Well, I belive that prae LT treatment with safosbuvir & daclatasvir or somerprevir would be a better choice. And you might prevent cholestatic HCV disease after LT in some cases.

So here is the debate, pre-LTX treatment for all HCV will treat patients who for some reason or another, never get to transplant. By most estimates, that might amount to 20% of patients, HCC and high MELD patients who would drop out or die. The question of wastage of resources is a concern for routine pre-LTX treatment. On the other hand, there are some patients with low MELD score, that may actually improve their MELD score and drop off the list.

I would have thought that this is going to come down to effective resource allocation whilst the cost of the drugs remains high, which means targeting selected patients pre transplant and treating the remainder post transplant

I agree, a thorough cost-analysis starting from time of referral for a variety of patients, whether they receive anti-viral therapy before or after, should be very interesting and help decide this question. I wonder if there is a registry or ongoing effort to do this.

The question is how much the payers (health insurance or health system) are willing to pay.?

I don't think the insurers in the US will have an option not to pay in the long-run. But there will be practical issues also in following these patients. There is need for fairly intense follow up for these patients during the duration of treatment, especially with the current protocols. It may be easier when the NRTI and polymerase inhibitor combinations come out later this year or next year.

The long-term management (economics) of liver cirrhosis should include right now a calculation for HCV treatment around (pré and/or post) trasnplantation,

Dear.

What do you think about "post LTx"? When does it means?

Immediate post LTx or 6 months or 1yr or post-Bx - advanced fibrosis ??

I think this point is also important.

Sincerely,

If you look at the literature, only about 35-50% of HCV positive recipients have problems with recurrent HCV, including cirrhosis/cholestatic hepatitis. That means that pre-emptive or pre-LTX treatment will overtreat at least 50% of patients who won't develop complications. So I would think that post-LTX treatment would target those with evidence of recurrent disease and moderate fibrosis/inflammation.

I know. However, in the era of DAA, as you can know, treatment patterns may change in HCV LTx. patient. Anyway, drug prices and insurance are important issues about that.

Thanks.

A carefull evaluation is needed about the different options as at present we need to take into account the high costs. In our experience 30- 40% of patients  were able to eradicate the Hepatitis C virus with the standard treatment after (6-12 months) and they never show recidivism. Relapser and non-responder need to be the first to be considered for the new DAA.

sincerely