore, Maryland, USA.
authors.forename: Abdelhai
authors.initials: A
authors.lastname: Abdelqader
authors.forename: Gokhan
authors.initials: G
authors.lastname: Kabacam
authors.forename: Tinsay A
authors.initials: TA
authors.lastname: Woreta
authors.forename: James P
authors.initials: JP
authors.lastname: Hamilton
authors.forename: Harry
authors.initials: H
authors.lastname: Luu
authors.forename: Kawtar
authors.initials: K
authors.lastname: Al Khalloufi
authors.forename: Behnam
authors.initials: B
authors.lastname: Saberi
authors.forename: Benjamin
authors.initials: B
authors.lastname: Philosophe
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Cameron
authors.forename: Ahmet
authors.initials: A
authors.lastname: Gurakar
mesh_terms: D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000008:administration & dosage* / Q000009:adverse effects; D046148:Donor Selection; D004334:Drug Administration Schedule; D004608:Eligibility Determination; D005260:Female; D016174:Hepacivirus / Q000187:drug effects* / Q000472:pathogenicity; D006526:Hepatitis C / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000635:transmission; D006801:Humans; D007348:Insurance, Health; D016031:Liver Transplantation / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D014019:Tissue Donors / Q000600:supply & distribution*; D016896:Treatment Outcome; D014775:Virus Activation / Q000187:drug effects; D014850:Waiting Lists
chemical_list: D000998:Antiviral Agents