Research Open Access
Like 0



Liver transplantation is an important measure of burden from hepatitis C virus (HCV)-associated liver disease.


To describe transplant rates and survival in individuals with HCV infection from 2008 to 2017 in England through data linkage.


This is a retrospective observational cohort study. Laboratory reports of HCV infection were linked to the Liver Transplant Registry for individuals aged 15 years and over, first diagnosed between 1998 and 2017. We estimated age-sex standardised incidence rates and used Poisson regression to investigate predictors of liver transplantation and test for a change in incidence after introduction of direct-acting antivirals (DAAs) in 2014. Kaplan-Meier survival analysis was used to calculate post-transplant survival rates.


Of 124,238 individuals diagnosed with HCV infection, 1,480 were registered and 1,217 received a liver transplant. Of individuals registered, 1,395 had post-HCV cirrhosis and 636 had hepatocellular carcinoma (618 also had post-HCV cirrhosis). Median time from HCV diagnosis to transplant was 3.4 years (interquartile range: 1.3–6.8 years). Liver transplant rates were lower 2014–17 compared with 2011–13 (incidence rate ratio: 0.64; 95% confidence interval: 0.55–0.76). Survival rates were 93.4%, 79.9% and 67.9% at 1, 5 and 10 years, respectively. Data linkage showed minimal under-reporting of HCV in the transplant registry.


In the post-DAA era, liver transplant rates have fallen in individuals with HCV infection, showing early impact of HCV treatment scale-up; but the short time from HCV diagnosis to liver transplant suggests late diagnosis is a problem.


Article metrics loading...

Loading full text...

Full text loading...



  1. Harris RJ, Harris HE, Mandal S, Ramsay M, Vickerman P, Hickman M, et al. Monitoring the hepatitis C epidemic in England and evaluating intervention scale-up using routinely collected data. J Viral Hepat. 2019;26(5):541-51.  https://doi.org/10.1111/jvh.13063  PMID: 30663179 
  2. Public Health England (PHE). Hepatitis C in England- 2019 report. Working to eliminate hepatitis C as a major public health threat. London: PHE; 2019. Available from
  3. Harris RJ, Thomas B, Griffiths J, Costella A, Chapman R, Ramsay M, et al. Increased uptake and new therapies are needed to avert rising hepatitis C-related end stage liver disease in England: modelling the predicted impact of treatment under different scenarios. J Hepatol. 2014;61(3):530-7.  https://doi.org/10.1016/j.jhep.2014.05.008  PMID: 24824282 
  4. Banerjee D, Reddy KR. Review article: safety and tolerability of direct-acting anti-viral agents in the new era of hepatitis C therapy. Aliment Pharmacol Ther. 2016;43(6):674-96.  https://doi.org/10.1111/apt.13514  PMID: 26787287 
  5. Public Health England (PHE). Hepatitis C treatment monitoring in England. Content, completeness and preliminary findings from the Hepatitis C patient registry and treatment outcome system. London: PHE; 2018. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/756748/HCV_treatment_monitoring_report_2018.pdf
  6. Foster GR, Irving WL, Cheung MCM, Walker AJ, Hudson BE, Verma S, et al. HCV Research, UK. Impact of direct acting antiviral therapy in patients with chronic hepatitis C and decompensated cirrhosis. J Hepatol. 2016;64(6):1224-31.  https://doi.org/10.1016/j.jhep.2016.01.029  PMID: 26829205 
  7. Ponziani FR, Mangiola F, Binda C, Zocco MA, Siciliano M, Grieco A, et al. Future of liver disease in the era of direct acting antivirals for the treatment of hepatitis C. World J Hepatol. 2017;9(7):352-67.  https://doi.org/10.4254/wjh.v9.i7.352  PMID: 28321272 
  8. Vaziri A, Gimson A, Agarwal K, Aldersley M, Bathgate A, MacDonald D, et al. Liver transplant listing for hepatitis C-associated cirrhosis and hepatocellular carcinoma has fallen in the United Kingdom since the introduction of direct-acting antiviral therapy. J Viral Hepat. 2019;26(2):231-5.  https://doi.org/10.1111/jvh.13022  PMID: 30339294 
  9. Young K, Liu B, Bhuket T, Gish RG, Wong RJ. Improved liver transplant waitlist mortality and lower risk of disease progression among chronic hepatitis C patients awaiting liver transplantation after the introduction of direct-acting antiviral therapies in the United States. J Viral Hepat. 2019;26(3):350-61.  https://doi.org/10.1111/jvh.13039  PMID: 30412318 
  10. Ferrarese A, Germani G, Gambato M, Russo FP, Senzolo M, Zanetto A, et al. Hepatitis C virus related cirrhosis decreased as indication to liver transplantation since the introduction of direct-acting antivirals: A single-center study. World J Gastroenterol. 2018;24(38):4403-11.  https://doi.org/10.3748/wjg.v24.i38.4403  PMID: 30344424 
  11. Dirchwolf M, Marciano S, Giunta DH, Posadas-Martínez ML, Biggins SW, Ruf AE. Trends in liver transplantation for hepatitis C in a country with reduced access to direct-acting antiviral agents. Clin Transplant. 2018;32(4):e13230.  https://doi.org/10.1111/ctr.13230  PMID: 29485711 
  12. Simmons R, Ireland G, Ijaz S, Ramsay M, Mandal SNational Institute for Health Research Health Protection Research Unit. (NIHR HPRU) in Blood Borne, Sexually Transmitted Infections. Causes of death among persons diagnosed with hepatitis C infection in the pre- and post-DAA era in England: A record linkage study. J Viral Hepat. 2019;26(7):873-80.  https://doi.org/10.1111/jvh.13096  PMID: 30896055 
  13. Brant LJ, Hurrelle M, Balogun MA, Klapper P, Ahmad F, Boxall E, et al. Sentinel laboratory surveillance of hepatitis C antibody testing in England: understanding the epidemiology of HCV infection. Epidemiol Infect. 2007;135(3):417-26.  https://doi.org/10.1017/S0950268806006832  PMID: 16836798 
  14. Public Health England (PHE). Annual report from the sentinel surveillance study of blood borne virus testing in England: data for January to December 2017. London: PHE; 2018. Available from
  15. Office for National Statistics (ONS). Population estimates 2018. Newport: ONS. [Accessed 15 Dec 2018]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates
  16. Ireland G, Mandal S, Hickman M, Ramsay M, Harris R, Simmons R. Mortality rates among individuals diagnosed with hepatitis C virus (HCV); an observational cohort study, England, 2008 to 2016. Euro Surveill. 2019;24(30):1800695.  https://doi.org/10.2807/1560-7917.ES.2019.24.30.1800695  PMID: 31362807 
  17. Moosavy SH, Davoodian P, Nazarnezhad MA, Nejatizaheh A, Eftekhar E, Mahboobi H. Epidemiology, transmission, diagnosis, and outcome of Hepatitis C virus infection. Electron Physician. 2017;9(10):5646-56.  https://doi.org/10.19082/5646  PMID: 29238510 
  18. Werner CR, Schwarz JM, Egetemeyr DP, Beck R, Malek NP, Lauer UM, et al. Second-generation direct-acting-antiviral hepatitis C virus treatment: Efficacy, safety, and predictors of SVR12. World J Gastroenterol. 2016;22(35):8050-9.  https://doi.org/10.3748/wjg.v22.i35.8050  PMID: 27672299 
  19. Lanini S, Scognamiglio P, Mecozzi A, Lombardozzi L, Vullo V, Angelico M, et al. members of the Lazio Region HCV treatment group. Impact of new DAA therapy on real clinical practice: a multicenter region-wide cohort study. BMC Infect Dis. 2018;18(1):223.  https://doi.org/10.1186/s12879-018-3125-6  PMID: 29769038 
  20. Saxena V, Nyberg L, Pauly M, Dasgupta A, Nyberg A, Piasecki B, et al. Safety and efficacy of simeprevir/sofosbuvir in hepatitis C-infected patients with compensated and decompensated cirrhosis. Hepatology. 2015;62(3):715-25.  https://doi.org/10.1002/hep.27922  PMID: 26033798 
  21. van der Meer AJ, Feld JJ, Hofer H, Almasio PL, Calvaruso V, Fernández-Rodríguez CM, et al. Risk of cirrhosis-related complications in patients with advanced fibrosis following hepatitis C virus eradication. J Hepatol. 2017;66(3):485-93.  https://doi.org/10.1016/j.jhep.2016.10.017  PMID: 27780714 
  22. Kondili LA, Gaeta GB, Brunetto MR, Di Leo A, Iannone A, Santantonio TA, et al. Incidence of DAA failure and the clinical impact of retreatment in real-life patients treated in the advanced stage of liver disease: Interim evaluations from the PITER network. PLoS One. 2017;12(10):e0185728.  https://doi.org/10.1371/journal.pone.0185728  PMID: 28977040 
  23. Lau SY, Woodman RJ, Silva MF, Muller K, Libby J, Chen JW, et al. Good outcomes of liver transplantation for hepatitis C at a low volume centre. Ann Hepatol. 2016;15(2):207-14. PMID: 31196402 
  24. NHS Blood and Transplant. Annual report on liver transplantation- report for 2015/2016 (1 April 2006 – 31 March 2016). London: NHS; 2016. Available from: https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/1314/organ_specific_report_liver_2016.pdf
  25. Mahajan R, Xing J, Liu SJ, Ly KN, Moorman AC, Rupp L, et al. Chronic Hepatitis Cohort Study. (CHeCS) Investigators. Mortality among persons in care with hepatitis C virus infection: the Chronic Hepatitis Cohort Study (CHeCS), 2006-2010. Clin Infect Dis. 2014;58(8):1055-61.  https://doi.org/10.1093/cid/ciu077  PMID: 24523214 
  26. McDonald SA, Hutchinson SJ, Bird SM, Robertson C, Mills PR, Graham L, et al. The growing contribution of hepatitis C virus infection to liver-related mortality in Scotland. Euro Surveill. 2010;15(18):19562. PMID: 20460092 
  27. World Health Organisation (WHO). Global Health Sector Strategy on Viral Hepatitis 2016-2021- Towards ending viral hepatitis. 2016. Geneva: WHO; 2016. Available from: https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf;jsessionid=B414D1806598317BE385218FA7F29E6A?sequence=1

Data & Media loading...

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error