From the AGA Journals

Scoring system quantified chances of HCV treatment benefit

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Escaping 'MELD purgatory'

Patients with decompensated cirrhosis are now able to receive antiviral therapy without risk of worsening symptoms of decompensation. More clinics are able to offer DAA therapy to patients with hepatitis C, without the need for expertise in managing the side effects of interferon-based therapy.

The study by El-Sherif et al. summarizes well the benefits and potential pitfalls of treatment of hepatitis C in patients with decompensated cirrhosis. Their scoring system is largely intuitive and mirrors the traditional Child-Turcotte-Pugh score in that patients with low serum albumin, hepatic encephalopathy, and ascites are at risk of failing to improve clinically. Patients can have their hepatitis C successfully treated but can be trapped in “MELD purgatory,” a state of significant symptoms of liver disease, without the objective priority points necessary to be candidates for liver transplantation.

As experience is gained in the use of DAA medications for HCV, it is incumbent on physicians to gather knowledge that will further refine their understanding of which patients with signs of liver decompensation might benefit. It is also clear that patients with decompensated cirrhosis should be managed by clinicians who have experience in liver transplantation, to ensure that patients are counseled regarding not just the benefits, but potential risks of DAA therapy for hepatitis C.

Roman E. Perri, MD, is assistant professor of medicine, division of gastroenterology and hepatology, Medical Director for Liver Transplantion, Vanderbilt University, Nashville, Tenn. He has no conflicts of interest.



A new scoring system predicted which patients with decompensated cirrhosis caused by hepatitis C virus (HCV) infection were most likely to experience meaningful benefits from direct-acting antiviral (DAA) therapy.

Dubbed BEA3, their scoring system assigns one point each for body mass index under 25 kg/m2, absence of encephalopathy, absence of ascites, ALT more than 1.5 times the upper limit of normal, and albumin above 3.5 g/dL. Patients who scored 4 or 5 were more than 50 times more likely to improve to Child-Pugh Turcotte (CPT) class A (compensated) cirrhosis with DAA therapy than were patients who scored 0 (hazard ratio, 52.3; 95% confidence interval, 15.2-179.7; P less than .001), wrote Omar El-Sherif, MB, BCh, of St. James’s Hospital, Dublin, together with his associates in the June issue of Gastroenterology.

Eradicating HCV does not necessarily improve the odds of transplant-free survival in the setting of decompensated cirrhosis, the researchers noted. Patients can end up in “MELD [Model for End-Stage Liver Disease] purgatory,” meaning they are still decompensated despite achieving sustained virologic response and improved MELD scores. Such patients can face longer waits for liver transplantation than if they had foregone DAA therapy. “There is an urgent need for data to refine our understanding of the reversibility of hepatic decompensation with viral eradication, and, ultimately, define the “point of no return,” the degree of liver dysfunction at which HCV therapy does not yield any meaningful clinical benefit, the researchers wrote.

Their study included 622 patients from the SOLAR-1, SOLAR-2, ASTRAL-4, and GS-US-334-0125 trials, which evaluated interferon-free sofosbuvir-based DAA therapy in patients with chronic hepatitis C virus infection and advanced liver disease. Patients received 12 or 24 weeks of therapy with ledipasvir, sofosbuvir, and ribavirin or velpatasvir, sofosbuvir, and/or ribavirin, or 48 weeks of treatment with sofosbuvir and ribavirin.

A total of 32% of patients with CPT class B cirrhosis improved to class A, as did 12% of patients with class C cirrhosis. Each factor in the scoring system independently affected the chances of reaching CPT class A cirrhosis, even after accounting for SVR.

Notably, patients with intermediate BEA3 scores of 1, 2, or 3 were significantly more likely to reach CPT class A cirrhosis than were patients with scores of 0, with hazard ratios ranging from 4.2 (for a score of 1) to 21.2 (for a score of 3). Most patients had scores of 0 (106 individuals), 1 (219 individuals), or 2 (180 individuals), and only 23 patients scored a 4 or a 5.

CPT score reflects prothrombin time, serum albumin and bilirubin, and the presence or severity of ascites. The investigators called the new scoring system “a tool that can enhance shared decision making at the point of care, quantifying the potential benefits of DAA therapy for patients with decompensated cirrhosis in the pretransplant setting.”Dr. El-Sherif disclosed ties to Gilead Sciences, Bristol-Myers Squibb, and the Health Research Board of Ireland. Four coinvestigators disclosed employment with Gilead, and several other coinvestigators disclosed ties to Gilead, BMS, AbbVie, and other companies.

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