Patient with decompensated hepatitis C virus–related cirrhosis delisted for liver transplantation after successful sofosbuvir‐based treatment

Decompensated cirrhosis related to chronic hepatitis C virus (HCV) accounts for the majority of liver transplants in Western countries. Recurrent HCV infection is universal in transplant patients with detectable HCV RNA at the time of liver transplantation, and it leads to rapidly aggravated liver graft function in a substantial number of these patients. Studies of patients with compensated cirrhosis as well as portal hypertension and poor liver function (platelet count 100,000/mm and serum albumin level<35 g/L) who were treated with protease inhibitor–based therapy have demonstrated a potential benefit in terms of the prevention of posttransplant HCV recurrence, but they have also emphasized the poor tolerability of this therapy by this group of patients. New direct-acting anti-HCV drugs that can be used in interferon-free combination strategies are now available. In October 2013, a 67-year-old woman who was chronically infected with HCV genotype 4 and was a null responder to pegylated interferon a and ribavirin presented with decompensated cirrhosis and rapid degradation of her liver function during the last 6 months, and liver transplantation was indicated. The patient had refractory ascites, which required weekly paracentesis, and grade 2 chronic hepatic encephalopathy, which caused several hospitalizations. This presentation was related to end-stage liver disease. Causes of acute liver decompensation, such as alcohol or drug consumption, bacterial infections, hemorrhagic events, hepatocellular carcinoma, venous portal thrombosis, and a viral coinfection, were excluded. Her Child-Pugh score was C12, and her Model for End-Stage Liver Disease score was 16. Treatment with sofosbuvir at 400 mg/day and with ribavirin at 1200 mg/day was started for 24 weeks. The treatment was well tolerated, and her HCV RNA level rapidly decreased and became undetectable at week 8 of therapy. A sustained virological response (undetectable HCV RNA) was achieved 12 weeks after treatment discontinuation. Hepatic encephalopathy and ascites regressed at weeks 4 and 16 of therapy, respectively, and the Child-Pugh and Model for EndStage Liver Disease scores decreased from C12 to A6 and from 16 to 12, respectively (Table 1). Because of this improvement, the patient was removed from the transplant list. The advent of new direct-acting antiviral drugs that are well tolerated and can be used in all-oral, interferon-free combinations will likely offer the opportunity for the efficient prevention of HCV recurrence after liver transplantation. A recent study showed that 93% of 46 patients with compensated liver disease and with hepatocellular carcinoma as the indication for transplantation who were treated with sofosbuvir and ribavirin had undetectable HCV RNA levels at the time of transplantation, and 70% had no HCV recurrence after transplantation. There is a lack of data on new interferon-free regimens in patients with decompensated cirrhosis, who could greatly benefit from such regimens and eventually be removed from liver transplant wait lists. This is, to our knowledge, the first report of delisting from the liver transplant wait list for a patient with HCV-induced decompensated cirrhosis. This observation is a proof of concept that all-oral, interferon-free combinations could substantially reduce the need for liver transplantation in patients with HCV-related decompensated cirrhosis if the clinical outcome seen