Should organs from hepatitis C-positive donors be used in hepatitis C-negative recipients for liver transplantation?

Expanding the liver donor pool worldwide with hepatitis C infected livers, is it the time?

Liver transplantation (LT) provides a life-saving option for cirrhotic patients with complications and hepatocellular carcinoma. Despite the increasing number of liver transplants performed each year, the number of LT candidates on the waitlist remains unchanged due to an imbalance between donor organ supply and the demand which increases the waitlist time and mortality. Living donor liver transplant had a great role in increasing the donor pool and shortened waitlist time for LT candidates. Nevertheless, further strategies can be implemented to increase the pool of potential donors in deceased donor LT, such as reducing the rate of organ discards. Utilizing hepatitis C virus (HCV) seropositive liver grafts is one of the expanded donor organ criteria. A yearly increase of hundreds of transplants is anticipated as a result of maximizing the utilization of HCV-positive organs for HCV-negative recipients. Direct-acting antiviral therapy's efficacy has revolutionized the treatment of HCV infection and the use of HCV-seropositive donors in transplantation. The American Society of Transplantation advises against performing transplants from HCV-infected liver donors (D+) into HCV-negative recipient (R-) unless under Institutional Review Board-approved study rules and with full informed consent of the knowledge gaps associated with such transplants. Proper selection of patients to be transplanted with HCV-infected grafts and confirming their access to direct-acting antivirals if needed is important. National and international consensuses are needed to regulate this process to ensure the maximum benefit and the least adverse events.

Impact of utilization of hepatitis C positive organs in liver transplant: Analysis of united network for organ sharing database

BACKGROUND

The utility of hepatitis C virus (HCV) organs has increased after the Food and Drug Administration approval of direct acting anti-viral (DAA) medications for the HCV treatment. The efficacy of DAA in treating HCV is nearly 100%.

AIM

To analyze the United Network for Organ Sharing (UNOS) database to compare the survival rates between the hepatitis C positive donors and negative recipients and hepatitis C negative donors and recipients.

METHODS

We analyzed the adult patients in UNOS database who underwent deceased donor liver transplant from January 2014 to December 2017. The primary endpoint was to compare the survival rates among the four groups with different hepatitis C donor and recipient status: (Group 1) Both donor and recipient negative for HCV (Group 2) Negative donor and positive recipient for HCV (Group 3) Positive donor and negative recipient for HCV (Group 4) Both positive donor and recipient for HCV. SAS 9.4 software was used for the data analysis. Kaplan Meier log rank test was used to analyze the estimated survival rates among the four groups.

RESULTS

A total of 24512 patients were included: Group 1: 16436, Group 2: 6174, Group 3: 253 and Group 4: 1649. The 1-year (Group 1: 91.8%, Group 2: 92.12%, Group 3: 87%, Group 4: 92.8%), 2-year (Group 1: 88.4%, Group 2: 88.1%, Group 3: 84.3%, Group 4: 87.5%), 3-year (Group 1: 84.9%, Group 2: 84.3%, Group 3: 75.9%, Group 4: 83.2%) survival rates showed no statistical significance among the four groups. Kaplan Meier log rank test did not show any statistical significance difference in the estimated survival rates between Group 3 vs all the other groups.

CONCLUSION

The survival rates in hepatitis C positive donors and negative recipients are similar as compared to both hepatitis C negative donors and recipients. This could be due to the use of DAA therapy with cure rates of nearly 100%. This study supports the use of hepatitis C positive organs in the selected group of recipients with and without HCV infection. Further long-term studies are needed to further validate these findings.

Outcomes of hepatitis C virus seropositive donors to hepatitis C virus seronegative liver recipients: A large single center analysis

INTRODUCTION AND OBJECTIVES

The success of direct-acting antivirals (DAA) has transformed the management of hepatitis C virus (HCV) infection and has led to the expansion of the deceased donor organ pool for liver transplantation.

MATERIAL AND METHODS

We present a single center retrospective review of liver transplantations performed on HCV-seronegative recipients from HCV-seropositive organs from 11/2017 to 05/2020. HCV nucleic acid testing (NAT) was performed on HCV-seropositive donors to assess active HCV infection.

RESULTS

42 HCV-seronegative recipients underwent a liver transplant from a HCV-seropositive donor, including 21 NAT negative (20 liver, 1 simultaneous liver kidney transplant) and 21 NAT positive liver transplants. Two (9.5%) HCV antibody positive/NAT negative recipients developed HCV viremia and achieved sustained virologic response with DAA therapy. The remaining patients with available data (19 patients) remained polymerase chain reaction (PCR) negative at 6 months. 20 (95%) of HCV antibody positive/NAT positive recipients had a confirmed HCV viremia. 100% of patients with available data (15 patients) achieved SVR. Observed events include 1 mortality and graft loss and equivalent rates of post-transplant complications between NAT positive and NAT negative recipients.

CONCLUSIONS

HCV-seropositive organs can be safely transplanted into HCV-seronegative patients with minimal complications post-transplant.

Transplantation of Organs from Hepatitis C Virus-Positive Donors under Direct-Acting Antiviral Regimens

There is a discrepancy between the patients requiring organ transplants and the donors available to meet that demand. Many patients die every year while on the waiting list, and there is a need to bridge this gap. For many years, medical practitioners have been apprehensive of using donor organs from donors who have tested positive for the Hepatitis C virus (HCV), and with good reason. HCV has been proven to be among the leading causes of liver diseases requiring liver transplants. Over the years, studies have been carried out to find a treatment for Hepatitis C. The advent of direct-acting antivirals revolutionized the medical world. These medication regimens have been proven to treat Hepatitis C in transplant patients effectively. This systematic review will examine how DAA treatments affect transplants of different organs from HCV-positive donors to HCV-negative recipients.

An Update on Usage of High-Risk Donors in Liver Transplantation

The ideal management for end stage liver disease, acute liver failure, and hepatocellular carcinoma (HCC), within specific criteria, is liver transplantation (LT). Over the years, there has been a steady increase in the candidates listed for LT, without a corresponding increase in the donor pool. Therefore, due to organ shortage, it has been substantially difficult to reduce waitlist mortality among patients awaiting LT. Thus, marginal donors such as elderly donors, steatotic donors, split liver, and donors after cardiac death (DCD), which were once not commonly used, are now considered. Furthermore, it is encouraging to see the passing of Acts, such as the HIV Organ Policy Equity (HOPE) Act, enabling further research and development in utilizing HIV grafts. Subsequently, the newer antivirals have aided in successful post-transplant period, especially for hepatitis C positive grafts. However, currently, there is no standardization, and protocols are center specific in the usage of marginal donors. Therefore, studies with longer follow ups are required to standardize its use.

Hepatitis C-associated focal proliferative glomerulonephritis in an aviremic recipient of a hepatitis C-positive antibody donor liver

Shortage of organs for liver transplantation (LT) and the availability of highly efficient pan-genotypic direct-acting antivirals (DAAs) against hepatitis C virus (HCV) have allowed the use of livers from HCV-positive antibody/negative nucleic acid test donors (dHCV Ab+/NAT-) into aviremic HCV recipients over the last few years. We report the case of a patient who received an LT from an HCV Ab+/NAT- donor and, after HCV viremic conversion, developed a nephrotic syndrome due to a focal proliferative glomerulonephritis early after LT. Patient's renal function and proteinuria resolved after successful treatment with DAAs. Renal and hepatic function remain normal over 24 months of follow-up. This case restates the success of LT using livers from dHCV Ab+/NAT- in aviremic recipients in the context of DAAs while illustrating the risk for potential complications associated with the HCV transmission and reinforcing the importance of early initiation of anti-HCV therapy.

Organ Donation from Donors with Hepatitis B or C in South Korea: A 2013-2017 Nationwide Data Analysis

Background

The number of organ donations from hepatitis B virus (HBV) or hepatitis C virus (HCV)-positive donors is gradually increasing; however, the current status of organ donation from brain-dead donors with hepatitis in South Korea has not been analyzed. This study aimed to analyze this.

Material/Methods

In total, 9210 potential brain deaths were reported in South Korea from January 2013 to December 2017, of which 333 were hepatitis carriers (HBV, n=246; HCV, n=87). Based on the data from the Korean Network for Organ Sharing and Korea Organ Donation Agency, 2460 completion of transplantations from brain-dead donors have been performed, of which 71 were hepatitis carriers (HBV, n=60; HCV, n=11).

Results

There were 60 and 11 transplantations from HBV- and HCV-positive brain-dead donors, respectively. The main reasons for organ transplantation failure were recipient’s refusal (n=90), unsuitability as donors (n=80), non-brain death (n=45), and cardiac death (n=20). There were 71 and 31 kidney and liver donations, respectively; the average number of organs donated by HBV-positive donors was higher than that donated by HCV-positive donors. HBV-positive donors donated more hearts and livers than HCV-positive donors.

Conclusions

There are few organ donations from brain-dead donors with hepatitis B or C which led to transplantation completion in South Korea, and the main reasons for failure are recipient’s refusal to receive organs from donors with hepatitis and unsuitability for donation due to active viral conditions. To promote organ transplantations from donors with hepatitis B and C virus, we could consider 3 strategies: 1) reducing recipient’s refusal rates by educating recipients and their families on the outcomes of organ donation from hepatitis carriers, 2) establishing treatment protocols for infection management after organ transplantations from HBV/HCV brain-dead donors, and 3) increasing the relevant experience of medical staff.

Outcomes following liver transplantation from HCV-seropositive donors to HCV-seronegative recipients

BACKGROUND & AIMS

Grafts from HCV-seropositive donors can now be considered for liver transplantation (LT) owing to the advent of direct-acting antivirals (DAAs). We report on our multicenter experience of transplanting liver grafts from HCV-seropositive donors into HCV-seronegative recipients.

METHODS

This is a prospective multicenter observational study evaluating outcomes in adult HCV-seronegative LT recipients who received grafts from HCV-seropositive donors in 3 US centers.

RESULTS

From 01/18 to 09/19, 34 HCV-seronegative LT recipients received grafts from HCV-seropositive donors (20 HCV-viremic and 14 non-viremic). Seven grafts were from cardiac-dead donors. The median MELD-Na score at allocation was 20. Six recipients underwent simultaneous liver-kidney transplant and 4 repeat LT. No recipient of an HCV-non-viremic graft developed HCV viremia. All 20 patients who received HCV-viremic grafts had HCV viremia confirmed within 3 days after LT. DAA treatment was started at a median of 27.5 days after LT. Median pre-treatment viral load was 723,000 IU/ml. All (20/20) patients completed treatment and achieved SVR12. Treatment was well tolerated with minimal adverse events. One patient developed HCV-related acute membranous nephropathy that resulted in end-stage kidney disease, despite achieving viral clearance. This patient died due to presumed infectious complications. A recipient of an HCV-non-viremic graft died with acute myocardial infarction 610 days post LT.

CONCLUSIONS

Transplantation of liver grafts from HCV-seropositive donors into HCV-seronegative recipients resulted in excellent short-term outcomes. Antiviral therapy was effective and well tolerated. Careful ongoing assessment and prompt initiation of antiviral therapy are recommended. Longer term follow-up in carefully conducted clinical trials is still required to confirm these results.

LAY SUMMARY

This study shows that livers from donors exposed to HCV expand the donor pool and can be used safely in patients who are seronegative for hepatitis C infection. Treatment, initiated early post transplantation, is effective and resulted in cure in all patients.

Liver Transplantation Using Hepatitis C Virus-Viremic Donors Into Hepatitis C Virus-Aviremic Recipients as Standard of Care

Liver transplantation (LT) using allografts from hepatitis C virus (HCV)-viremic/nucleic acid testing-positive donors' (DNAT+) organs into HCV-aviremic recipients (rHCV-) has been limited owing to nearly universal HCV transmission and concerns regarding availability, safety, and efficacy post-LT with direct-acting antiviral (DAA) therapy. We report our experience of LT using DNAT+ organs into rHCV- as a routine standard of care. Following verification of DAA access, absence of critical drug-drug interactions (DDIs) with DAAs, and informed consent, allocated DNAT+ organs were offered to patients on the waiting list for LT irrespective of recipient HCV status. Between June 2018 and December 2019, 292/339 rHCV- received an LT. Forty-seven patients were excluded from analysis because of recipient HCV viremia, refusal to receive DNAT+ organs, or inability to receive DAA therapy post-LT. Of these 292 patients, 61 rHCV- received DNAT+ livers (study group), and 231 rHCV- received DNAT- (aviremic donors [nuclear acid test-negative donors]) livers (control group). Recipient and donor characteristics as well as 1-year post-LT patient and graft survival were similar between groups. In the study group, 4 patients died, and 1 patient required retransplantation within the first year post-LT (all unrelated to HCV); 56 patients received DAA therapy, with a median time from LT to the start of DAA treatment of 66.9 days (interquartile range [IQR], 36-68.5), and 51 patients completed DAA treatment, all achieving sustained virologic response for 12 or more weeks (SVR-12) (1 patient required retreatment owing to relapse following initial DAA therapy). No patients had evidence of fibrosing cholestatic hepatitis or extrahepatic manifestations of HCV. This report indicates that transplantation of DNAT+ livers into rHCV- and subsequent DAA therapy is associated with clinical outcomes comparable to those achieved with DNAT- allografts.

Treatment of Hepatitis C Post-Liver Transplantation Could Mitigate Discard Rates of Hepatitis C-Positive Deceased Donor Livers and Expand the Donor Pool

Background

Prior to 2014, treatment for hepatitis C was limited. However, the subsequent introduction of direct acting antiviral medications (DAA) against hepatitis C led to improvements in morbidity and better medication tolerance. DAA therapy allowed for an increase in treatment rates of hepatitis C in patients on the liver transplant waiting list. With the popularization of DAA, there became a growing concern about the utility of hepatitis C-positive (HCV+) deceased liver donors, especially after treating HCV+ potential recipients on the transplant waiting list.

Methods

This is a retrospective, observational study using Mid-America Transplant Services (MTS) database from 2008 to 2017. Comparison was made before the widespread use of DAAs 2008–2013 (pre-DAA) against their common practice use 2014–2017 (post-DAA). All deceased liver donors with HCV antibody or nucleic acid positive results were evaluated.

Results

Between 2008 and 2017, 96 deceased liver donors were positive for HCV. In the pre-DAA era, 47 deceased liver donors were positive for HCV, of which 32 (68.1%) were transplanted and 15 (31.9%) were discarded. In the post-DAA era, a total of 49 HCV+ organs were identified, out of which 43 (87.8%) livers were transplanted and 6 (12.2%) were discarded. Discard rate was significantly higher in the pre-DAA population (31.9% vs. 12.2%, p = 0.026). Secondary analysis showed a distinct trend towards increased regional sharing and utilization of HCV+ donors.

Conclusion

In order to reduce discard rates of HCV+ patients, our data suggest that transplant centers could potentially delay HCV treatment in patients on the transplant waitlist.

Liver transplantation: current and future

PURPOSE

The aim of this paper is to summarize the allocation challenges facing the field of liver transplantation while providing examples of the expansion of indications for the procedure.

METHODS

UNOS allocation policy was reviewed as well as the recent literature describing expanded criteria for recipient candidate selection.

RESULTS

Liver allocation policy changes for deceased-donor organs remain gridlocked in legal and bureaucratic red tape. Meanwhile, the indications for liver transplantation are being expanded to include acute alcoholic hepatitis, intrahepatic cholangiocarcinoma, and colorectal metastasis, previously viewed as absolute contraindications, but under strict selection criteria.

CONCLUSIONS

Attempting to meet the demand for livers, transplant centers are increasingly turning to living donor liver transplantation, protocols such as HCV-positive to HCV-negative transplants, and machine perfusion of marginal organs.

EASL recommendations on treatment of hepatitis C: Final update of the series☆

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease, with approximately 71 million chronically infected individuals worldwide. Clinical care for patients with HCV-related liver disease has advanced considerably thanks to an enhanced understanding of the pathophysiology of the disease, as well as developments in diagnostic procedures and improvements in therapy and prevention. These therapies make it possible to eliminate hepatitis C as a major public health threat, as per the World Health Organization target, although the timeline and feasibility vary from region to region. These European Association for the Study of the Liver recommendations on treatment of hepatitis C describe the optimal management of patients with recently acquired and chronic HCV infections in 2020 and onwards.

Organ utilization - the next hurdle in transplantation?

Nonutilization of organs from consented deceased donors remains a significant factor in limiting patient access to transplantation. Critical to reducing waste is a clear understanding of why organs are not used: accurate metrics are essential to identify the extent and causes of waste but use of these measures as targets or comparators between units/jurisdictions must be done with caution as focus on any one measure may result in unintended adverse consequences. Comparison between centres or countries may be misleading because of variation in definitions, patient or graft characteristics. Two of the most challenging areas to improve appropriate deceased donor organ utilization are appetite for risk and lack of validated tools to help identify an organ that will function appropriately. Currently, the implanting surgeon is widely considered to be accountable for the use of a donated organ so guidelines must be clear to allow and support sensible decisions and recognition that graft failure or inadvertent disease transmission are not necessarily attributable to poor decision-making. Accepting an organ involves balancing risk and benefit for the potential recipient. Novel technologies such as machine perfusion may allow for more robust guidance as to the functioning of the organ.

Post-transplant survey to assess patient experiences with donor-derived HCV infection

BACKGROUND

Despite increased utilization of hepatitis C virus-infected (HCV+) organs for transplantation into HCV-uninfected recipients, there is lack of standardization in HCV-related patient education/consent and limited data on financial and social impact on patients.

METHODS

We conducted a survey on patients with donor-derived HCV infection at our center transplanted between 4/1/2017 and 11/1/2019 to assess: why patients chose to accept HCV+ organ(s), the adequacy of their pre-transplant HCV education and informed consent process, financial issues related to copays after discharge, and social challenges they faced.

RESULTS

Among 49 patients surveyed, transplanted organs included heart (n = 19), lung (n = 9), kidney (n = 11), liver (n = 4), heart/kidney (n = 4), and liver/kidney (n = 2). Many recipients accepted an HCV-viremic (HCV-V) organ due to perceived reduction in waitlist time (n = 33) and/or trust in their physician's recommendation (n = 29). Almost all (n = 47) felt that pre-transplant education and consent was appropriate. Thirty patients had no copay for direct-acting antivirals (DAA) for HCV, including 21 with household income <$20 000; seven had copays of <$100 and one had a copay >$1000. Two patients reported feeling isolated due to HCV infection and eight reported higher than anticipated medication costs. Patients' biggest concern was potential HCV transmission to partners (n = 18) and family/friends (n = 15). Overall almost all (n = 47) patients reported a positive experience with HCV-V organ transplantation.

CONCLUSION

We demonstrate that real-world patient experiences surrounding HCV-V organ transplantation have been favorable. Almost all patients report comprehensive HCV-related pre-transplant consent and education. Additionally, medication costs and social isolation/exclusion were not barriers to the use of these organs.

Hepatitis C: looking into the future

INTRODUCTION

The recent availability of highly effective hepatitis C medications, with a cure rate approaching 100%, has created a wide range of questions and uncertainties.

AREAS COVERED

The most recent data around hepatitis C virus (HCV) elimination will be reviewed. In addition, the impact of HCV cure or sustained virologic response (SVR) on the risk for hepatocellular carcinoma (HCC) development will be discussed. Although the terms 'SVR' and 'cure' are used interchangeably, there are little data to support that they are actually the same. In this review, we will shed some light on the status of HCV vaccine development, obstacles, and published experience. Finally, in the face of decreasing HCV patients needing transplantation, and increasing available organs from donors infected with HCV, the question is that, is it possible to transplant an organ infected with HCV to a patient who is not infected? The pros and cons of transplanting HCV-positive organs to HCV-negative recipients will be discussed.

EXPERT OPINION

Although the new advances in HCV treatment have solved many problems, it created several new issues which the medical community has to deal with and which will likely remain in the near future.

Usage of HCV viremic organs in liver transplantation to anti-HCV negative recipients: The current status and review of literature

Liver transplantation is the main curative therapy for end-stage liver disease. The number of transplanted organs is increasing globally. However, the number of available organs in the pool is insufficient, considering the excessive number of patients on the waiting list, which is a major concern for transplant programs. Hepatitis C infection (HCV) is a common indication for liver transplantation, and in recent years, a major progress has been made in its treatment with direct-acting antiviral (DAA) agents. HCV-positive livers have been transplanted to HCV-positive recipients for a long time. The high rate of sustained virologic response through DAA has brought new treatment options for the patients during the pre- and post-transplantation periods. Recently, there have been few reports of transplanting the available HCV-positive organs to HCV noninfected recipients. However, there is not yet an agreement on the optimal selection of patients who would benefit from such transplantation, and this has become a current topic of interest. Thus, we aim to review the current literature on this evolving topic.

Successful Treatment of a Reinfected Liver Graft Because of Receipt of a HCV-Positive Kidney

Transplantation of hepatitis C virus (HCV)-positive organs has undergone a paradigm shift because of the advent of direct-acting antivirals. We present the case of a 57-year-old man successfully treated initially with pegylated interferon and ribavirin after HCV recurrence postliver transplantation. He subsequently developed end-stage renal disease and received a genotype 1a HCV-positive kidney transplant. A 12-week course of ledipasvir/sofosbuvir and low-dose ribavirin was initiated and sustained virologic response was achieved. This constitutes the first reported case of a patient successfully treated for HCV a second time after receiving an HCV-positive organ.

Balancing the risk and rewards of utilizing organs from hepatitis C viremic donors

PURPOSE OF REVIEW

Owing to long waitlist times and high waitlist morbidity and mortality, strategies to increase utilization of hepatitis C viremic-deceased donor organs are under investigation in kidney, liver, heart, and lung transplantation.

RECENT FINDINGS

Direct-acting antiviral medications for hepatitis C virus infection have high cure rates and are well tolerated. Small, single-center trials in kidney and heart transplant recipients have demonstrated that with early posttransplant direct-acting antiviral therapy, 100% of uninfected recipients of hepatitis C viremic organs have been cured of infection after transplantation.

SUMMARY

In this manuscript, we review the risks and rewards of utilizing hepatitis C viremic organs for transplantation.

Challenges and future developments in liver transplantation

Liver transplantation (LT) has become the treatment of choice for a wide range of liver diseases in both adult and pediatric patients. Until recently, the largest proportion of LT in adults, were performed in patients with hepatitis C (HCV) related cirrhosis. The recent availability of safe and effective direct antiviral agents to cure HCV infection in almost all patients whatever the HCV genotype and severity of liver disease, will reduce the need for LT in this category of recipients. Thus, it is presumed that in the next 1 to 2 decades HCV related liver disease will diminish substantially, whereas non-alcoholic steato-hepatitis (NASH) will correspondingly escalate as an indication for LT. The greatest challenges facing LT remain the limited supply of donor organs, and the need for chronic immunosuppression, which represent the true obstacles to the greater application and durable success of the LT procedure. This review aimed to highlight, in different sections, the main open issues and future developments in LT. These will be focused to explore current and future strategies to maximize the use of limited organs, to offer an update on potential new approaches to immunosuppression and to imagine new indications for LT when the number of patients awaiting transplants for HCV related liver disease is reduced.