![]() ![]() A ≥2 point decrease in MELD score among patients with Child-Pugh B/C cirrhosis was not associated with improved clinical outcome ( Krassenburg, 2021). In a real-world study, DAA-induced SVR was associated with reduced risk of clinical disease progression in patients with Child-Pugh A cirrhosis but not in those with Child-Pugh B/C cirrhosis. Whether this lower SVR can be overcome with an extended duration of therapy is unknown. After adjusting for confounders, the presence of HCC was associated with a lower likelihood of SVR (AOR=0.38). In a large VA study including sofosbuvir, ledipasvir/sofosbuvir, and paritaprevir/ritonavir/ombitasvir plus dasabuvir regimens (± ribavirin), overall SVR rates were 91% in patients without HCC versus 74% in those with HCC ( Beste, 2017). Real-world data comparing DAA response rates demonstrate that patients with cirrhosis and hepatocellular carcinoma (HCC) have lower SVR rates than cirrhotic patients without HCC ( Beste, 2017) ( Prenner, 2017). Predictors of improvement or decline have not been clearly identified, although patients with a Model for End-Stage Liver Disease (MELD) score >20 or severe portal hypertension complications may be less likely to improve and might be better served by transplantation than antiviral treatment ( El-Sherif, 2018) ( Terrault, 2017) ( Belli, 2016). Most deaths among those receiving DAA therapy relate to the severity of the underlying liver disease. Improvements, however, may be insufficient to avoid liver-related death or the need for liver transplantation ( Belli, 2016), highlighting that not everyone benefits from DAA therapy ( Fernandez-Carrillo, 2016). Clinical trial data demonstrate that in the population of persons with decompensated cirrhosis, most patients receiving direct-acting antiviral (DAA) therapy experience improvement in clinical and biochemical indicators of liver disease between baseline and posttreatment week 12, including patients with CTP class C cirrhosis ( Manns, 2016) ( Welzel, 2016) ( Charlton, 2015) ( Curry, 2015).
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