Accepted Manuscript

Multicentre experience using daclatasvir and sofosbuvir to treat hepatitis C re-currence after liver transplantation - The CO23 ANRS CUPILT study

Audrey Coilly, Claire Fougerou-Leurent, Victor de Ledinghen, PaulineHoussel-Debry, Christophe Duvoux, Vincent Di Martino, Sylvie Radenne,Nassim Kamar, Louis D’Alteroche, Vincent Leroy, Valérie Canva, PascalLebray, Christophe Moreno, Jérôme Dumortier, Christine Silvain, CamilleBesch, Philippe Perre, Danielle Botta-Fridlund, Rodolphe Anty, Claire Francoz,Armando Abergel, Maryline Debette-Gratien, Filomena Conti, FrançoisHabersetzer, Alexandra Rohel, Emilie Rossignol, Hélène Danjou, Anne-MarieRoque-Afonso, Didier Samuel, Jean-Charles Duclos-Vallee, Georges-PhilippePageaux, for the ANRS C023 CUPILT study group,

PII: S0168-8278(16)30253-7DOI: http://dx.doi.org/10.1016/j.jhep.2016.05.039Reference: JHEPAT 6137

To appear in: Journal of Hepatology

Received Date: 27 November 2015Revised Date: 19 May 2016Accepted Date: 23 May 2016

Please cite this article as: Coilly, A., Fougerou-Leurent, C., de Ledinghen, V., Houssel-Debry, P., Duvoux, C., DiMartino, V., Radenne, S., Kamar, N., D’Alteroche, L., Leroy, V., Canva, V., Lebray, P., Moreno, C., Dumortier,J., Silvain, C., Besch, C., Perre, P., Botta-Fridlund, D., Anty, R., Francoz, C., Abergel, A., Debette-Gratien, M.,Conti, F., Habersetzer, F., Rohel, A., Rossignol, E., Danjou, H., Roque-Afonso, A-M., Samuel, D., Duclos-Vallee,J-C., Pageaux, G-P., for the ANRS C023 CUPILT study group, Multicentre experience using daclatasvir andsofosbuvir to treat hepatitis C recurrence after liver transplantation - The CO23 ANRS CUPILT study, Journal ofHepatology (2016), doi: http://dx.doi.org/10.1016/j.jhep.2016.05.039

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Multicentre experience using daclatasvir and sofosbuvir to treat hepatitis C recurrence after

liver transplantation - The CO23 ANRS CUPILT study

Audrey Coilly1-4

, Claire Fougerou-Leurent5,6

, Victor de Ledinghen7, Pauline Houssel-Debry

8,

Christophe Duvoux9, Vincent Di Martino

10, Sylvie Radenne

11, Nassim Kamar

12, Louis D'Alteroche

13,

Vincent Leroy14

, Valérie Canva15

, Pascal Lebray16

, Christophe Moreno17

, Jérôme Dumortier18

,

Christine Silvain19

, Camille Besch20

, Philippe Perre21

, Danielle Botta-Fridlund22

, Rodolphe Anty23

,

Claire Francoz24

, Armando Abergel25

, Maryline Debette-Gratien26

, Filomena Conti16

, François

Habersetzer27

, Alexandra Rohel28

, Emilie Rossignol5,6

, Hélène Danjou5,6

, Anne-Marie Roque-

Afonso29,2-4

, Didier Samuel1-4

, Jean-Charles Duclos-Vallee1-4

, Georges-Philippe Pageaux30

, for the

ANRS C023 CUPILT study group.

Affiliations:

1. AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif F-94800, France;

2. Université Paris-Sud, Université Paris Sud-Saclay, UMR-S 1193, Villejuif F-94800, France;

3. INSERM, Unité 1193, Villejuif F-94800, France;

4. DHU Hepatinov, Villejuif F-94800, France;

5. Hôpital Universitaire de Pontchaillou, Service de Pharmacologie, Rennes, France;

6. INSERM, CIC 1414 Clinical Investigation Centre, Rennes, France;

7. Service d’Hépato-Gastroentérologie, Hôpital Haut-Lévêque, CHU Bordeaux, & INSERM

U1053, Bordeaux, France;

8. Hôpital Universitaire de Pontchaillou, Service d’Hépatologie et Transplantation Hépatique,

Rennes, France;

9. Service d’Hépatologie, Hôpital Henri-Mondor, AP–HP, 94000 Créteil, France;

2

10. Service d’Hépatologie, CHRU Jean Minjoz et Université de Franche-Comté, Besançon,

France;

11. Service d’Hépatologie, HCL, Hôpital de la Croix-Rousse, 69205 Lyon, France;

12. Département de Néphrologie et Transplantation d’Organes, CHU Rangueil, INSERM U1043,

IFR–BMT, Université Paul Sabatier, Toulouse, France;

13. Service Hépato-gastro-entérologie, CHU Tours, France;

14. Clinique Universitaire d’Hépato-Gastroentérologie, Pôle Digidune, CHU de Grenoble, France;

15. CHRU de Lille, Service d’Hépatologie, Hôpital Huriez, CHRU Lille, 59037 Lille;

16. Service d’Hépatologie et de Transplantation Hépatique, AP-HP, Groupe Hospitalier Pitié-

Salpêtrière, Paris, France;

17. Département de Gastroenterologie, d’Hépatopancréatologie et Cancérologie Digestive, CUB

Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgique;

18. Unité de Transplantation Hépatique, Fédération des Spécialités Digestives, Hôpital Edouard

Herriot, Hospices Civils de Lyon et Université Claude Bernard Lyon 1, Lyon;

19. Service Hépato-gastro-entérologie, CHU Poitiers, France;

20. Centre de Chirurgie Digestive et Transplantation Hépatique, Université de Strasbourg, France;

21. Service de MPU Infectiologie CHD Vendée, 85925, La Roche sur Yon, France;

22. CHU Timone, Service d’Hépato-gastroentérologie, Marseille F-13005, France;

23. Hôpital universitaire de Nice, Service d’Hépato-gastroentérologie; INSERM, U1065, Equipe 8,

Université de Nice-Sophia-Antipolis, Faculté de Médecine, Nice, F-06107, Cedex 2, France;

24. Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy,

France;

3

25. Service d’Hépato-gastroentérologie, CHU Estaing Clermont-Ferrand, Clermont-Ferrand,

France;

26. Service d'Hépato-gastroentérologie, CHU Limoges, Limoges, France ;

27. Hôpitaux Universitaires de Strasbourg, Inserm U 1110, LabEx HepSYS, Université de

Strasbourg, Strasbourg, France;

28. Unité de recherché Clinique et Fondamentale sur les Hépatites Virales, Agence Nationale de

Recherche sur le Sida et les Hépatites Virales, Paris, France;

29. AP-HP Hôpital Paul-Brousse, Service de Virologie, Villejuif F-94800, France;

30. Département d’Hépato-gastroentérologie et de Transplantation Hépatique, CHU Saint-Eloi,

Université de Montpellier, Montpellier F-34295, France;

Corresponding author: Audrey Coilly, MD

Centre Hépato-Biliaire

Hôpital Paul-Brousse

12-14 avenue Paul-Vaillant Couturier

94800 Villejuif

FRANCE

Tel.: 00 33 1 45 59 66 36 Fax: 00 33 1 45 59 38 57

Email: audrey.coilly@aphp.fr

4

Disclosures

1. Audrey Coilly has been a clinical investigator, speaker and/or consultant for Astellas, Bristol-

Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Novartis, Merck Sharp & Dohme

and Abbvie;

2. Claire Fougerou-Leurent has nothing to disclose;

3. Victor De Ledinghen has been a clinical investigator, speaker and/or consultant for Abbvie,

Bristol-Myers Squibb, Gilead Sciences, Jansen Pharmaceuticals, Merck Sharp & Dohme;

4. Pauline Houssel-Debry has been speaker and/or consultant for Astellas, Novartis and Gilead

Sciences;

5. Christophe Duvoux has nothing to disclose;

6. Vincent Di Martino has been a clinical investigator, speaker and/or consultant for Abbvie,

Bristol-Myers Squibb, Gilead Sciences, Jansen Pharmaceuticals, Merck Sharp & Dohme;

7. Sylvie Radenne has nothing to disclose;

8. Nassim Kamar has been a clinical investigator, speaker and/or consultant for Astellas, Bristol-

Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, Novartis, Alexion, Fresenius, Amgen

and Roche;

9. Louis D’Alteroche has nothing to disclose;

10. Vincent Leroy has been a clinical investigator, speaker and/or consultant for Abbvie, Bristol-

Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Merck Sharp & Dohme, and

Roche;

11. Valerie Canva has nothing to disclose;

12. Pascal Lebray has been a clinical investigator, speaker and/or consultant for Bristol-Myers

Squibb, Gilead Sciences, Jansen Pharmaceuticals, Biotest and Merck Sharp & Dohme;

13. Christophe Moreno has nothing to disclose;

14. Jérôme Dumortier has been a clinical investigator, speaker and/or consultant for Astellas,

Gilead Sciences, Janssen Pharmaceuticals, Novartis and Roche;

15. Christine Silvain has been a clinical investigator, speaker for Abbvie, Bristol-Myers Squibb,

Gilead Sciences, Jansen Pharmaceuticals, Astellas;

16. Camille Besch has nothing to disclose;

17. Philippe Perré has nothing to disclose;

5

18. Danielle Botta-Fridlund has been a clinical investigator, speaker and/or consultant for Abbvie,

Bristol-Myers Squibb, Janssen, Gilead and Roche;

19. Rodolphe Anty has nothing to disclose;

20. Claire Francoz has nothing to disclose;

21. Armando Abergel has nothing to disclose;

22. Maryline Debette-Gratien has nothing to disclose;

23. Filomena Conti has nothing to disclose;

24. François Habersetzer has nothing to disclose;

25. Alexandra Rohel has nothing to disclose;

26. Emily Rossignol has nothing to disclose;

27. Hélène Danjou has nothing to disclose;

28. Didier Samuel has been a clinical investigator, speaker and/or consultant for Astellas, Bristol-

Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Abbvie, Novartis, Merck Sharp &

Dohme and Roche.

29. Jean-Charles Duclos-Vallée has been a clinical investigator, speaker and/or consultant for

Astellas, Bristol-Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Abbvie, Novartis

and Roche;

30. Georges-Philippe Pageaux has been a clinical investigator, speaker and/or consultant for

Astellas, Bristol-Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Merck Sharp &

Dohme, Novartis and Roche.

6

Abbreviations:

AE: Adverse events

DAAs: Direct-acting antiviral agents

DCV: Daclatasvir

EOT: End of treatment

GFR: Glomerular filtration rate

HCV: Hepatitis C virus

HIV: Human immunodeficiency virus

IMS: Immunosuppressive

LLOQ: Lower limit of quantification

LT: Liver transplantation

MDRD: Modified Diet in Renal Disease

MELD: Model for End-stage Liver Disease

PEG-IFN: pegylated interferon

RBV: Ribavirin

SAE: Serious adverse events

SOF: Sofosbuvir

SVR: Sustained virological response

TBC: Trough blood concentration

W: Week

Keywords: daclatasvir, direct-acting antiviral agents, hepatitis C, liver transplantation, recurrence,

sofosbuvir.

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Abstract

Background & Aims: HCV recurrence remains a major issue in the liver transplant field, as it has a

negative impact on both graft and patient survival. The purpose of this study was to investigate the

efficacy and safety of treating HCV recurrence with sofosbuvir (SOF) and daclatasvir (DCV)

combination therapy.

Methods: From October 2013 to March 2015, 559 liver recipients were enrolled in the prospective

multicentre ANRS CUPILT cohort. We selected 137 patients with an HCV recurrence receiving SOF

and DCV, whatever the genotype or fibrosis stage. The use of ribavirin and the duration of therapy

were at the investigator’s discretion. The primary efficacy end point was a sustained virological

response (SVR) 12 weeks after the end of treatment.

Results: The SVR rate 12 weeks after completing treatment was 96% under the intention-to treat

analysis and 99% when excluding non-virological failures. Only two patients experienced a virological

failure. The serious adverse event (SAE) rate reached 17.5%. Four patients (3%) stopped their

treatment prematurely because of SAEs. Anaemia was the most common AE, with significantly more

cases in the ribavirin group (56% versus 18%; p<0.0001). A slight but significant reduction in

creatinine clearance was reported. No clinically relevant drug-drug interactions were noted, but 52% of

patients required a change to the dosage of immunosuppressive drugs.

Conclusion: Treatment with SOF plus DCV was associated with a high SVR12 and low rates of

serious adverse events among liver recipients with HCV recurrence.

Lay Summary

The recurrence of hepatitis C used to be the first cause of graft failure in infected liver transplanted

recipients. Our study demonstrates the great efficacy of one combination of new all-oral direct acting

antiviral, sofosbuvir and daclatasvir, to treat the recurrence of hepatitis C on the graft. Ninety-six per

cent of recipients were cured. The safety profile of this combination seemed to be good, especially no

relevant drug-drug interaction with immunosuppressive drugs.

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Introduction

Hepatitis C virus (HCV) represents a major healthcare issue, in that some 170 million people are

chronically infected worldwide [1]. When patients develop end-stage liver disease or hepatocellular

carcinoma, liver transplantation (LT) remains the only curative option. In France, more than 20% of

candidates for LT are infected with HCV [2]. Among patients with a positive viral load, a recurrence of

HCV infection on the graft is constant and constituted a challenge in the past because fibrosis

progression may be accelerated when compared to the situation in non-transplant patients. Twenty to

30% of HCV-infected recipients develop graft cirrhosis within 5 years of LT [3]

. This results in poorer

graft and patient survival rates compared to those of recipients transplanted for another indication [4].

The clearance of HCV is the only way to improve the outcome of these patients. The standard of care

for treating HCV recurrence used to be 48 weeks of peg-interferon (PEG-IFN) with ribavirin (RBV),

although this was only effective in 30% of patients, mainly because of poor tolerance which led to

premature treatment discontinuation in 30% of cases. The combination of a first-generation protease

inhibitor (telaprevir or boceprevir) with PEG-IFN and RBV subsequently improved sustained virological

response (SVR) rates to 50%-65% in genotype 1 HCV-infected recipients, but at the cost of an even

poorer safety profile and potent drug-drug interactions [5, 6]. Although feasible, these regimens

required close monitoring and considerable clinical expertise.

In 2013, two second-generation direct-acting antiviral agents (DAAs), the nucleotide analogue NS5B

polymerase inhibitor sofosbuvir (SOF), and the nucleotide analogue NS5A polymerase inhibitor

daclatasvir (DCV), became available through an early access programme and were then approved by

the French Agency for the Safety of Medicines and Healthcare Products (ANSM). Although limited, the

preliminary data on the combined use of SOF and DCV with or without RBV have shown high SVR

rates of >90%, with minimal side effects in non-transplant patients [7]. Consequently, access to this

combination was available from the outset for the sickest patients, including those undergoing a liver

transplant.

Initial experience using SOF plus DCV in the transplant setting took the form of a case report [8]. Our

group then reported on the efficacy and safety of this type of combination in the most urgent and

difficult-to-treat patients. Among 15 patients suffering from fibrosing cholestatic hepatitis, a significant

clinical improvement was achieved, with an SVR12 of 96% [9]. Recently, the open-label ALLY-1 study

9

assessed the safety and efficacy of the SOF and DCV combination plus RBV to treat HCV infection in

the context of advanced cirrhosis or post-LT recurrence in 53 patients [10]. SVR was achieved by 95%

and 91% of patients with genotype 1 and 3 infections, respectively. We report here on our multicentre

experience including a large number of patients who received SOF and DCV, with or without RBV, to

treat an HCV recurrence of varying degrees of severity following liver transplantation.

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Patients and Methods

Study design and patients

The ANRS C023 “Compassionate use of Protease Inhibitors in viral C Liver Transplantation” (CUPILT)

study is a multicentre prospective cohort being implemented in 24 French and one Belgian LT centre

(ClinicalTrials.gov number NCT01944527). It is being funded and sponsored by ANRS (France

REcherche Nord&Sud Sida-hiv Hépatites). To be enrolled in this cohort, patients must have (1)

received a liver transplant for an HCV infection, (2) experienced an HCV recurrence whatever the

stage of fibrosis, (3) been treated with second-generation DAAs, and (4) given their written informed

consent. At enrolment, fibrosis stage was established based on a histological assessment (according

to the METAVIR scoring system [11]) and/or elastometry (such as F3 ≥9.5 kPa and F4 ≥14.5kPa). The

protocol has been carried out in accordance with the Declaration of Helsinki and French laws on

biomedical research, and was approved by the "South Mediterranean Ethics Committee” (France).

Exclusion criteria were an age under 18 and pregnancy.

Between October 2013 and March 2015, 559 liver recipients were enrolled. For the present study, we

selected patients receiving both SOF and DCV who were followed for at least 12 weeks after

treatment discontinuation. Patients were excluded if they were co-infected with the human

immunodeficiency virus (HIV) or diagnosed with fibrosing cholestatic hepatitis (such as previously

defined [9]).

This study is observational so that the type of treatment, dosing of drugs and duration of treatment are

at the discretion of each investigator. However, the CUPILT Scientific Committee (Supplemental

Appendix 1) issues treatment recommendations every 6 months. Patients receive SOF and DCV at a

once-daily dose of 400 mg and 60 mg, respectively. When used, the RBV dose is adjusted by

considering body weight, potential ribavirin-related haematological toxicity and renal function in the LT

recipients. Treatment duration was initially planned for 12 or 24 weeks, but the investigators are

allowed to extend this period if they deem this clinically necessary.

Efficacy assessments

For this study, plasma HCV RNA levels were quantified using the Abbott Real Time HCV PCR assay

(lower limit of quantification (LLOQ) of 12 IU/mL, Abbott Diagnostics®, USA) or COBAS AmpliPrep®

11

or COBAS TaqMan® (LLOQ of 15 IU/mL, Roche Molecular Systems, Pleasanton, California).

Hepatitis C virus RNA was monitored at baseline, during scheduled visits throughout treatment (1, 2,

3, 4, 6, 8, 12, and if applicable 16, 20 and 24 W) and then at 4, 12, 24, 48 W after the completion of

treatment. The primary endpoint was the proportion of patients who achieved undetected HCV RNA

levels or an SVR at W12 after treatment discontinuation (SVR12). Secondary endpoints included viral

kinetics, and on-treatment (W4) and end-of-treatment (EOT) response rates. Virological failures were

also reported. Viral breakthrough and relapse were defined as plasma HCV RNA levels higher than

the LLOQ after achieving a level lower than the LLOQ, during treatment and after the end of treatment,

respectively. When a virological failure occurred, baseline and relapse resistance-associated viral

(RAV) mutations in the NS3/A4, NS5A and NS5B regions were obtained by population sequencing

using in-house methods. RAVs were defined according to the Geno2Pheno algorithm

(http://hcv.geno2pheno.org/), developed by the Max-Planck-Institut für Informatik, Saarbrücken,

Germany.

Another secondary endpoint was an improvement in liver function. Clinical evaluations, including

clinical signs of decompensated liver disease (ascites, hepatic encephalopathy) and laboratory tests

were performed by applying a similar visit timetable as that used for virological assessments; i.e. at

baseline, during scheduled visits throughout the treatment (1, 2, 3, 4, 6, 8, 12, and if applicable 16, 20

and 24 W) and then at weeks 4, 12, 24 and 48 after the completion of treatment.

Safety assessments

Data on the following adverse events were collected: serious adverse events (SAE), as defined in

Supplemental Appendix 2, clinical and laboratory grade 3 or 4 adverse events (assessed using the

INSERM-ANRS scale to score the severity of adverse events, v6 dated 9 September 2003 and given

in Supplemental Appendix 3) and adverse events of any grade related to neutrophils, platelets,

prothrombin values, bilirubin, creatinine, haemoglobin or infections.

Decisions to reduce, interrupt, or discontinue ribavirin doses because of toxic effects were based on

the drug manufacturer's labelling. The investigators were encouraged to manage all AE according to

the guidelines issued by the French Association for the Study of the Liver (AFEF) [12]. The glomerular

filtration rate (GFR) was calculated using the Modified Diet in Renal Disease (MDRD)-6 equation [13].

12

During treatment, the trough blood concentration (TBC) of calcineurin inhibitors was monitored. The

TBC targeted depended on the past medical history of the patients. Changes to the dosage of

immunosuppressive drugs were made accordingly, at the investigators’ discretion.

Statistical Analysis

Analyses were performed in the modified intention-to-treat population, which included all patients who

had received at least one dose of treatment. In the case of a non-normal distribution, continuous

variables were expressed by median and inter-quartile ranges, and in case of a normal distribution,

continuous variables were expressed by mean and standard deviation. Categorical variables were

expressed in terms of the number of patients and percentages. Differences in baseline characteristics

between the four groups, as reflected by the duration of therapy and RBV use, were evaluated using

Kruskall-Wallis test for continuous data and the chi-square test or Fisher's exact test for categorical

data. To test for changes over time (i.e W0 and EOT) in continuous variables, a paired t-test was used

in the case of a normal distribution and a Wilcoxon signed rank sum test for a non-normal distribution.

All statistical tests and 95% confidence intervals had a significance level of 0.05. SAS software,

Version 9.4 (SAS Institute Inc., Cary, NC, USA) was used.

13

Results

Baseline demographic and clinical characteristics

One hundred thirty-seven liver transplant recipients treated with SOF plus DCV were selected for the

present study between October 2013 and March 2015 (Figure 1). The baseline characteristics of these

patients are presented in Table 1. There was a majority of men (77.4%), with a median age of 59.0

[53.0–65.0] years. Most patients were infected with HCV genotype 1 (n=109; 79.6%), mainly of the 1b

type (n=62; 45.3%). Although 69 patients (50.4%) were treatment-naive, when treated, a majority of

patients were proved to be non-responders (19.0%). The median MELD score at baseline was 10 [7–

13] (Supplemental Table 1). Forty-six patients (33.6%) experienced cirrhosis on the graft. The

characteristics of cirrhotic patients are detailed in Supplemental Table 1. The median period elapsing

between LT and treatment initiation was 72.3 months [24.6–123.8]. Eighty-nine patients (65.0%)

received SOF and DCV without RBV. The treatment duration was 12 or 24 weeks for 21 and 68

patients, respectively. Forty-eight patients (35.0%) were treated with SOF and DCV plus RBV (four for

12 weeks and 44 for 24 weeks). In this latter group, the median baseline RBV dosage was 800 [600–

1000] mg/day.

Treatment efficacy

By W4 of treatment, HCV RNA levels had fallen below the LLOQ in 71 patients (53%). The median

time required to achieve undetectability was 4 weeks [3–8]. Concerning viral kinetics during treatment,

there were no differences regarding the use of RBV or fibrosis stage at baseline (Supplemental Figure

1). As for the primary endpoint, 132 out of 137 patients (96.4%) had a sustained virological response

at post-treatment W12 (Figure 2). Among the five patients who did not achieve an SVR12, one was

lost to follow-up and two died between EOT and SVR 12. Excluding non-virological failures, the

SVR12 rate thus reached 98.5% (132/134). Two patients in the study population therefore

experienced a virological failure. One was a 55-year old treatment-naive man who experienced a

recurrence of genotype 1a HCV and fibrosis stage ≤2 on the graft, and a virological breakthrough at

W11. He was receiving SOF+DCV with RBV for a planned treatment duration of 12 weeks.

Retrospectively, we investigated his resistance mutations both at baseline and after this failure: no

mutation was found in the NS5B regions but one de novo Q30R mutation in the NS5A region

14

appeared after breakthrough. The other patient was a 49-year old man who had previously not

responded to PEG-IFN/RBV, was infected with genotype 4 and had cirrhosis on the graft (baseline

MELD score of 19). He relapsed four weeks after completion of a 24-week course of SOF+DCV. As

previously, no mutation was found in the NS5B regions but one pre-existing mutation in the NS5A

region (Q30R) was observed at baseline and another was found after the relapse (Y93H). No factors

were found to influence SVR12 rates with respect to genotype, fibrosis stage or previous response to

therapy (Supplemental Figure 2). Patients with cirrhosis responded remarkably well, with an SVR12

rate of 96%.

Clinical improvement

All clinical and biological parameters reflecting liver function and general status improved significantly

during treatment (Table 2). In the overall population, the mean reduction in the MELD score between

baseline and EOT was 0±2 [-10-5]. However, among potential candidates for a re-transplantation with

a MELD score at baseline over 15, 65% improved, the MELD score falling by between 1 and 10 points

(Figure 3). Among the four patients with refractory ascites at baseline, only one (relapser) still had

ascites at EOT. Ascites disappeared in three of the five patients with mild or moderate ascites at

baseline. No hepatic encephalopathy was reported at EOT.

Safety

Adverse events were common, affecting 105 patients (77%), although the majority were mild to

moderate in severity (Table 3). The most common AE was anaemia, which increased significantly with

the use of RBV (18.0% versus 56.3%, P<0.0001). In 17 patients (35%) treated with RBV, it was

necessary to reduce the RBV dosage during treatment, and a discontinuation was required in seven

patients (15%). A serious AE was reported in 17.5% of patients. Two patients (1.5%) died during the

study period. The first experienced a severe decompensation of diabetes mellitus, leading to

hyperosmolar coma then multi-organ failure one week after treatment initiation. No relationship

between treatment initiation and this event was determined (in accordance with the mandatory

declaration procedure under the early access programme when it was applicable). The second patient

experienced a recurrence of hepatocellular carcinoma after treatment initiation and finally died 8

weeks after treatment completion. One patient (0.01%) prematurely discontinued his therapy following

the investigator's decision due to severe flare-up of psoriasis. Two patients suffered from biopsy-

15

proven acute graft rejection at W8 and W9 of treatment, respectively, but recovered fully after an

increase in their immunosuppressive therapy. A severe infection occurred in 4 patients (2.9%), with

favourable outcomes. Eighty-six patients (62.8%) developed or experienced a worsening of renal

insufficiency during treatment, with an estimated GFR ≤60ml/min. Figure 4 represents the kinetics of

GFR during therapy. In the overall population, there was a moderate but significant decrease in GFR

values between baseline and EOT, from 70.1±27.1 to 64.5±25.0 mL/min (P<0.0001). There were no

differences regarding the use of RBV, the fibrosis stage at baseline or combined liver-kidney

transplant status (n=2) (data not shown).

Immunosuppression

At baseline, 120 patients (88%) were receiving a calcineurin inhibitor-based regimen, mainly

tacrolimus (in 85 patients (62%)). The immunosuppressive drug regimens are detailed in Figure 5.

Changes to immunosuppressive drug dosages were required in 52%, 49%, 58% and 7% of patients

treated with tacrolimus, cyclosporine, everolimus and mycophenolate mofetil, respectively. The degree

of these changes was moderate, but greater for patients treated with tacrolimus. Between baseline

and W4, the tacrolimus and cyclosporine dosages needed to be increased by 19% and 4%,

respectively. Between baseline and EOT, the tacrolimus and everolimus dosages needed to be

increased by 34% and 9%, respectively, whereas the variations were minor with cyclosporine and

mycophenolate mofetil (2% and 0%, respectively).

16

Discussion

In this study, we describe our multicentre experience in treating HCV recurrence in LT recipients using

an all-oral, interferon-free, antiviral regimen including DCV and SOF, with or without RBV, for 12 or 24

weeks. The SVR rate 12 weeks after completing treatment was 96% under the intention-to treat

analysis and 99% when excluding non-virological failures. This combination therapy was very well

tolerated, although SAE rates reached 17.5%. Two patients (1.5%) stopped their treatment

prematurely due to SAE; both patients died, but their deaths were not related to the antiviral drugs

under investigation.

Earlier studies had shown that overall graft and patient survival rates were lower among liver

transplant recipients with HCV infection than in those transplanted for other indications, because of

universal HCV reinfection of the graft and an accelerated progression of fibrosis in immuno-

compromised patients [14]. Among liver transplant recipients, studies of PEG-IFN/RBV or first-

generation protease inhibitors (boceprevir or telaprevir) in combination with this dual therapy produced

low SVR rates (from 20% to 60%), and high rates of potentially life-threatening SAEs [5, 6, 15-17].

Furthermore, drug-drug interactions were potent between first generation protease inhibitors and

immunosuppressive drugs [18]. Experience of treating liver transplant recipients using an all-oral,

interferon-free, antiviral regimen is currently emerging. In a phase II study, SOF and RBV for 24 weeks

resulted in an SVR12 rate of 70% [19]. During a recent randomised study, 34 liver transplant recipients

infected with genotype 1 under ombitasvir/paritaprevir/ritonavir/dasabuvir (OPRB) and RBV for 24

weeks achieved an SVR12 of 97% [20], although these patients were only infected with HCV genotype

1 and had no or mild fibrosis on the graft. In another recent multicentre study, an SVR12 was achieved

in 90% of 123 liver transplant recipients infected with genotype 1 treated with SOF plus simeprevir

(SIM), with or without RBV, for 12 weeks [21]. During a recent phase II open-label study, Charlton et

al. reported on their experience of combining SOF plus ledipasvir with RBV for 12 or 24 weeks in order

to treat genotypes 1 or 4 cirrhotic or liver transplant patients [22]. Among the graft recipients, SVR12

rates ranged from 96% to 98% among 227 patients. Recently, the combination of SOF plus DCV with

RBV was studied during a phase II open-label study. In 53 liver transplant patients, an SVR12 was

achieved by 95% and 91% of patients with G1 and G3 infection, respectively [10]. Our study is the

only one to have reported on real-life liver transplant patients, regardless of genotype and fibrosis

stage at baseline. Despite this, our excellent SVR12 rate of 96% demonstrated the considerable

17

efficacy of the SOF plus DCV combination in treating liver transplant recipients. These results were

particularly impressive in the patients most difficult to treat, such as cirrhotic patients, with a SVR12

rate of 96%. These data thus confirm the findings of several recent publications regarding this latter

population whose prognosis has been dramatically modified [9, 23].

There are many advantages to using a combination of NS5A and NS5B inhibitors to treat liver

transplant recipients. These drugs are both pangenotypic, with a high barrier of resistance. To date,

NS5B inhibitors such as SOF have usually been the backbone of interferon-free antiviral regimens.

Thanks to their renal metabolism, these inhibitors can be used in patients with severe hepatic

impairment. On the other hand, no drug-drug interactions have been described with

immunosuppressive drugs22

. Based on the findings of pharmacokinetic studies, NS5A inhibitors such

as DCV are also convenient in the context of LT [24]. Unlike protease inhibitors, trough blood

concentrations (TBC) of DCV remain stable, even in the event of severe hepatic impairment. As for

drug-drug interactions, the concomitant administration of SMV may decrease the TBC of tacrolimus.

Using SMV and cyclosporine together is not recommended, as the TBC of both drugs are increased

when in combination [25]. The dosage of calcineurin inhibitors still requires adjustment when a

combination of OPRD is used in a liver transplant recipient [20]. During our study, no significant drug-

drug interactions were highlighted. However, an adjustment of immunosuppressive regimens was

required in more than a half of our study population (52%, 49%, 58% and 7% of patients treated with

tacrolimus, cyclosporine, everolimus and mycophenolate mofetil, respectively). Most changes were

necessary four weeks after treatment initiation, probably as a result of improved hepatic function under

therapy. All these factors imply a need to closely monitor the TBC of immunosuppressive drugs during

antiviral therapy in liver transplant patients.

One limitation of our study consisted in the problem of comparing efficacy according to the duration of

treatment or the use of RBV. However, the use of RBV does not appear to be mandatory in light of the

SVR12 rates of 100% and 97% achieved under SOF plus DCV without RBV for 12 and 24 weeks,

respectively. RBV is known to be responsible for several AEs, and particularly haematological toxicity

[26]. Although a reduction in the RBV dosage was required in 35% of the patients in our study,

anaemia remained the most common AE, leading to a significant increase in erythropoietin use among

patients receiving RBV. Not using RBV in the context of LT would improve tolerance, but its withdrawal

18

could have a deleterious impact on efficacy. In our study, patients treated without RBV for 12 weeks

achieved a SVR12 rate of 100%, but their number was too small to draw any definitive conclusions

(n=21). The majority of the patients were treated with 24 weeks of therapy and thus we cannot make a

recommendation on duration and/or use of ribavirin based on our results. Overall all groups had a high

SVR rate.

Finally, in our cohort, we observed a small but significant reduction in the GFR during treatment (from

70.1±27.1 to 64.5±25.0 mL/min. between baseline and EOT). This could not be attributed to the use of

RBV, because a similar decrease was seen in the arm without RBV. This finding was only possible

because we enrolled real-life patients, regardless of any previous renal impairment. Renal function is a

major prognostic factor following liver transplantation, and further studies are necessary to investigate

predictive factors for renal impairment during antiviral therapy. Longer term follow-up would also be

useful, in order to determine whether this decline persists over time. Other studies coming from the

ANRS CO23 CUPILT cohort and investigating pharmacokinetic changes and renal function are

currently on-going. A final report on the entire cohort will be also published.

In conclusion, we found that the combination of DCV and SOF, with or without RBV, administered for

12 or 24 weeks, enabled an SVR12 rate of 96% among LT recipients. Overall, this regimen was safe

and well tolerated. The combination of DCV and SOF could become the gold standard for the

treatment of HCV recurrence after LT, allowing us to treat patients earlier, before the development of

fibrosis on the graft. It would help to eradicate HCV infection in a specific population at high risk of

severe liver disease and life threatening events, for whom treatment guidelines are still awaited.

19

ACKNOWLEDGEMENTS:

We would like to thank all the patients and their families, and all the co-investigators of the CUPILT

study in France and Belgium for their support and for making this study feasible. Our particular thanks

go to Laurent Alric, Teresa Maria Antonini, Ellada Ayvazyan, Eleonora De Martin, Djamel Elaribi,

Laure Esposito, Stéphanie Faure, Joelle Guitard, Stéphanie Haïm Boukobza, Laurence Lavayssière,

Sophie Metivier, Gilles Pelletier, Bruno Roche, Lionel Rostaing, Faouzi Saliba, Rodolphe Sobesky,

Maria Grazia Tateo, Albert Tran who participated actively in the study. We also acknowledge the

assistance provided by the clinical research associates: Mustapha Ahmim, Neila Bouchard, Alain

Caro, Selma El Andaloussi, Anne Laligant, Khellaf Ouamara, Julie Raimon, Régine Thierry and

Aurélie Veislinger. Finally, we thank all the staff at the ANRS (France REcherche Nord&Sud Sida-hiv

Hépatites) who were responsible for this study, and notably Professor Jean-François Delfraissy, Inga

Bertucci, Alexandra Rohel, Alpha Diallo and Ventzislava Petrov-Sanchez.

20

Figures and Tables

Figure 1: Breakdown of patient details

Patients were selected between October 2013 and March 2015. Two patients were excluded: one who

did not meet the inclusion criteria and one who did not start treatment.

Figure 2: Virological responses according to treatment duration and RBV use

Two virological failures were observed: one virological breakthrough (in the group receiving

SOF+DCV+RBV for 12 weeks) and one relapse (in the group receiving SOF+DCV for 24 weeks). One

patient was lost to follow-up between EOT and SVR12 (in the SOF+DCV 24 weeks group). Two

patients died in the SOF+DCV+RBV 24 weeks group.

Figure 3: Changes to MELD score between baseline and EOT among the 23 patients with a

baseline MELD score >15

Each bar represents one patient. Above the line, 7 patients correspond to an increase in the MELD

score (4 in SOF+DCV and 3 in SOF+DCV+RBV) and thus a worsening of their condition, while one

patient remained stable. The majority of patients (65%) improved during treatment.

Figure 4: Kinetics of creatinine clearance according to RBV use (A) and IMS use (B)

Creatinine clearance was estimated according to the MDRD6 formula. Results are given as medians

according to time. A small but significant decrease in creatinine clearance during treatment was

observed (from 70.1 ± 27.1 to 64.5 ± 25 mL/min between baseline and EOT). There was no difference

regarding the use of RBV.

Figure 5: Immunosuppressive regimens and their management during the study

(A) The Table shows the breakdown of immunosuppressive drugs at baseline, week 4 and EOT (B)

The graph represents the intensity and direction of dosage changes, between baseline and week 4,

and baseline and EOT, for each immunosuppressive drug.

21

Table 1: Baseline characteristics of the study population

Table 2: Evolution of clinical and biological liver function parameters during the study

Table 3: Adverse events and laboratory abnormalities during treatment

Supplemental Table 1: Parameters assessing the severity of liver disease in the study population

Supplemental Figure 1: Virological kinetics during treatment according to RBV use (A), cirrhotic status (B) and with the intended duration extended (n=3) (C)

Supplemental Figure 2: Virological responses according to previous response to therapy, genotype and fibrosis stage

Supplemental Appendix 1: Scientific committee of the ANRS C023 CUPILT Study

Supplemental Appendix 2: Definitions of adverse events and serious adverse events

Supplemental Appendix 3: ANRS scale used to grade the severity of adverse events in adults

22

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23

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Author names in bold designate first author or shared co-first authorship.

24

Table 1: Baseline characteristics of the study population

Continuous variables are expressed as median (IQR)

Overall population SOF+DCV SOF+DCV+RBV SOF+DCV SOF+DCV+RBV

P 12 weeks 12 weeks 24 weeks 24 weeks

(n=137) (n=21) (n=4) (n=68) (n=44)

Age (years) 59.0 (53.0 - 65.0) 64.0 (57.0 - 71.0) 59.5 (53.5 - 69.5) 59.5 (52.0 - 64.0) 58.5 (53.0 - 64.0) 0.43

Gender (M) – n (%) 106 (77.4) 16 (76.2) 4 (100.0) 52 (76.5) 34 (77.3) 0.91

Body Mass Index (Kg/m2) 24.1 (21.8 - 27.2) 23.5 (21.4 - 25.1) 27.4 (24.1 - 28.1) 25.3 (22.2 - 28.1) 23.6 (21.3 - 26.2) 0.15

Indication for LT – n (%)

0.24

End-stage liver disease 58 (42.3) 7 (33.3) 2 (50.0) 35 (51.5) 14 (31.8)

HCC 67 (48.9) 13 (61.9) 2 (50.0) 29 (42.6) 23 (52.3)

HCV ReLT 12 (8.8) 1 (4.8) 0 (0.0) 4 (5.9) 7 (15.9)

Previous treatment response post-LT – n (%)

0.64

Treatment-naïve patients 69 (50.4) 14 (66.7) 2 (50.0) 36 (52.9) 17 (38.6)

Non-responders 26 (19.0) 3 (14.3) 0 (0.0) 12 (17.6) 11 (25.0)

Relapsers 5 (3.6) 0 (0.0) 0 (0.0) 2 (2.9) 3 (6.8)

Virological breakthroughs 16 (11.7) 2 (9.5) 1 (25.0) 6 (8.8) 7 (15.9)

Intolerance 21 (15.3) 2 (9.5) 1 (25.0) 12 (17.6) 6 (13.6)

Exposure to previous regimens – n (%)

0.39

PEG-IFN/RBV 56 (40.9) 7 (33.3) 2 (50.0) 25 (36.8) 22 (50.0)

First generation PI 11 (8.0) 0 (0.0) 0 (0.0) 7 (10.3) 4 (9.1)

25

SOF based regimen 1 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3)

Interval between LT and antiviral therapy (months)

72.3 (24.6 - 123.8) 76.5 (45.4 - 152.3) 94.8 (40.1 - 153.7) 72.7 (24.8 -

125.3) 61.4 (19.6 -

111.4) 0.67

Overall population SOF+DCV SOF+DCV+RBV SOF+DCV SOF+DCV+RBV

P 12 weeks 12 weeks 24 weeks 24 weeks

(n=137) (n=21) (n=4) (n=68) (n=44)

HCV Genotype – n (%)

N/A

1a 11 (8.0) 2 (9.5) 0 (0.0) 7 (10.3) 2 (4.5)

1b 36 (26.3) 6 (28.6) 2 (50.0) 15 (22.1) 13 (29.5)

1 62 (45.3) 10 (47.6) 1 (25.0) 33 (48.5) 18 (40.9)

3 15 (10.9) 2 (9.5) 1 (25.0) 5 (7.4) 7 (15.9)

4 12 (8.8) 1 (4.8) 0 (0.0) 7 (10.3) 4 (9.1)

5 1 (0.7) 0 (0.0) 0 (0.0) 1 (1.5) 0 (0.0)

Fibrosis stage – n (%)

0.91

≤F2 60 (43.8) 10 (47.6) 3 (75.0) 29 (42.6) 18 (40.9)

F3 31 (22.6) 5 (23.8) 0 (0.0) 17 (25.0) 9 (20.5)

F4 46 (33.6) 6 (28.6) 1 (25.0) 22 (32.4) 17 (38.6)

MELD score 10 (7 - 13) 8 (6 - 13) 9 (7 - 10) 9 (8 - 13) 11 (7 - 15) 0.14

Total bilirubin (µmol/L) 13.2 (8.6 - 20.0) 12.0 (10.5 - 17.5) 10.5 (8.0 - 17.5) 13.9 (8.6 - 19.5) 14.0 (8.0 - 26.5) 0.88

ALT (IU/L) 67 (43 - 107) 60 (31 - 117) 45 (37 - 85) 73 (44 - 105) 74 (40 - 108) 0.67

Albuminemia (g/L) 37.9 (34.1 - 42.0) 35.5 (33.4 - 41.0) 37.2 (34.7 - 41.5) 38.0 (35.0 - 42.1) 38.0 (33.6 - 39.5) 0.69

Creatinine clearance (mL/min) 68.6 (50.5 - 88.8) 80.9 (45.4 - 92.5) 66.0 (61.6 - 77.6) 68.6 (50.7 - 89.1) 65.4 (48.8 - 89.1) 0.96

Haemoglobin (g/dL) 13.2 (11.7 - 14.7) 13.0 (11.8 - 14.2) 15.2 (14.6 - 15.9) 13.2 (10.9 - 14.6) 13.4 (12.0 - 14.7) 0.13

Neutrophil count (G/L) 2.73 (1.96 - 3.86) 3.10 (2.36 - 4.17) 2.97 (2.25 - 5.57) 2.61 (1.98 - 3.73) 2.68 (1.73 - 3.91) 0.44

Platelet count (G/L) 131 (89 - 172) 145 (101 - 172) 192 (107 - 250) 128 (88 - 171) 128 (88 - 169) 0.62

26

HCV viral load (log10 IU/mL) 6.32 (6.01 - 6.74) 6.23 (5.77 - 6.53) 6.17 (6.00 - 6.37) 6.35 (6.01 - 6.72) 6.43 (6.13 - 6.83) 0.36

Abbreviations: IQR: inter-quartile ranges; HCC: hepatocellular carcinoma; HCV: hepatitis C virus; DCV: daclatasvir; M: male; n: number; LT: liver transplantation; PEG-IFN: pegylated interferon; PI: protease inhibitor; RBV: ribavirin; SOF: sofosbuvir

Table 2: Evolution of clinical and biological liver function parameters during the study

Results are given in mean ± standard deviation.

Baseline EOT Follow-up week

12 P*

Body mass index (Kg/m2) 24.6 ± 4.4 25.5 ± 5.0 25.2 ± 4.5 < 0.0001

ALT (IU/L) 87 ± 78 24 ± 12 30 ± 52 < 0.0001

γGT (IU/L) 292 ± 370 80 ± 105 81 ± 114 < 0.0001

Total Bilirubin level (µmol/L) 19.2 ± 23.1 13.5 ± 9.5 12.3 ± 7.8 0.0008

Albumin level (g/L) 37.6 ± 5.2 39.7 ± 4.3 40.8 ± 4.3 < 0.0001

Platelet count (G/L) 137 ± 65 155 ± 72 154 ± 69 < 0.0001

MELD score 11 ± 4 11 ± 4 11 ± 5 0.3197

CHILD score in cirrhotic patients** 6 (5 - 7) 5 (5 - 6) 5 (5 - 6) 0.0011

* P was evaluated for the difference between baseline and Follow-up week 12.

**Results are given in median (IQR)

IQR: inter-quartile ranges; ALT: alanine amino-transferase; EOT: end of treatment; GGT: gammaglutamyl-transferase; INR: international normalized ratio

Overall population SOF+DCV SOF+DCV+RBV

(n=137) (n=89) (n=48)

Serious AE – n (%) 24 (17.5) 15 (16.9) 9 (18.8)

Death – n (%) 2 (1.5) 0 (0.0) 2 (4.2)

Anaemia – n (%) 43 (31.4) 16 (18.0) 27 (56.3)

Grade 0 (but EPO) 6 (4.4) 1 (1.1) 5 (10.4)

Grade 1/2 (<10g/dL) 28 (20.4) 12 (13.5) 16 (33.3)

Grade 3/4 (<8 g/dL) 9 (6.6) 3 (3.4) 6 (12.5)

Erythropoietin use 23 (16.8) 10 (11.2) 13 (27.1)

Blood transfusion 7 (5.1) 3 (3.4) 4 (8.3)

RBV reduction for AE 17 (12.4) - 17 (35.4)

Discontinuation of RBV for AE 7 (5.1) - 7 (14.6)

Neutropenia – n (%) 26 (19.0) 12 (13.5) 14 (29.2) Grade 1/2 (<1.5G/L) 23 (16.8) 11 (12.4) 12 (25.0)

Grade 3/4 (<0.75G/L) 3 (2.2) 1 (1.1) 2 (4.2)

G-CSF use 1 (0.7) 1 (1.1) 0 (0.0)

Thrombocytopenia – n (%) 29 (21.2) 19 (21.3) 10 (20.8) Grade 1/2 (<99G/L) 24 (17.5) 15 (16.9) 9 (18.8)

Grade 3/4 (<50G/L) 5 (3.6) 4 (4.5) 1 (2.1)

Creatinine clearance (MDRD) – n (%) 86 (62.8) 56 (62.9) 30 (62.5)

Creatinine clearance ≤ 60 ml/min 71 (51.8) 43 (48.3) 28 (58.3)

Creatinine clearance ≤ 30 ml/min 11 (8.0) 10 (11.2) 1 (2.1)

Creatinine clearance ≤ 10 ml/min 4 (2.9)*** 3 (3.4) 1 (2.1)

Cardiac Disorders – n (%) 5 (3.6) 3 (3.4) 2 (4.2) Grade 1/2 0 (0.0) 0 (0.0) 0 (0.0)

Grade 3/4* 5 (3.6) 3 (3.4) 2 (4.2)

Infections – n (%) 30 (21.9) 13 (14.6) 17 (35.4)

Grade 1/2 26 (19.0) 11 (12.4) 15 (31.3)

Grade 3/4** 4 (2.9) 2 (2.2) 2 (4.2)

Biopsy proven acute rejection – n (%) 2 (1.5) 1 (1.1) 1 (2.1)

* 5 patients with cardiac disorders: 2 High Blood Pressure, 2 cardiac decompensations in patients with a past history of cardiomyopathy and 1 ischaemic heart disease

** 4 patients with severe infections: 2 abdominal infections (2 spontaneous bacterial peritonitis), 1 bronchopulmonary infection, 1 urinary tract infection, 2 other infections

*** Among the 4 patients with creatinine clearance ≤ 10 ml/min, SOF was adjusted to 400mg/2days in only one patient.

AE: adverse events; DCV: daclatasvir; EPO: erythropoietin use; G-CSF: granulocyte colony stimulating factor; n: number of patients; RBV: ribavirin; SOF: sofosbuvir.

Table 3: Adverse events and laboratory abnormalities during treatment

27

28

Figure 2: Virological responses according to treatment duration and RBV use

Two virological failures were observed: one virological breakthrough (in the group receiving SOF+DCV+RBV for 12 weeks) and one

relapse (in the group receiving SOF+DCV for 24 weeks). One patient was lost to follow-up between EOT and SVR12 (in the SOF+DCV 24 weeks group). Two patients died in the SOF+DCV+RBV 24 weeks group.

DCV: Daclatasvir; EOT: end of treatment response; RBV: ribavirin; SOF: sofosbuvir; SVR12: sustained virological response at 12

weeks after treatment discontinuation

Results are given in intention-to-treat.

100% 75% 100% 98%100% 75% 97% 95%

SOF+DCV (n=21) SOF+DCV+RBV (n= 4) SOF+DCV (n=68) SOF+DCV+RBV (n=44)

Week 12 Week 24

EOT SVR12

Figure 3: Changes to MELD score between baseline and EOT among the 23 patients with a baseline MELD score >15

Each bar represents one patient. Above the line, 7 patients correspond to an increase in the MELD score (4 in SOF+DCV and 3 in SOF+DCV+RBV) and thus a worsening of their condition, while one patient remained stable. The majority of patients (65%) improvedduring treatment.*For 2 patients, data were missing.

DCV: Daclatasvir; EOT: end of treatment response; RBV: ribavirin; SOF: sofosbuvir.

-14

-12

-10

-8

-6

-4

-2

0

2

4

6SOF+DCV, n=11*

n=1

-14

-12

-10

-8

-6

-4

-2

0

2

4

6SOF+DCV+RBV, n=12*

30

Figure 4: Kinetics of creatinine clearance according to RBV use (A) and IMS drugs (B)

Creatinine clearance was estimated according to the MDRD6 formula. Results are given as medians according to time. A small but significant decrease in creatinine clearance during treatment was observed (from 70.1 ± 27.1 to 64.5 ± 25 mL/min between baseline

and EOT). There was no difference regarding the use of RBV.

DCV: Daclatasvir; FUW: follow-up week X means X week after treatment completion; RBV: Ribavirin; SOF: Sofosbuvir; IMS:

Immunosuppressive

50

60

70

80

0 4 8 12 16 20 24 28 32Cre

ati

nin

e c

leara

nce

(m

l/m

in)

Weeks

SOF+DCV SOF+DCV+RBV

FUW4 FUW12

40

50

60

70

80

0 4 8 12 16 20 24 28 32Cre

ati

nin

e c

lea

ran

ce

(m

l/m

in)

Weeks

Cyclosporine Tacrolimus Others

FUW4 FUW12

A

B

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Figure 5: Immunosuppressive regimens and their management during study

(A) The Table shows the breakdown of immunosuppressive drugs at baseline, week 4 and EOT (B) The graph represents the intensity and direction of dosage changes, between baseline and week 4, and baseline and EOT, for each immunosuppressive drug. DCV: Daclatasvir; EOT: end of treatment; MMF: Mycophenolate mofetil; N: Number of patients; RBV: Ribavirin; SOF: Sofosbuvir

Cyclosporine Tacrolimus Everolimus MMF

4%

19%

0% 2%2%

34%

9%

0%

Baseline/W4 Baseline/EOT

Cyclosporine Tacrolimus Everolimus MMF

At baseline

N (%) 35 (26%) 85 (62%) 11 (8%) 68 (50%)

Dosage (mg/d) 111 ± 51 2 ± 1 1 ± 1 1385 ± 678

Concentration (ng/mL) 76.3 ± 44.2 6.5 ± 3.3 - -

At week 4

N (%) 29 (21%) 75 (55%) 8 (6%) 63 (46%)

Dosage (mg/d) 106 ± 47 2 ± 1 1 ± 1 1396 ± 689

Concentration (ng/mL) 102.1 ± 66.4 4.4 ± 2.2 - -

At EOT

N (%) 31 (23%) 80 (58%) 10 (7%) 62 (45%)

Dosage (mg/d) 105 ± 45 2 ± 1 1 ± 0 1386 ± 702

Concentration (ng/mL) 82.3 ± 56.3 4.6 ± 2.1 - -

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