Viral hepatitis paradox: Better outcomes in geriatric HCC transplant patients

Hepatocellular carcinoma (HCC) causes significant mortality among elderly patients requiring liver transplantation. Traditional assumptions suggest viral hepatitis worsens transplant outcomes. We hypothesized that viral status would significantly influence survival outcomes, with potential interactions between HBV/HCV co-infection and metabolic comorbidities. We analyzed 7,890 geriatric patients (≥65 years) from the United Network for Organ Sharing database who received liver transplants for HCC, stratifying them by hepatitis B virus (HBV) and hepatitis C virus (HCV) status. Contrary to expectations, HCV-positive patients demonstrated significantly superior 5-year survival rates, with HBV+/HCV+ patients achieving 33.9% survival versus 27.3% for HBV-/HCV- patients. Mean survival time was 182 days longer for HBV+/HCV+ patients compared to HBV-/HCV- patients (1,361 vs. 1,179 days, p<0.001). Diabetes mellitus showed complex associations with outcomes, with particularly poor survival in coinfected diabetic patients (6.2% vs. 45.0% for non-diabetics). Age showed negative correlations with survival in all groups, relatively high in co-infected patients (r=-0.160). These findings challenge current transplant evaluation paradigms, suggesting viral status complexity requires reassessment in geriatric populations. Our results indicate that HCV should not automatically exclude elderly patients from transplant consideration, while diabetes requires careful management, especially in co-infected patients.