Clinical Characteristics and Outcomes of Patients with Cirrhosis and Hepatocellular Carcinoma in the Gambia, West Africa

Background: Chronic liver disease is a major cause of premature death in sub-Saharan Africa (sSA). However, due to lack of curative treatment for cirrhosis and hepatocellular carcinoma (HCC), clinical relevance of screening and surveillance of cirrhosis and HCC in sSA remains unclear. We described the clinical characteristics and outcomes of patients with cirrhosis and HCC in The Gambia and assessed the impact of Tenofovir Disoproxil Fumarate (TDF) on survival.Methods: We prospectively followed up adults consecutively diagnosed with cirrhosis or HCC between 2012-2019 in The Gambia, West Africa. HBV-positive patients with cirrhosis, without HCC, were offered TDF. Primary outcome was overall survival estimated using the Kaplan-Meier method. Multivariable Cox proportional hazards models with the inverse probability of treatment weighted (IPTW) were performed to determine the effect of TDF.Findings: Of 529 patients enrolled in this study, 336 patients (252 with HCC and 84 with cirrhosis) were analysed. Patients were predominantly male (75.3%) with median age 42 years (IQR: 33-55). HBV, HCV and HDV serologies were positive in 84.4%, 9.9% and 9.9%, respectively. Sixty-four percent of HCC patients had multifocal tumour, with a median size of 7.5 cm (IQR: 5.4-10.8). Median survival was 17.1, 11.3 and 1.5 months among patients with compensated cirrhosis, decompensated cirrhosis, and HCC, respectively (log rank p<0.0001).In HBV-positive patients with cirrhosis, median turnaround time between cirrhosis diagnosis and TDF initiation was 4.9 months. TDF treatment was associated with improved survival in patients with HBV-related cirrhosis (IPTW-adjusted Cox analysis HR: 0.14; 95%Cl: 0.06-0.34, p<0.001). Ascites (HR: 1.83, 95%CI: 1.09–3.09) and portal thrombosis (HR: 3.81, 95%CI: 1.99–7.30) were independent risk factors of mortality in HCC cases.Interpretation: Early screening and treatment programs of cirrhosis and HCC alongside simplified treatment guidelines are urgently required in Africa.Funding Information: This study was supported by European Commission (FP7 grant 265994) and MRC UK (NIRG).Declaration of Interests: ML, YS, PI, GN, MT received research funding and consultancy fees from Gilead Sciences. All other authors declare no competing interests.Ethics Approval Statement: The study was approved by the Gambia Government/MRCG Joint Ethics Committee. Patients provided informed consent.