Direct-acting HpC antiviral drug drives ‘revolution’ in liver transplantation

Today, hepatitis C cases account for only 11% of liver transplant cases, compared with 31% in 2014. Currently, the most common causes of cirrhosis and the reason why more patients undergo transplantation are alcohol abuse and lipometabolic liver disease. Obesity and diabetes and a combination of the two. Following the launch of the Strategic Plan for Hepatitis C in National Health Systems (PEAHC) in 2015, the Alliance to Eliminate Viral Hepatitis (AEHVE) ensures the progressive rollout of infection-curing antiviral treatment (ADD), with clear universal access to all patients by 2017,” was a decisive factor in this decline, which constitutes another success in the fight to eliminate this disease, which today is even closer”.

In 2014, 744 people with hepatitis C were listed in Spain, according to this entity, which consists of scientific and patient associations dedicated to the elimination of viral hepatitis and the Spanish Association for the Study of the Liver (AEEH). There are only 184 people on the waiting list for liver transplants today. At the same time, logically, the number of people receiving hepatitis C transplants has also decreased over the years, 135 in 2022 compared to 345 in 2015, a 60% decrease.

The liver transplant waiting list peaked in 2015 with 2,175 patients. Since then, fewer people with hepatitis C need transplants, reducing the total number of people waiting for a liver transplant by 25% to 1,627 in 2022. The number of patients waiting for liver transplants has decreased, while the number of transplants performed has remained fairly stable, at 1,097 in 2015, 1,012 in 2021, and 1,159 in 2022.

Although increased transplantation rates and organ availability may have favored this decline, and given that derivation criteria have not become more stringent, but the opposite, everything points to DAA – and the subsequent success of the approach – being effective against hepatitis C. – the driving force behind this massive change.

AEHVE estimates that the reduction in liver transplant waiting lists is another great achievement in the fight against hepatitis C in Spain, and they not only positively evaluate the impact it has already had in reducing liver transplant waiting lists; Opportunity. It may be opened up to expand indications for transplantation in the future. Spanish standards have begun to become more flexible, following a consensus reached in 2020 between the AEEH and six other scientific societies.

The consensus recommends “a modest expansion of the Milan criteria for liver transplantation (…), as long as equitable access to transplantation is maintained for patients with indications other than hepatocellular carcinoma”, “taking into account the epidemiological heterogeneity between different autonomous communities”, and variable donation rates and waiting list composition,” and to “prospectively monitor the impact of expanded criteria on wait list composition in order to take necessary corrective actions in the future to uphold the ethical principles of usefulness, equity, and transplantation of justice. “

In addition to bringing new opportunities for liver transplantation, progress in eliminating hepatitis C “should mean that more resources may be devoted in the future to other liver diseases that have become increasingly prevalent in recent years,” such as alcoholic liver disease. disease and so-called fatty liver disease (metabolic liver disease). “Therefore, the AEEH has asked the Ministry of Health to develop a liver health plan,” explains Javier García-Samaniego, coordinator of the AEHVE.

A complete success

But while progress is being made to address other increasingly prevalent liver diseases, “the great goal of eliminating hepatitis C must be achieved,” Garcia-Samaniego added. Spain is the country with the highest number of treated and cured hepatitis C patients per million inhabitants in the world (more than 165,000), which leaves the infection rate at very low levels: 0.85% and 0.22% respectively. Antibody positivity and active infection were higher in men over 50 and women over 70 in 2019 (these numbers are likely lower today).

Likewise, in some vulnerable groups with higher rates of hepatitis C, such as prison populations, prevalence was estimated at 20% but has virtually been eliminated. For people co-infected with HIV, where the risk of liver disease progression is greater, the rate of active infection has dropped from 22% to less than 1%. “In any case, these achievements were absolutely unimaginable before the treatment became widely available. The number of patients waiting for liver transplants has also been reduced,” says the AEHVE coordinator.

However, AEHVE, in conjunction with other scientific and patient associations, insists that not everything is yet done and that further steps are necessary to complete this great success for the country. Given that hepatitis C is an asymptomatic infection with few symptoms until it progresses to its most severe form, and that there is no vaccine to prevent transmission and reinfection, this great consensus and effort around universalization of treatment is necessary Add another equivalent for screening and diagnosing infections in people who don’t know they are infected.

“Not only must everyone diagnosed be treated, but also everyone with active infection must be diagnosed,” they said. To achieve this, scientific consensus established two paths: Aggressive treatment of the most vulnerable Search, especially for homeless people, intravenous drug users and men who have sex with men, who are the main sources of active infection; Introduce age-based opportunistic screening, i.e. testing all persons entering the health system for hepatitis C, From the age group with the highest probability of infection (45-70 years old) to the age group with the lowest probability.

Current recommendations from the Ministry of Health do not currently include this age screening, and AEHVE and AEHH unanimously request that, taking advantage of the reduction in diagnostics, allow the use of PCR technology (pooling) to group blood samples for analysis, which has been successfully used to treat COVID-19, It is also used to treat hepatitis C in communities such as Galicia.

“Fortunately, serological diagnosis of hepatitis C is not expensive and is now much cheaper. The test consists of a simple blood test and costs just over one euro. With experience in dealing with COVID-19, by age Strategies for opportunistic screening are much simpler, cost-effective, feasible and easy to implement. Therefore, the scientific community believes that the Ministry of Health should not delay in promoting consensus among all autonomous communities on a more ambitious screening strategy that All Spaniards are allowed to be tested for hepatitis C at least once in their lifetime, said Dr. Javier García-Samaniego, director of the Department of Hepatology at the University Hospital of La Paz.

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