Association between sustained virological response and adverse liver-related events in patients with decompensated HCV cirrhosis

Background & aims: Sustained virological response (SVR) improves prognosis in chronic hepatitis C virus (HCV) patients with compensated cirrhosis, but whether similar benefit can be obtained in decompensated patients is controversial. We studied the association between SVR and liver-related events (LREs) in patients with decompensated HCV cirrhosis. Methods: We included patients with decompensated HCV cirrhosis (Child-Turcotte-Pugh (CTP) ≥7 and/or history of decompensation) treated with direct-acting antivirals. The association between SVR and LREs, and between SVR-related change in MELD score and LREs were assessed. Results: In total, 914 patients were included with median age of 54.7, 45% had alcohol use disorder, 87% CTP-B, and median MELD score was 12.1. SVR was achieved in 834 (91.2%) patients, with a median follow-up of 28 months. The 3-year cumulative incidence of LREs was 47.5% in patients with SVR compared to 58.6% in those without (p<0.001). Findings were consistent in multivariable analysis (aHR:0.692, p=0.011). SVR was associated with a reduced risk of LREs in patients with a pretreatment MELD <15 (44.4% vs. 57.6%, aHR:0.601, p=0.004), but not amongst patients with MELD ≥15 (62.8% vs. 58.9%, aHR:0.936, p=0.801). Amongst patients with SVR, a ≥2-point decrease in MELD was observed in 23.4% and was not associated with a reduced risk of LREs (52.1% vs. 50.7%, p=0.473). Findings were consistent in multivariable analysis (aHR:0.730, p=0.122), and in patients with a pretreatment MELD score ≥15. Conclusions: SVR was associated with a reduced risk of LREs in patients with decompensated HCV cirrhosis with a MELD score <15, whereas no clinical benefit was observed in those with higher MELD scores despite an SVR-associated MELD decrease.