1. Treatment of HCV-positive Liver Transplant Candidates Bijan Eghtesad, M.D. Hepato-Pancreato-Biliary/Liver Transplantation Surgery Cleveland Clinic USA Hepatitis C in Iran Tehran, Iran July 22, 2016

2. Natural History of HCV infection

3. 5 years After OLT

4. Years after OLT

5. Patterns Of HCV Recurrence After OLT Fibrosing Cholestatic HCV Recurrence Chronic Hepatitis Linear Rate Of Fibrosis Progression Delayed Onset Progression 5% 25%*65%* * At 5 years follow-up

7. Post-transplant Graft Survival

8. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

9. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

10. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

11. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

12. Evolution of HCV Therapy Independent of the treatment regimen used, sustained virological response (SVR) is the ultimate goal of therapy

13. Management of HCV Disease Prior to 2014  Antiviral therapy is primarily given post-LT  Annual biopsies used to monitor for fibrosis change  Treat early severe recurrence and those with progression (F2 or more)  Mainstay of treatment = peg-IFN, ribavirin and Protease inhibitors (PIs)

14. Protease Inhibitors: First Generation DAA 05/23/201105/14/2011

15. Every Step of HCV Replication Can be Targeted Manns MP et al. Nat Rev Drug Discov. 2013

16. Sofosbuvir A “Game Changer” For Management of Recurrent HCV Disease  Positives  Excellent tolerability  No DDI with immunosuppression  Consistent HCV RNA suppression on treatment  Negatives  Renal insufficiency requires dose reduction  Unknown dosing if on dialysis  Cost and access

17. HCV treatment in patients on the liver transplant waiting list Several proof of concept studies have shown – Safety – Efficacy – Compensated liver disease – Mild-to-moderately decompensated cirrhosis Safe prevention of post liver transplant recurrence

18. HCV treatment in patients on the liver transplant waiting list Interferon-based therapies – Interferon and Ribavirin – Sofosbovir-based triple therapy – Daclatasvir-based triple therapy Good results, however, toxicities of INF still present.

19. HCV treatment in patients on the liver transplant waiting list Ideal regimen Not limited to G1 infection No drug-drug interactions Minimal adverse effects No emergence of resistance All oral Shortest duration of treatment with SVR

20. HCV treatment in patients on the liver transplant waiting list Interferon-free regimens Treatment regimens for Genotype 1 Treatment regimens for all genotypes

21. SOF + RBV in Wait-Listed HCV Patients (G1-4)  N=61 DDLT candidates with MELD exception for HCC  CPT ≤8 (43% CP=5, 73% CP-A)  Median MELD =8 (8-14)  CrCl ≥60 mL/min  Rx- naïve (25%) or experienced (75%)  Absence of HIV or HBV 21 pTVR12 SOF 400 mg + RBV 1000‒1200 mg (n=61) Curry M et al. Gastroenterology 2015

22. Viral Responses with SOF-RBV BL12384 Study Week Mean Change in HCV RNA±SD (log 10 IU/mL) At time LT ≥12 Wks Post-LT Patients (%) 41/4425/39 HCV RNA Change from Baseline (n=61) HCV RNA <LLOQ at Transplant *3 subjects were >LLOQ at transplant. † 1 subject has not reached pTVR12, 1 subject LTFU at Week 8 post transplant. Curry M et al, Gastroenterology 2015

23. Days HCV RNA Negative Prior to LT and Rate of Recurrence No Recurrence (n=28)Recurrence (n=10) Median days of HCV RNA undetectable No recurrence: 95 Recurrence: 5.5 p <0.001 >30 days TND

24. SPARE Study: Sofosbuvir + RBV in Difficult-to-Treat GT1 Patients Treatment-naive subjects; primarily GT1a (68%), male (59%), black (85%), IL28B CT/TT (78%) [1,2] Advanced liver disease in 26% for cohort 2 (N=3 cirrhosis) No safety signals or drug-related discontinuations Wk 24 Osinusi A, et al. JAMA. 2013;28;310(8):804-11 Sofosbuvir 400 mg + RBV 1000/1200 mg (n = 10) Sofosbuvir 400 mg + RBV 1000/1200 mg (n = 25) Sofosbuvir 400 mg + RBV 600 mg (n = 25) Part 1 (stage F0-2 fibrosis) [1] SVR12 90 Part 2 (all stages of fibrosis) [2] Viral Response (ITT), % 48 68

25. Pre-Transplant Treatment HCV Summary  Treatment decisions require consideration of:  Time to LT  Severity of liver disease (CPS)  If aiming for prevention of post-LT HCV, need at least 4 weeks of HCV RNA negativity  SOF + RBV appears safe for CP-A, B & C patients  Requirement for RBV can be limiting in sick patients  If aiming for SVR  limited current options for Childs B(+) and C patients  SOF + RBV for 24-48 weeks

26. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

27. SOLAR-1 LDV/SOF + RBV Randomisation* of the 7 groups 1 : 1 Open-label SOLAR-1 Study: LDV/SOF + RBV in advanced liver disease Design W12W24 ≥ 18 years Chronic HCV infection Genotypes 1 or 4 Cirrhosis or previous liver transplantation No prior exposure to NS5A inhibitor No HBV or HIV co-infection Charlton M. Gastroenterology 2015 ; 149: 649-659 N = 30 N = 26 N = 4 N = 26 Child-Pugh B N = 23 N = 55 N = 5 N = 40 LDV/SOF + RBV Child-Pugh C No cirrhosis Child-Pugh B Chid-Pugh A Child-Pugh C Fibrosing cholestasic hepatitis N = 29 N = 25 N = 2 N = 26 N = 56 N = 4 LDV/SOF 90mg/400 mg : 1 pill qd RBV : 1000 or 1200 mg/day (bid dosing) according to body weight (< or ≥ 75 kg) ; dose escalation in Child-Pugh B and C Cohort A Cirrhosis No transplantation Cohort B Prior liver transplantation

28. SOLAR-1 Study: LDV/SOF + RBV in advanced liver disease Summary – LDV/SOF + RBV for 12 weeks is an effective treatment for patients with advanced liver disease, including those with decompensated liver function before and after liver transplantation. Extending treatment to 24 weeks was not associated with improved outcomes, although there were no relapses in these groups – Rates of SVR 12 were over 85% in every group of patients with Child- Pugh class B decompensated cirrhosis - in those who had and had not undergone liver transplantation-, as well as those who received 12 and 24 weeks of treatment. – Similar response rates were observed in Child-Pugh class C patients who had not undergone liver transplantation – Results are very encouraging for fibrosing cholestatic hepatitis which may now be a manageable complication of liver transplantation – SVR 12 in patients with decompensated cirrhosis was associated with early improvements in Child-Pugh and MELD scores – Patients with decompensated liver disease experienced high frequencies of RBV hematotoxicity Charlton M. Gastroenterology 2015 ; 149: 649-659 SOLAR-1

29. SOLAR-1 Study: LDV/SOF + RBV in advanced liver disease Summary – LDV/SOF + RBV for 12 weeks is an effective treatment for patients with advanced liver disease, including those with decompensated liver function before and after liver transplantation. Extending treatment to 24 weeks was not associated with improved outcomes, although there were no relapses in these groups – Rates of SVR 12 were over 85% in every group of patients with Child- Pugh class B decompensated cirrhosis - in those who had and had not undergone liver transplantation-, as well as those who received 12 and 24 weeks of treatment. – Similar response rates were observed in Child-Pugh class C patients who had not undergone liver transplantation – Results are very encouraging for fibrosing cholestatic hepatitis which may now be a manageable complication of liver transplantation – SVR 12 in patients with decompensated cirrhosis was associated with early improvements in Child-Pugh and MELD scores – Patients with decompensated liver disease experienced high frequencies of RBV hematotoxicity Charlton M. Gastroenterology 2015 ; 149: 649-659 SOLAR-1

30. SOLAR-1 Study: LDV/SOF + RBV in advanced liver disease Summary – LDV/SOF + RBV for 12 weeks is an effective treatment for patients with advanced liver disease, including those with decompensated liver function before and after liver transplantation. Extending treatment to 24 weeks was not associated with improved outcomes, although there were no relapses in these groups – Rates of SVR 12 were over 85% in every group of patients with Child- Pugh class B decompensated cirrhosis - in those who had and had not undergone liver transplantation-, as well as those who received 12 and 24 weeks of treatment. – Similar response rates were observed in Child-Pugh class C patients who had not undergone liver transplantation – Results are very encouraging for fibrosing cholestatic hepatitis which may now be a manageable complication of liver transplantation – SVR 12 in patients with decompensated cirrhosis was associated with early improvements in Child-Pugh and MELD scores – Patients with decompensated liver disease experienced high frequencies of RBV hematotoxicity Charlton M. Gastroenterology 2015 ; 149: 649-659 SOLAR-1

31. HCV treatment for genotype 2 TARGET Sofosbuvir + RBV for compensated and decompensated cirrhosis High response rate in genotype 2 Extension of treatment from 12 to 16 weeks with increased SVR rate (88%), in advanced and treatment failure patients

32.  Objective – SVR 12 (HCV RNA < 25 IU/ml), with 95% CI, next observation carried backward DCV + SOF + RBV Randomised* 1:1 Open-label ALLY-3+ study: DCV + SOF + RBV for HCV genotype 3 with advanced fibrosis or cirrhosis W16 ≥ 18 years Chronic HCV infection Genotype 3 Treatment-naïve or experienced NS5A inhibitor-naïve HCV RNA ≥ 50,000 IU/ml Advanced fibrosis (F3) or compensated cirrhosis (F4)** No HBV or HIV co-infection Leroy V. Hepatology 2016, Jan 28 (Epub ahead of print) ** Liver biopsy or Fibroscan (≥ 9.6 to 14.6 = F3 ; > 14.6 kPa = F4), or Fibrotest ® ≥ 0.75 + APRI > 2 * Randomisation was stratified by fibrosis stage (F3 or F4) W12 SVR 12 –DCV : 60 mg qd –SOF : 400 mg qd –RBV : 1000 or 1200 mg/day (bid dosing) according to body weight (< or ≥ 75 kg) N = 24 N = 26  Design ALLY-3+

33. ALLY-3+ study: DCV + SOF + RBV for HCV genotype 3 with advanced fibrosis or cirrhosis Summary – Overall, 90% SVR 12 was achieved in HCV genotype 3-infected patients with advanced fibrosis or compensated cirrhosis treated with DCV + SOF + RBV SVR 12 was comparable for the 12-week (88%) and 16-week (92%) groups No on-treatment virologic failures; two relapses in each treatment arm – 100% SVR 12 among patients with advanced fibrosis – 86% SVR 12 among patients with cirrhosis (mostly treatment experienced) – Treatment was safe and well tolerated; no patient discontinued for adverse event – DCV + SOF + RBV for 12 or 16 weeks is a highly efficacious therapy for genotype 3-infected patients with advanced fibrosis or compensated cirrhosis ALLY-3+ Leroy V. Hepatology 2016, Jan 28 (Epub ahead of print)

34. Pre-transplant treatment for hepatitis C Genotype Treatment Genotype 1 (CTP A) Sofosbuvir/Ledipasvir +/- Ribavirin Ombitasvir/Paritaprevir/Ritonavir with dasabuvir Ribavirin-based regime Sofosbuvir/Simeprevir +/- Ribavirin Genotype 1 (CTP B,C) Access to transplant Sofosbuvir/Ledipasvir + Ribavirin 12 weeks Sofosbuvir/Ribavirin until transplant (<48 weeks)

35. Pre-transplant treatment for hepatitis C Genotype Treatment Genotype 2 Sofosbuvir /Ribavirin 12-16 weeks Genotype 3 (compensated) Sofosbuvir /Ribavirin 24 weeks (decompensated) Sofosbuvir /Ribavirin 48 weeks while awaiting liver transplant Daclatasvir/Sofosbuvir +Ribavirin Genotype 4 (compensated) Sofosbuvir/Ledipasvir Ombitasvir/Paritaprevir/Ritonavir + Ribavirin (decompensated) Sofosbuvir/Ledipasvir + Ribavirin

36. Conclusions Treatment Strategies in Wait-Listed Patients with Chronic HCV Pros  Uniformly prevent post-LT HCV infection  May reverse / improve liver function allowing avoidance of liver transplantation Cons  Improvement insufficient to avoid LT but reduces MELD to range less likely to get LT  HCC patients needed to be transplanted, regardless Antiviral Therapy for 48 wks Follow-up Liver Transplantation SVR Candidates with renal insufficiency (HRS) limited options for treatment

37. Conclusions Treatment Strategies in Wait-Listed Patients with Chronic HCV Pros:  Shorter duration therapy (reduced adverse events)  Higher rates of virologic response Cons:  Will not prevent need for LT  Timing of treatment can be difficult  HCC patients still need LT  Caution: less than 4 weeks of SVR  Use of HCV-positive donors! Antiviral Therapy for 4-16 wks Follow-up Liver Transplantation On-Treatment Response

38. Opportunities to Intervene with Antiviral Therapy Biggins SW, Terrault NA. Infect Dis Clin N Am 2006; 20:155

39. Liver transplantation for hepatitis C Role of perioperative treatment Genotype 1 or 4 Single dose of LDV/SOF the day before LT followed by additional 28 days of LDV/SOF Baseline GFR > 40 mL/min at screening and day of LT 11 finished the course: 55% female, 82% Caucasian, 64% IL28B non-CC, 36% treatment experience, all G-1 CTP class: A (27%), B (36%), C (36%) Median MELD 13 (7-16) 4/11 LDLTx One patients stopped Rx because of Ccl <30 9/10 achieved SVR4 and maintained Verna et el. ATC 2016

40. Liver transplantation for hepatitis C Role of perioperative treatment Advantage: Short duration of therapy with excellent SVR Tolerable No DDI especially early after transplant Good regimen for LDLTx Disadvantage: Not able to transplant with HCV-positive donors (need for longer therapy) With MELD score this low chances of getting a good quality liver, at least in US and some western countries, is very low Verna et el. ATC 2016

41. Liver transplantation for hepatitis C Role of perioperative treatment Antibody to HCV E2 glycoprotein Mass Biologic Attempt to decrease post-LT recurrence of HCV Intraoperative and postoperative infusion of antibody Patients HCV-RNA negative on HCV treatment (PI) at the time of LT – 92% of patients on polyclonal immunoglobulin – 80% control group HCV RNA negative at 8 weeks post-LT (Late recurrences seen) In an era of 96-98% SVR with oral agents not the best treatment

44. Case presentation Hepatitis C and liver transplantation

45. Case 1 HPI: 56 yo male with HCV associated ESLD diagnosed 5 years ago - HCV genotype 1 No prior treatment. ESLD complicated by ascites, esophageal varices, and mild encephalopathy. Lab-Data (At transplant) WBC 7.2, Hb/Hct 13.3/40.4, Platelet 66, PT-INR 1.5, AST/ALT 107/56, T-Bil 6.5, Alb 2.3, Cr 1.29, MELD 20 HCV-RNA (4 months prior to OLT) 135K IU/mL

46. OR DATA DONOR: 52 Y/F PROCEDURE: OLT CAVA: Conventional w/o bypass DUCT: Duct-to-duct Hospital Course POD1 Extubated. Tacrolimus and MMF with steroid taper in 21 days Uneventful recovery POD7 Discharged home Bili 1.2, Alk Phos 190, ALT 190 HCV RNA at transplant 3 million IU/mL HCV RNA at discharge 18 million IU/mL Case 1

47. LFTs on day 20 post transplant Bilirubin 4 mg/dL, Alk Phos 410, ALT 150 Tacrolimus level 12 ng/mL What should be done? Treat for rejection Treat for recurrent HCV Ultrasound of the liver and liver biopsy Nothing to be done and just watch

48. Case 1 Ultrasound was done and negative for any vascular problems Liver biopsy was done and was read by pathologist as mild rejection The patient received a gram of solumedrol

49. Case 1 3 days later Bili 6.0, Alk Phos 450, ALT 125, Tacrolimus 13 ng/mL Now what to do? –Further treatment for rejection –Treat HCV –Re-biopsy

50. Case 1 Biopsy repeated Hepatitis C recurrence Review of the first biopsy by pathologist Hepatitis C The patient continued to get worse and eventually developed fibrosing cholestatic hepatitis. He was started on DAA with viral clearance in 4 weeks and SVR. Complete histological recovery in 6 months

51. Lessons learned

52. So what to do? Diagnosis Histological diagnosis (Mild AR vs. HCV) by pathologist Mild AR: Portal inflammation and bile duct injury with >50% of all portal tract vs. HCV : Interface activity and lobular inflammation with spotty hepatocyte necrosis Clinical information by clinical physician HCV-RNA > 10 million: Most likely HCV rather than AR Detailed clinical information (LFT, IS, ATP etc) need to be given to pathologist.

53. Case 1 AR Treatment Avoid steroid bolus if HCV is suspected. 1 st Dx 2 nd Dx HCV Mild AR Do NOT increase IS. Re-biopsy if LFT continues to rise. Mild AR HCV Increase FK trough Mild AR (-) Increase FK trough (+- steroid bolus) Moderate - Severe ACR (-) Steroid bolus with high FK trough +- additional IS (MMF)

54. Case 1 Points Histological findings can be problematic when Mild AR and HCV become differential diagnosis. Moderate - severe AR should have clear-cut AR features.