Peltec A, Buga D, Hotineanu A, Wedemeyer H. Impact of hepatitis delta virus infection on waiting list outcomes: A competing-risks analysis. World J Hepatol 2026; 18(10): 124709 [DOI: 10.4254/wjh.124709]
Corresponding Author of This Article
Angela Peltec, PhD, Associate Professor, Discipline of Gastroenterology, Department of Internal Medicine, “Nicolae Testemitanu” State University of Medicine and Pharmacy, Str. Testemitanu 29, Chisinau 2019, Moldova. angela.peltec@usmf.md
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Gastroenterology & Hepatology
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Peltec A, Buga D, Hotineanu A, Wedemeyer H. Impact of hepatitis delta virus infection on waiting list outcomes: A competing-risks analysis. World J Hepatol 2026; 18(10): 124709 [DOI: 10.4254/wjh.124709]
World J Hepatol. Oct 27, 2026; 18(10): 124709 Published online Oct 27, 2026. doi: 10.4254/wjh.124709
Impact of hepatitis delta virus infection on waiting list outcomes: A competing-risks analysis
Angela Peltec, Diana Buga, Adrian Hotineanu, Heiner Wedemeyer
Angela Peltec, Diana Buga, Discipline of Gastroenterology, Department of Internal Medicine, “Nicolae Testemitanu” State University of Medicine and Pharmacy, Chisinau 2019, Moldova
Adrian Hotineanu, Surgery Department No. 2, “Nicolae Testemitanu” State University of Medicine and Pharmacy, Chisinau 2019, Moldova
Heiner Wedemeyer, Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover 30625, Germany
Author contributions: Peltec A designed and conducted the study and wrote the paper; Buga D contributed to the analysis and wrote the paper; Hotineanu A provided clinical advice; Wedemeyer H supervised the study.
AI contribution statement: Certain sections of this manuscript were revised with the assistance of AI tools exclusively for language improvement. All AI-generated suggestions were thoroughly checked and validated by the authors, who assume full responsibility for the scientific content of the manuscript.
Institutional review board statement: This study was reviewed and approved by the Research Ethics Committee of the Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova (approval No. 40).
Informed consent statement: Written informed consent was obtained from all participants included in the prospective phase of the study. For the retrospective phase, anonymized clinical data from the National Transplant Registry were used in accordance with institutional review board approval.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement- checklist of items.
Data sharing statement: The statistical code and de-identified dataset supporting the findings of this study are available from the corresponding author upon reasonable request, subject to compliance with national data protection regulations.
Corresponding author: Angela Peltec, PhD, Associate Professor, Discipline of Gastroenterology, Department of Internal Medicine, “Nicolae Testemitanu” State University of Medicine and Pharmacy, Str. Testemitanu 29, Chisinau 2019, Moldova. angela.peltec@usmf.md
Received: June 23, 2026 Revised: July 27, 2026 Accepted: September 23, 2026 Published online: October 27, 2026 Processing time: 120 Days and 10.3 Hours
Abstract
BACKGROUND
Liver transplantation is the gold standard for end-stage liver disease, but the shortage of donor organs results in extended waiting lists and considerable mortality before a graft becomes available. Model for end-stage liver disease (MELD)-based allocation has reduced waiting-list mortality and shortened waiting times across many national programs, but its predictive accuracy is not uniform. Hepatitis D virus (HDV) infection promotes faster progression of fibrosis and leads to earlier decompensation. Whether HDV status provides independent prognostic information beyond the MELD score in predicting waiting-list outcomes remains insufficiently investigated.
AIM
To assess the impact of hepatitis delta infection on waiting-list outcomes through a competing-risks analysis.
METHODS
We conducted an ambispective national cohort study of adults listed for liver transplantation (1 January 2013-31 December 2025). The retrospective phase covered 2013-2017 and the prospective phase 2018-2025. Two separate etiologic analyses were performed, comparing HDV infection first with hepatitis B virus (HBV) monoinfection and then with non-delta viral infection, comprising HBV monoinfection, HBV/hepatitis C virus (HCV) coinfection, and HCV monoinfection. Death on the waiting list and transplantation were treated as competing events. Cumulative incidence functions (CIF) were estimated using the Aalen-Johansen method. Multivariable cause-specific Cox and Fine-Gray subdistribution hazard models were fitted for death and for transplantation.
RESULTS
Of 313 adults, 174 (55.6%) had delta infection. The delta group had a more advanced baseline profile. The 5-year CIF of waiting-list death did not differ between the delta and non-delta viral groups (45.9% vs 42.9%; Gray’s test, P = 0.696), whereas transplantation was more frequent in the delta group (43.1% vs 21.7%; P = 0.001). In cause-specific models for the viral cohort, HDV approximately doubled the hazard of both waiting-list death [cause-specific hazard ratio (csHR) = 2.12, 95%CI: 1.38-3.24, P < 0.01] and transplantation [csHR = 2.71, 95%CI: 1.58-4.64, P < 0.01]. On the subdistribution scale for the viral cohort, HDV was not independently associated with waiting-list death [subdistribution hazard ratio (sHR) = 1.19, 95%CI: 0.84-1.68; P = 0.22] but was associated with transplantation [sHR = 2.09, 95%CI: 1.20-3.64; P < 0.01].
CONCLUSION
HDV increased the cause-specific hazard of waiting-list death, but this effect was attenuated by more frequent transplantation. HDV status may aid risk stratification in endemic settings, although current evidence is insufficient to justify a formal MELD exception.
Core Tip: This national competing-risks study shows that hepatitis D virus infection approximately doubled the cause-specific hazards of both waiting-list death and liver transplantation. However, the cumulative incidence of waiting-list death was not increased because patients with hepatitis D underwent transplantation more frequently. This divergence between cause-specific and subdistribution effects highlights how transplantation modifies the observed mortality risk. Hepatitis D status may therefore improve clinical risk stratification in endemic settings, although the current evidence does not support a formal model for end-stage liver disease exception.
