Transplantation of hepatitis C-positive livers in hepatitis C-positive patients is equivalent to transplanting hepatitis C-negative livers

Hepatitis C and liver transplantation: enhancing outcomes and should patients be retransplanted

Hepatitis C (HCV)-related end-stage liver disease is the most common indication for liver transplantation. Safe expansion of the donor pool with improved rates of deceased donation and more widespread use of living and extended criteria donation are likely to decrease wait list mortality. In addition, improved antiviral treatments and a better understanding of the delicate balance between under- and over-immunosuppression in this population are needed. Finally, when recurrent advanced fibrosis occurs, the criteria for patient selection for retransplantation remain widely debated. This article reviews the literature on these topics and the work being done in each area to maximize outcomes in patients receiving transplants for HCV-related cirrhosis.

Organ shortage crisis: problems and possible solutions

The demand for organ transplantation has rapidly increased all over the world during the past decade due to the increased incidence of vital organ failure, the rising success and greater improvement in posttransplant outcome. However, the unavailability of adequate organs for transplantation to meet the existing demand has resulted in major organ shortage crises. As a result there has been a major increase in the number of patients on transplant waiting lists as well as in the number of patients dying while on the waiting list. In the United States, for example, the number of patients on the waiting list in the year 2006 had risen to over 95,000, while the number of patient deaths was over 6,300. This organ shortage crisis has deprived thousands of patients of a new and better quality of life and has caused a substantial increase in the cost of alternative medical care such as dialysis. There are several procedures and pathways which have been shown to provide practical and effective solutions to this crisis. These include implementation of appropriate educational programs for the public and hospital staff regarding the need and benefits of organ donation, the appropriate utilization of marginal (extended criteria donors), acceptance of paired organ donation, the acceptance of the concept of "presumed consent," implementation of a system of "rewarded gifting" for the family of the diseased donor and also for the living donor, developing an altruistic system of donation from a living donor to an unknown recipient, and accepting the concept of a controlled system of financial payment for the donor. As is outlined in this presentation, we strongly believe that the implementation of these pathways for obtaining organs from the living and the dead donors, with appropriate consideration of the ethical, religious and social criteria of the society, the organ shortage crisis will be eliminated and many lives will be saved through the process of organ donation and transplantation.

Expanding donor options: marginal, living, and split donors

One of the most important factors in the increasing number of liver transplantations performed in the United States is the growing acceptance of marginal grafts, which are defined as organs at increased risk for poor function or failure that may subject the recipient to greater risks of morbidity or mortality. Based on encouraging results, a growing number of liver transplantation centers are broadening their criteria for transplantation of marginal grafts. This article discusses the use of the extended criteria donor liver, split-liver, and living-donor liver transplantation.

Should antihepatitis B virus core positive or antihepatitis C virus core positive subjects be accepted as organ donors for liver transplantation?

Since the introduction of liver transplantation as a routine surgical procedure for the treatment of end-stage liver disease, there has been an increasing gap between the number of available grafts and the number of patients on the waiting list. This has led transplant centers to expand the donor pool by different means. One of them has been the introduction of living donor liver transplantation. Other strategies include using less than optimal allografts from deceased donors, the so-called marginal donors, which include the use of grafts from older subjects, livers with moderate amounts of steatosis, or from donors with markers of past or current infection with hepatitis viruses who have absent or minimal liver biochemical or histologic injury. In this review, we will focus on the current use of allografts from donors with antihepatitis B core antibody and/or antibodies against hepatitis C virus in cadaveric and living donor liver transplantation.

Use of extended criteria livers decreases wait time for liver transplantation without adversely impacting posttransplant survival

INTRODUCTION

The use of extended criteria donors (ECDs) could minimize shortage of suitable donor livers for transplantation. In 3 years, the aggressive use of ECD livers has reduced the wait list at our center from 257 to 30 patients with a median wait time of 18 days without using living donors. This study compares the graft/patient survival from standard (SD) and ECD for our transplant population between 2001 and 2005.

METHODS

Records of all adult liver transplant recipients over 4 years were reviewed (n = 571). ECD criteria included: age >59 years, BMI >34.9, maximum AST/ALT >500, maximum bilirubin >2.0, peak serum sodium >170, HBV/HCV/HTLV reactive, donation after cardiac death, cold ischemia time >12 hours, ICU stay >5 days, 3 or more pressors simultaneously, extensive alcohol abuse, cancer history (nonskin), active meningitis/bacteremia, or significant donor liver trauma. Outcomes included graft and patient survival at 90 days, 1 year, and 2 years.

RESULTS

Sixty-eight percent of recipients (n = 388) received ECD livers. Primary factors accounting for ECD-liver status included: elevated liver function tests (20%), hypernatremia (12.6%), and extensive alcohol abuse (11.4%). Graft survival was (SD, ECD): 90-day 91%, 88%; 1-year 84%, 80%; 2-year 78%, 77%; patient survival was: 90-day 93%, 90%; 1-year 87%, 82%; 2-year 83%, 79%. Kaplan-Meier survival analysis failed to demonstrate an overall difference in graft or patient survival at any time point. Only donor age >60 years was associated with decreased graft and patient survival.

CONCLUSIONS

Liver grafts from ECD can be used to dramatically reduce wait list time with outcomes comparable to those for SD without resorting to living donor liver transplantation.

Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV+ allografts

Studies have suggested that the use of hepatitis C virus (HCV)-positive (HCV+) donor allografts has no impact on survival. However, no studies have examined the effect that HCV+ donor histology has upon recipient and graft survival. We evaluated the clinical outcome and impact of histological features in HCV patients transplanted using HCV+ livers. We reviewed all patients transplanted for HCV at our institution from 1988 to 2004; 39 received HCV+ allografts and 580 received HCV-negative (HCV-) allografts. Survival curves compared graft and patient survival. Each HCV+ allograft was stringently matched to a control of HCV- graft recipients. No significant difference in survival was noted between recipients of HCV+ livers and controls. Patients receiving HCV+ allografts from older donors (age > or =50 yr) had higher rates of graft failure (hazard ratio, 2.74) and death rates (hazard ratio, 2.63) compared to HCV- allograft recipients receiving similarly-aged older donor livers. Matched case-control analysis revealed that recipients of HCV+ allografts had more severe fibrosis post-liver transplantation than recipients of HCV- livers (P = 0.008). More advanced fibrosis was observed in HCV+ grafts from older donors compared to HCV+ grafts from younger donors (P = 0.012). In conclusion, recipients of HCV+ grafts from older donors have higher rates of death and graft failure, and develop more extensive fibrosis than HCV- graft recipients from older donors. Recipients of HCV+ grafts, regardless of donor age, develop more advanced liver fibrosis than recipients of HCV- grafts.

Treating hepatitis C infection in liver transplant recipients

Chronic infection with hepatitis C virus (HCV) is a growing problem worldwide, with up to 300 million individuals infected, and those with chronic infection are at risk for cirrhosis and hepatocellular carcinoma. HCV infection is the most common indication for liver transplantation in the United States and Europe. Unfortunately, although transplantation is effective for treating decompensated cirrhosis and limited hepatocellular carcinoma associated with hepatitis C, HCV reinfection is virtually the rule among transplant recipients. Reinfection of the graft is associated with more rapidly progressive disease, with a median time to cirrhosis of 8 to 10 yr. Unfortunately, treatment of chronic HCV in liver transplant recipients is suboptimal. Combination therapy with interferon (pegylated and nonpegylated forms) plus ribavirin appears to provide maximum benefits. Drug therapy is usually administered for recurrent disease. No prophylactic therapy is available. Preemptive regimens offer no distinctive advantages over treatments begun for recurrent disease. Overall, treatment is poorly tolerated, with frequent need for dose reductions, especially from cytopenias, and drug discontinuations in up to 50% of patients. Optimizing drug doses is important in maximizing sustained virological response rates. Future therapies may include ribavirin alternatives with lower rates of anemia, alternative interferons with lower rates of cytopenias, and new antiviral drugs that can be used alone or in combination with either interferon or ribavirin to enhance sustained virological response rates and improve tolerability. Liver Transpl 12:1192-1204, 2006. (c) 2006 AASLD.

AASLD/ILTS transplant course: is there an extended donor suitable for everyone?

1. The clinical success of liver transplantation coupled with the current era of organ shortage has caused many centers to expand their criteria for acceptable donors. 2. The definition of "Extended Criteria Donor" (ECD) is becoming better understood and quantified. 3. Recipient factors that portend poor outcome must be recognized and factored in as well. Grafts and recipients must be "matched" to manage and minimize the risk from ECDs. 4. Maintaining acceptable outcomes as ECD concepts evolve is paramount. 5. Absolute risk factors for poor graft function still exist and must be respected, but relative risk factors are now well identified, quantified, accepted, and managed as an alternative to high waiting list mortality.

Hepatitis B Core Antibody Positive Donors as a Safe and Effective Therapeutic Option to Increase Available Organs for Lung Transplantation

BACKGROUND

The use of hepatitis B core antibody (HBcAb+) and hepatitis C antibody (HCV Ab+) positive donors represents one strategy to increase available donor organs, but this remains controversial because of concern for viral transmission to recipients. We hypothesized that isolated HBcAb+ donors represent minimal risk of viral transmission in vaccinated lung transplant (LTx) recipients.

METHODS

A retrospective study was performed of LTx recipients who received HBcAb+ or HCV Ab+ pulmonary allografts. We analyzed liver function studies, viral hepatitis screening tests, quantitative polymerase chain reaction for hepatitis B viral DNA (HBV DNA) and hepatitis C viral RNA (HCV RNA), freedom from bronchiolitis obliterans syndrome, acute rejection, and survival.

RESULTS

Between April 1992 and August 2003, 456 LTx operations were performed. Twenty-nine patients (HB group) received HBcAb+ allograft transplants with a median posttransplant follow-up of 24.5 months. Three critically ill patients (HC group) received HCV Ab+ allografts with a median follow-up of 21.5 months. One-year survival for the HB group is 83% versus 82% for all patients who received non-HB organs (P=0.36). No patient in the HB group developed clinical liver disease because of viral hepatitis, and all patients alive (n=21) at follow-up are, to date, HBV DNA and/or HBcAb negative. All patients in the HC group tested HCV RNA positive; one patient died of liver failure at 22 months.

CONCLUSIONS

Risk of viral transmission with HCV Ab+ allografts seems high after LTx. However, the use of HBcAb+ pulmonary allografts in recipients with prior hepatitis B vaccination seems to be a safe and effective strategy to increase organ availability.

Use of Hepatitis C Virus-Positive Grafts in Liver Transplantation: A Single-Centre Experience

AIM

Our goal was to evaluate the outcome of HCV(+) recipients after liver transplantation (LT) using HCV(+) donors and the interaction between donor and recipient viral strain.

METHODS

We performed a retrospective analysis of 21 LT performed between 1998 and 2004 using livers from HCV(+) donors in HCV(+) recipients. Two hundred thirty-seven patients with HCV cirrhosis who underwent LT with livers from HCV(-) donors were the control group. Ishak score (IS) was evaluated for all HCV(+) grafts. The considered variables included donor age, hepatic enzymes, intensive care unit stay, HCV genotype, ischemia time, recipient age, UNOS status, Child score, HCV genotype (before and 6 months after LT) and IS (after LT). We analyzed patient, graft, and disease-free survival.

RESULTS

HCV(+) donors were significantly older than HCV(-) donors. The cumulative 5-year patient and graft survivals and disease free intervals were not different between groups. IS grading was more than 2/18 in two cases; the only graft with a staging score over 2/6 was retransplanted for early nonfunction. In two cases, different HCV genotypes were matched and donor strain took over the recipient strain. In one patient, donor genotyping 2a-2c took over recipient genotyping 1b and 9 months after LT recurrent hepatitis was documented, but antiviral therapy cleared HCV.

CONCLUSIONS

Livers from HCV(+) donors can safely be used in HCV(+) recipients. Hepatic biopsy must always be performed; livers with bridging fibrosis should not be used. The takeover of one strain by another may change the prognosis of the patient if the predominant strain is more sensitive to antiviral therapy.

The use of hepatitis C-infected grafts in liver transplantation

1. Liver grafts from hepatitis C virus (HCV)-infected deceased donors can be used safely in HCV-infected recipients. 2. Histological assessment of the graft before orthotopic liver transplantation (OLT) is advised. 3. Recipients of these grafts should give consent accordingly. 4. The course of HCV disease after OLT parallels that in patients who received noninfected organs.

Outcomes of hepatitis C- and hepatitis B core antibody-positive grafts in orthotopic liver transplantation

The use of hepatitis B core antibody (HBcAb)- and hepatitis C virus antibody (HCV+) liver grafts for transplantation in selected populations has not affected patient and graft survival. We reexamined the clinical outcomes of using these HBcAb+ and HCV+ grafts at our institution, in addition to studying recipients of combined HBcAb+/HCV+ grafts. We identified 377 patients who underwent transplantation for either hepatitis B and/or hepatitis C, or received both HBcAb+ and HCV+ grafts. Patient and graft survival at 5 years posttransplantation was 73% and 71%, respectively, in the HBcAb+ grafts compared with 81% and 75% in the HBcAb- grafts (P =.65; P =.94). For HCV+ grafts, patient and graft survival at 5 years posttransplantation was 89% and 73%, respectively, compared with 69% and 59% in the HCV- grafts; (P =.22; P =.77). The 5-year patient and graft survival rate in those who received combined HBcAb+/HCV+ grafts was 74% and 69%, respectively, and there was no statistical difference compared with the HBcAb+ and HCV+ grafts (P =.76; P =.90). The 5-year patient and graft survival rate in patients who received dual HBV prophylaxis with hepatitis B immunoglobulin (HBIg) and lamivudine was 88% and 84%, respectively, which was significantly higher than for patients who received single prophylaxis or no prophylaxis (P <.01; P =.02). Our study supports previous observations that patient and graft survival is not affected with the use of HBcAb+ and HCV+ grafts, and that dual prophylaxis with HBIg and lamivudine offers substantial survival benefits. Furthermore, the use of combined HBcAb+/HCV+ grafts did not impact patient or graft survival. This provides a potential new pool of donor livers that can be used for transplantation in select patients.

Hepatitis C positive grafts may be used in orthotopic liver transplantation: a matched analysis

Hepatitis C (HCV)-positive liver grafts have been increasingly used in patients with decompensated liver disease from HCV because of critical shortage of available organs. Fifty-nine recipients of HCV-positive grafts were matched to patients who received HCV-negative grafts. All recipients were transplanted for HCV liver disease. Matching variables were (1) status, (2) pre-transplant creatinine, (3) recipient age, (4) donor age, (5) warm ischemia time, and (6) year of transplantation. Both unmatched and matched analyses were performed on patient survival, graft survival, and time to HCV recurrence. There was no significant statistical difference in patient, graft, or HCV recurrence-free survival between recipients of HCV-positive and HCV-negative grafts with matched and unmatched analyses (p > 0.05). The 3-year estimates of HCV disease-free survival were 12% (+/- 9%) and 19% (+/- 7%) using HCV-positive and -negative grafts, respectively. The use of HCV-positive grafts in recipients with HCV does not appear to affect patient survival, graft survival, or HCV recurrence when compared with the use of HCV-negative grafts. Our results suggest that HCV-positive grafts can be used in a HCV liver transplant recipient.

The use of virologically compromised organs in liver transplantation

The present organ donor crisis has led to accepted use of organs from donors infected with hepatitis C virus (HCV) and hepatitis B virus (HBV). Although capable of transmitting disease, these grafts offer opportunities to expand the donor pool for certain populations. Anti-HBc positive grafts can be used if care is taken to provide prophylaxis. Good quality grafts from HCV+ donors may be used in recipients who are themselves HCV+ with good outcomes.

The utility of marginal donors in liver transplantation

The shortage of organs has led centers to expand their criteria for the acceptance of marginal donors. The combination of multiple marginal factors seems to be additive on graft injury. In this review, the utility of various marginal donors in patients requiring liver transplantation will be described, including older donors, steatotic livers, non-heart-beating donors, donors with viral hepatitis, and donors with malignancies. The pathophysiology of the marginal donor will be discussed, along with strategies for minimizing the ischemia reperfusion injury experienced by these organs. Finally, new strategies for improving the function of the marginal/expanded donor liver will be reviewed.

Hepatitis C in the liver transplant recipient: current understanding and treatment

Hepatitis C virus (HCV)-related liver disease is the leading indication for orthotopic liver transplantation worldwide. Recurrent HCV infection as defined by viremia after transplantation is nearly universal, with histologic evidence of recurrent hepatitis present in the majority. Although short-term survival appears to be similar to that in other causes of liver failure, it has recently been demonstrated that approximately 20-30% of HCV-positive patients develop allograft cirrhosis by 5 years. Therefore, it is possible to define disease outcomes within a relatively short period of follow-up. Identification of patients who are likely to develop progressive HCV-related allograft injury is important to optimize results of current antiviral therapy.

Liver transplantation for hepatocellular carcinoma: analysis of survival according to the intention-to-treat principle and dropout from the waiting list

A major obstacle for orthotopic liver transplantation (OLT) as treatment for hepatocellular carcinoma (HCC) is tumor growth resulting in dropout from the waiting list for OLT. There is a paucity of data on survival according to intention-to-treat analysis and the rate of dropout from the waiting list for OLT among patients with HCC. To further evaluate these issues, we analyzed the outcome of 46 consecutive patients with HCC listed for OLT between January 1998 and January 2001. Exclusion criteria for OLT were tumor size greater than 5 cm for one to three lesions or four lesions or greater of any size. Twenty-one patients underwent OLT. There were 11 dropouts because of tumor progression and six deaths, including three deaths after dropout. Kaplan-Meier 1- and 2-year intention-to-treat survival rates were 91.7% and 72.6%, respectively. Monthly dropout rates were 0% from 0 to 3 months, 1.5% from 3 to 6 months, 1.0% from 6 to 9 months, 4.9% from 9 to 12 months, and 5.6% from 12 to 15 months. One dropout occurred beyond 15 months among 4 patients remaining at risk. Cumulative probabilities for dropout at 6, 12, and 24 months were 7.3%, 25.3%, and 43.6%, respectively. Predictors for dropout included two or three tumor nodules or a solitary lesion greater than 3 cm at initial presentation and previous hepatic resection. Our results support recent changes in the scheme of organ allocation aimed at reducing the dropout rate and improving outcome for patients with HCC awaiting OLT.