Liver Transplantation For HDV/HBV Coinfection In Italy: An Intention-To-Treat Analysis Of Long-Term Outcomes

: Patients with HDV/HBV-related end-stage liver disease candidates for liver transplantation(LT) have traditionally been regarded as a special population, although their outcomes are controversial. A intention-to-treat(ITT) analysis of long-term outcomes of HDV/HBV-coinfected patients waitlisted for LT in Italy, between 2011-2020, was performed and compared to HBV-monoinfected LT candidates. Out of 1,731 HBV-infected LT candidates, 1,237(71.5%) had HBV-monoinfection and 494(28.5%) HDV/HBV-coinfection. At listing, HDV/HBV-coinfected patients were significantly younger, listed mainly for decompensated cirrhosis, and with less hepatocellular carcinoma (HCC:26% vs 65.8%,P<0.0001) compared to HBV-monoinfected patients. HDV/HBV-coinfected patients showed better 5-year ITT-survival (83.2%,95%CI:79.4-83.4% vs 71.6%,95%CI:68.8-74.2%;P<0.0001). ITT-multivariable analysis identified the presence of HCC, advanced recipient age, and high-MELD-Na scores as mortality risk factors. Five-years after LT, 99.1% of HDV/HBV-coinfected patients received oral nucleos(t)ide analogues, with immunoglobulins against HBsAg(HBIg) in 91.8% of cases. HBV and HDV viral recurrences were 1.1% and 0.2%, respectively, whereas recurrent or de novo HCC were 8.9% and 0.3%, respectively. In Italy, HDV/HBV-coinfected patients waitlisted for LT showed more favourable outcomes compared to HBV-monoinfected patients, both before and after LT. These excellent results, from the largest cohort reported so far, suggest that HDV/HBV-coinfected LT recipients don't represent a risky population and may be considered for simpler long-term antiviral prophylactic strategies.