Reply
Authors: Jagpreet Chhatwal, Sumeyye Samur, Emily Bethea, Raymond T. Chung
Journal: Hepatology (2017)

Potential conflict of interest: Nothing to report. We appreciate Cholankeril et al.'s interest in our study evaluating the optimal timing of hepatitis C virus (HCV) treatment of decompensated patients with cirrhosis on the transplant waiting list.1 The purpose of our study was to provide a guide for clinicians to help determine the timing of HCV treatment pre‐ versus posttransplantation. Our model's recommendations that the threshold below which to treat HCV pretransplantation is between 23 and 27, depending on the United Network for Organ Sharing (UNOS) region, holds for the majority of liver transplant candidates. Further analysis of patients subdivided by ABO blood groups demonstrated that for the vast majority of patients on the waiting list, the Model for End‐Stage Liver Disease (MELD) score thresholds for pretransplantation direct‐acting antiviral (DAA) therapy presented in our study remain unchanged (Fig. 1). A lower threshold for pretransplantation HCV treatment was observed in the less common AB and B blood groups.Figure 1: Difference in life years (LY) if HCV is treated pretransplantation versus posttransplantation in patients with decompensated cirrhosis on the transplant waiting list by blood type.At the time of our analysis, data on 2016 regional variations in mean MELD score at LT were not available. However, our model can be updated to accommodate changes in UNOS data and future trends in transplantation practice. Transplantation of HCV‐positive donor grafts into HCV‐positive recipients was included in our study model. Our published study already included a sensitivity analysis on the percentage of usable HCV‐positive donor grafts ranging between 5% and 15% and found that the results remained robust. Future analysis can be constructed to incorporate transplantation of HCV‐positive grafts to HCV‐negative recipients; however, this is not current practice. Although we did not consider delisting of HCV patients in our model, recent clinical data show that no patients with a MELD score >20 have been delisted because of treatment with DAAs.2 Because our model recommended that patients with a MELD score ≤23 receive pretransplantation HCV treatment, consideration of "delisting" would not have changed our conclusions. The number of patients expected to develop fibrosing cholestatic hepatitis is low; therefore, this was not included in our study. Our model accounted for reduction in retransplantation rates. Candidates in the postimplementation era of Regional Share 35 were more likely to receive a transplant within 90 days (66% versus 59%), and were less likely to die while waiting for a transplant (25% versus 32%).3 Our study already included sensitivity analysis wherein we changed the transplantation and mortality rates ±25% from the base case values and found that the results were not sensitive to these parameters. Therefore, Regional Share 35 would not change the MELD threshold for pretransplantation versus posttransplantation HCV treatment in our analysis. In conclusion, our study provides a guide, not a directive, to clinicians in making decisions about the timing of HCV treatment. Patient preferences and medical urgency not captured by MELD scores should be taken into consideration while making such decisions.