Improved Graft Survival After Liver Transplantation for Recipients With Hepatitis C Virus in the Direct-Acting Antiviral Era

Liver Transpl. 2019 Apr;25(4):598-609. doi: 10.1002/lt.25424.


Highly effective direct-acting antiviral (DAA) therapy has transformed outcomes of liver transplantation in hepatitis C virus (HCV) patients. We examined longer-term outcomes in HCV-positive recipients in the DAA era and analyzed the Scientific Registry of Transplant Recipients for primary adult, single-organ, nonfulminant liver transplant recipients in the United States from January 1, 2008 to June 30, 2018. Graft loss was compared among HCV-positive liver transplant recipients who received either an HCV-negative or HCV-positive donor (donor [D]-/recipient [R]+; D+/R+) and HCV-negative liver transplant recipients who received a HCV-negative donor (D-/R-). The groups were further divided between the pre-DAA and DAA eras. There were 52,526 patients included: 31,193 were D-/R- patients; 18,746 were D-/R+ patients; and 2587 were D+/R+ patients. The number of D-/R+ transplants decreased from 2010 in 2008 to 1334 in 2017, with this decline particularly noticeable since 2015. D-/R+ patients in the DAA era (n = 7107) were older, had higher rates of hepatocellular carcinoma, and lower Model for End-Stage Liver Disease scores than those in the pre-DAA era. Graft survival improved for all recipients in the DAA era but improved most dramatically in HCV-positive recipients: D-/R+ 1-year survival was 92.4% versus 88.7% and 3-year survival was 83.7% versus 77.7% (DAA versus pre-DAA era, respectively) compared with D-/R- 1-year survival of 92.7% versus 91.0% and 3-year survival of 85.7% versus 84.0% (DAA versus pre-DAA era, respectively). The magnitude of improvement in 3-year graft survival was almost 4-fold greater for D-/R+ patients. The 3-year survival for D+/R+ patients was similar to HCV-negative patients. In conclusion, the number of liver transplants for HCV has decreased by more than one-third over the past decade. Graft survival among HCV-positive recipients has increased disproportionately in the DAA era with HCV-positive recipients now achieving similar outcomes to non-HCV recipients.

MeSH terms

  • Adult
  • Aged
  • Allografts / drug effects
  • Allografts / virology
  • Antiviral Agents / administration & dosage*
  • End Stage Liver Disease / diagnosis
  • End Stage Liver Disease / mortality
  • End Stage Liver Disease / surgery*
  • End Stage Liver Disease / virology
  • Female
  • Graft Rejection / epidemiology*
  • Graft Rejection / virology
  • Graft Survival / drug effects
  • Hepacivirus / isolation & purification
  • Hepatitis C, Chronic / drug therapy*
  • Hepatitis C, Chronic / transmission
  • Hepatitis C, Chronic / virology
  • Humans
  • Kaplan-Meier Estimate
  • Liver / drug effects
  • Liver / virology
  • Liver Transplantation / adverse effects*
  • Liver Transplantation / statistics & numerical data
  • Male
  • Middle Aged
  • Prospective Studies
  • Registries / statistics & numerical data
  • Severity of Illness Index
  • Survival Rate
  • Treatment Outcome
  • United States / epidemiology
  • Young Adult


  • Antiviral Agents