The approval of potent antiviral therapy (AVT) with sofosfuvir/ledipasvir (sof/ldv) for hepatitis C (HCV) dramatically increased cure rates (SVR) to nearly 100%. A recent prospective trial in decomp. cirrhosis (Child B/C) reported an 89-91% cure and a mean MELD reduction of 2.5 points) after AVT with sof/ldv/rib (Flamm, Hepatology 2014;(60):320A, AASLD 2014). Aim: to evaluate consequences of ATV-induced MELD reduction on transplant wait-listed patients' continued need for liver allocation. Methods: Characteristics and MELD scores of HCV patients listed for liver transplantation (LTx) in 2012 (SRTR, n=4,612) were used as the study database. To evaluate AVT-MELD interactions, the observed reduction MELD score of 2.5 points by12 weeks of sof/ldv/rib in decomp. cirrhotics was incorporated into 3 models: A, MELD returned to pre-AVT level after completion of AVT; B: MELD improved by 2.5 points by end of AVT and remained stable thereafter; C: MELD continued to improve by 2.5 points every 3 months as a result of HCV cure by ATV. Primary outcome was "time to improve to a MELD of 15" (TTI-15; the threshold for LTx benefit). Model assumptions included: listed pts. treatment rate: 80%, cure (SVR) rate: 90% (as reported above), all patients conformed to the same model, and none deteriorated during AVT or after SVR. Natural MELD was assessed without upgrades for HCC. Results: In the A and B models there was no effect on primary outcome (TTI-15). C: listed patients with MELD > 35 reached TTI-15) in 34.5 months (30-39); those listed with MELD 25-35 reached TTI-15 in 27 mo (24-30), and those listed with MELD 15-25 reached TTI-15 in 12 mo (9-15). Estimates from the C model applied to the 2012 national LTx waiting list suggest that ATV-induced MELD reduction down to the threshold of 15 points would occur in 2,820 HCV patients (61.1% of all listed HCV-patients) over a period of 13.2 months (range:9-39) from the start of ATV. Simultaneously, approximately 857 donated livers would become available for re-distribution to other listed patients, leading to a substantial decrease in the gap between listed patients and available livers.

Conclusions: The high cure rates achieved with the new potent and safe HCV AVT in decompensated Childs class B and C cirrhotics are likely to have a substantial impact on the liver transplant wait-list and organ allocation.

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