Daniel Kimberly E, Said Adnan
Gastroenterology and Hepatology Fellow, Medical College of Wisconsin, Milwaukee, WI, USA.
Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health and Madison VAMC, Madison, WI, USA.
Curr Gastroenterol Rep. 2018 Apr 5;20(5):20. doi: 10.1007/s11894-018-0626-9.
This review examines the issues in determining the decision to treat a HCV-positive patient who is a liver transplant (LT) candidate with highly effective and well-tolerated direct-acting antiviral (DAA) therapies.
Cure of HCV with DAA can improve liver function and allow delisting in some patients. Beyond a threshold of hepatic impairment (likely MELD score > 16 to 20), patients may experience a decline in MELD score with HCV cure without improvement in liver-related complications resulting in decreased opportunity to receive a LT. Eradicating HCV from patients who need LT regardless also deprives them of the option of receiving HCV-positive donor organs. Patients with MELD > 16 or Child-Pugh B/C may also have reduced cure rates of HCV, increased risk of hepatic decompensation, and adverse events with DAA pre-LT compared to post-LT DAA therapy. Preliminary data demonstrates increase risk of hepatocellular carcinoma (HCC) recurrence after treatment with DAA with subsequent studies raising doubts about this association. Patients with HCV cirrhosis on the LT waiting list with MELD score > 16, CTP-B/C, and HCC are best treated after LT with better response, tolerability, and the ability to receive organs from a larger donor pool that includes HCV-positive donors. Larger, prospective studies are needed to assess whether increased HCC recurrence after DAA is a true effect.
本综述探讨了在决定使用高效且耐受性良好的直接作用抗病毒（DAA）疗法治疗丙型肝炎病毒（HCV）阳性且作为肝移植（LT）候选者的患者时所涉及的问题。
使用DAA治愈HCV可改善肝功能，并使部分患者能够从肝移植等候名单中除名。在肝损伤超过一定阈值（可能终末期肝病模型（MELD）评分>16至20）时，HCV治愈后患者的MELD评分可能会下降，而与肝脏相关的并发症并无改善，从而导致接受肝移植的机会减少。无论如何，对需要肝移植的患者根除HCV也使他们失去了接受HCV阳性供体器官的选择。与肝移植后使用DAA治疗相比，MELD>16或Child-Pugh B/C级的患者在肝移植前使用DAA治疗时，HCV治愈率可能降低，肝失代偿风险增加，且会出现不良事件。初步数据显示，使用DAA治疗后肝细胞癌（HCC）复发风险增加，后续研究对此关联提出了质疑。LT等候名单上MELD评分>16、CTP-B/C级且患有HCC的HCV肝硬化患者，在肝移植后接受治疗效果更佳，耐受性更好，并且能够接受来自更大供体库（包括HCV阳性供体）的器官。需要开展更大规模的前瞻性研究来评估DAA治疗后HCC复发增加是否为真实效应。
