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Annals of Hepatology

versión impresa ISSN 1665-2681

Ann. Hepatol. vol.16 no.3 Ciudad de México may./jun. 2017 


Persistence of Virologic Response after Liver Transplant in Hepatitis C Patients Treated with Ledipasvir/Sofosbuvir Plus Ribavirin Pretransplant

Carmen Vinaixa *   §  

Marina Berenguer *       §  

*Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia (Spain).

Networking Biomedical Research Centre in Hepatic and Digestive Diseases (CIBEREHD), Spain.

Department of Medicine, Universitat de València, Valencia (Spain).

§Instituto de Investigación Sanitaria, Hospital Universitari i Politècnic La Fe, Valencia (Spain).

In the field of hepatitis C treatment, currently almost all past issues are solved, including treatment of special populations. Nevertheless, some aspects remain unanswered, such as the controversial decision to treat pre vs. post-liver transplantation (LT), the “point of no return” for improvement of hepatic function after antiviral treatment, and optimizing treatment outcomes in some subgroups like genotype 3 infection in hemodialysis patients.

We read with interest the article by Eric M. Yoshida, et al., which is a post-hoc analysis of the persistence of viral response (pTVR) after LT in patients included in the SOLAR trials1 , 2 who received antiviral treatment and subsequently underwent LT. In the study by Yoshida, et al. , all 17 were decompensated cirrhotic patients (Child B or C) with median MELD score of 16 who started treatment with Ledipasvir/Sofosbuvir plus ribavirin (RBV) before LT. Of these, 10 patients completed their planned treatment duration before LT, while 7 underwent LT before completing the 12 or 24 weeks of planned antiviral treatment. Seventy-six percent of patients completed at least 12 weeks of antiviral treatment. As a result, all 17 patients achieved pTVR, although one died shortly after LT (unrelated to study drugs), leading to a 94% rate of pTVR-12.

The most obvious advantage for treating patients before LT is to prevent HCV recurrence in the post-transplant setting. Nevertheless, not many studies have examined this issue. In the interferon era, only one randomized controlled trial of treatment with pegylated interferon plus RBV for patients in the waiting list for LT was performed,3 with only 22% and 29% pTVR, for genotypes 1/4/6 and genotypes 2/3, respectively. The only factor that emerged as predictor of pTVR was the number of weeks the patient remained with undetectable viral load before LT (> 16 weeks). In the direct antiviral agent (DAA) era, a study by Curry, et al.4 examined the results of the administration of Sofosbuvir plus RBV in compensated cirrhotic patients listed for hepatocellular carcinoma (HCC); 70% of patients achieved pTVR. Once again, the number of consecutive days (> 30 days) with HCV RNA target not detected prior to transplant appeared to be the strongest predictor of post-transplant viral response. In other words, the amount of time the patient remains with undetectable HCV viral load before LT seems to be an important factor in order to prevent recurrence of HCV in the liver graft. There are no specifically designed studies to examine this issue with 2 or more DAAs, but existing data of treatment in compensated and decompensated cirrhotic patients with several DAA combinations show sustained viral response (SVR) rates over 90% with viral negativity achieved in most cases within the first month of treatment initiation, suggesting that the required duration of HCV undectectability could be even shorter. However, this question remains to date unanswered. The current study is interesting as it provides data related to patients successfully treated with ledipasvir/sofosbuvir ± RBV in the pretransplant setting who present no HCV recurrence post-transplant.

An alternative for patients not finishing the established duration of therapy before transplantation is to “bridge” treatment, i.e. to continue therapy during the peritrans- plant period. To date, two studies summarizing limited data of patients treated before, during and after transplantation are available.5 , 6 Both studies, one based on sofosbuvir plus RBV and the second based on several DAA combinations, have shown that this is a feasible and effective strategy.

An interesting and still controversial issue is whether antiviral treatment might avoid transplantation in HCV-infected patients with decompensated cirrhosis. All 17 decompensated patients in the SOLAR study underwent LT, suggesting that not all patients improve to a point where transplantation is prevented. However, even in these cases, it is likely that the condition of the patient is globally improved leading to better post-transplant outcomes. Nevertheless, the particularities of each waiting list (WL) are different and must be taken into account. For example, in settings where donors are scarce, a MELD improvement may result in worse patient access to LT (the so-called “MELD purgatory”).

In our center around 40% of waitlisted patients have HCV infection, with or without HCC. In the last three years, almost 50 patients in the WL for LT have received antiviral treatment and 30% of these have been delisted after confirming clinical and laboratory data improvement.7

In essence, although more studies are needed to determine the optimal timing of treatment with DAA combinations before LT, this is clearly an interesting strategy which may ultimately lead not only to prevention of viral recurrence but also to clinical improvement and potentially avoidance of LT. Given the rapidity at which DAA- based antiviral treatment is being applied in patients with advanced liver disease, at least in the western world and in countries with access to LT, it is unlikely that studies specifically designed at determining the best timing of treatment initiation will be undertaken, and studies like the one by Yoshida, et al. published in this issue will help understanding the benefits and limitations of such a strategy.


1. Charlton M, Everson GT, Flamm SL, Kumar P, Landis C, Brown RS Jr, Fried MW, et al. Ledipasvir and Sofosbuvir Plus Ribavirin for Treatment of HCV Infection in Patients With Advanced Liver Disease. Gastroenterology 2015; 149: 649- 659. doi:10.1053/j.gastro.2015.05.010. [ Links ]

2. Manns M, Samuel D, Gane EJ, Mutimer D, McCaughan G, Buti M, Prieto M, et al. Ledipasvir and sofosbuvir plus ribavirin in patients with genotype 1 or 4 hepatitis C virus infection and advanced liver disease: a multicentre, open-label, randomised, phase 2 trial. Lancet Infect Dis 2016; 16: 685-97. doi: 10.1016/S1473-309900052-9. [ Links ]

3. Everson GT, Terrault NA, Lok AS, Rodrigo del R, Brown RS Jr., Saab S, Shiftman ML, et al. A randomized controlled trial of pretransplant antiviral therapy to prevent recurrence of hepatitis C after liver transplantation. Hepatology 2013; 57: 1752-62. doi:10.1002/hep.25976. [ Links ]

4. Curry MP, Forns X, Chung RT, Terrault NA, Brown R Jr., Fenkel JM, Gordon F, et al. Sofosbuvir and ribavirin prevent recurrence of HCV infection after liver transplantation: An open-label study. Gastroenterology 2015; 148. doi: 10.1053/j.gastro.2014.09.023. [ Links ]

5. Donato MF, Morelli C, Romagnoli R, Invernizzi F, Mazzarelli C, lemmolo RM, Montalbano M, et al. Prevention of hepatitis C recurrence by bridging sofosbuvir/ribavirin from pre- to post-liver transplant: A real-life strategy. Liver Int 2016. doi: 10.1111/liv.l3322. [ Links ]

6. Carrillo CF, Crespo G, de la Revilla J, Castells L, Buti M, Montero JL, Fábrega E, et al. Successful continuation of HCV treatment following liver transplantation. Transplantation 2016: 1. doi:10.1097/TP.0000000000001596. [ Links ]

7. Belli LS, Berenguer M, Cortesi PA, Strazzabosco M, Rockenschaub SR, Martini S, Morelli C, et al. Delisting of liver transplant candidates with chronic hepatitis C after viral eradication: A European study. J Hepatol 2016; 65(3): 524-31. [ Links ]

Received a grant from the Instituto de Salud Carlos III (PI15/02010).

Received: March 22, 2017; Accepted: March 22, 2017

Correspondence and reprint request: Carmen Vinaixa, M.D. Hepatology and Liver Transplantation Unit, Gastroenterology Department. Hospital Universitari i Politècnic La Fe, Av. Fernando Abril. Martorell, 106, Valencia 46026, Spain. Tel.: +34. 620912468 E-mail:

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