“Liver damage, particularly cirrhosis, plays out over a few decades,” explains Andrew Muir, MD, chief of the division of gastroenterology at Duke University in Durham, North Carolina. While many people with hepatitis C can be treated with direct-acting antiviral (DAA) medications, some, including those who’ve suffered liver damage from cirrhosis or developed liver cancer, may also need to have a liver transplant. “The key is separating out the presence of the virus and how sick the liver is,” says Dr. Muir. “We have to ask, ‘Is this liver so damaged that the patient will not feel better with other treatments? Will his or her quality of life be drastically affected without a transplant?’ Or, worse, ‘Could they potentially die if they don’t get a transplant?’ We always first want to try to treat the patient before ever going the transplantation route.”
What to Know About Liver Transplants
People who are candidates for a liver transplant are first referred to a liver transplant center for further evaluation. There, doctors perform tests such as a stress test, cancer screening, and mental health screening to determine if the candidate can handle the stress of an organ transplant. “We need to know if a patient is emotionally and mentally stable enough to undergo a major surgery such as a liver transplant,” says Muir, adding that doctors also want to know if their patients have the support of friends and family. “They most certainly cannot do this alone,” he says. Doctors also want to determine whether people are physically strong enough to undergo the procedure and have health insurance that covers a transplant. Next, doctors will use a “MELD” (model for end-stage liver disease) score to assess the severity of a person’s liver damage. The score, which is based on lab tests, ranges from 6 (the least liver damage) to 40 (the most severe). “If a patient has a MELD score between 12 and 14, I always attempt to treat them first before pursuing a liver transplant,” says Muir. Anything above 14, though, and liver transplantation is greatly considered. Once a person “passes” these exams, they are placed on the liver transplant list and normally wait about 18 months for one to become available. In recent years, that wait time has started to decrease, thanks, in large part, to the same DAAs that can cure hepatitis C.
Treating Hepatitis C After a Liver Transplant
A liver transplant can save a person’s life, but it does not cure hepatitis C. Hepatitis C can be cured with DAA though. Christine Durand, MD, a transplant and infectious disease expert at Johns Hopkins University in Baltimore, refers to these medications as a game changer. These drugs treat the virus itself and reduce the need for liver transplants: A study published in March 2017 in the journal Hepatology found that since the introduction of DAAs, there has been a 30 percent decrease in people on liver transplant wait lists. They can also allow people to receive new, hepatitis C–positive livers faster, decreasing the time they spend waiting for a new organ. This increase in hepatitis C–positive organs, which are being used in transplantations, has increased during the opioid epidemic, explains Dr. Durand. (People who share intravenous drug equipment can transfer the virus to each other, according to the National Institute on Drug Abuse.) “Ten years ago, we could not perform an organ transplant with an HCV-positive organ to an HCV-negative patient,” says Durand. “That was only performed as the very last option, to save a person’s life.” But now, thanks to these antiviral medications, doctors can give HCV-negative people liver transplants using HVC-positive organs and then treat the virus after the surgery. The strategy is working: A study published in July 2020 in The American Journal of Gastroenterology found that “HCV-negative recipients receiving HCV-positive liver grafts had excellent one-year survival outcomes.” “Liver transplantation outcomes are overall improving,” says Durand. “The outlook is hopeful for all patients needing a liver transplant.”
