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

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.