Willingness of Kidney and Liver Transplant Candidates to Receive HCV-Infected Organs

Shifting perspectives in liver diseases after kidney transplantation

Liver diseases after kidney transplantation range from mild biochemical abnormalities to severe hepatitis or cirrhosis. The causes are diverse and mainly associated with hepatotropic viruses, drug toxicity and metabolic disorders. Over the past decade, the aetiology of liver disease in kidney recipients has changed significantly. These relates to the use of direct-acting antiviral agents against hepatitis C virus, the increasing availability of vaccination against hepatitis B and a better understanding of drug-induced hepatotoxicity. In addition, the emergence of the severe acute respiratory syndrome coronavirus 2 pandemic has brought new challenges to kidney recipients. This review aims to provide healthcare professionals with a comprehensive understanding of recent advances in the management of liver complications in kidney recipients and to enable them to make informed decisions regarding the risks and impact of liver disease in this population.

Beyond donation to organ utilization in the USA

PURPOSE OF REVIEW

The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization.

RECENT FINDINGS

We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers.

SUMMARY

Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.

Utilization of hepatitis C virus-positive donors in kidney transplantation

PURPOSE OF REVIEW

Direct-acting antivirals (DAA) have transformed kidney transplantation by increasing the donor pool from hepatitis C virus (HCV)-infected donors and allowing HCV nucleic acid amplification testing (NAT) donor-positive/recipient-negative (D+/R-) transplantation over the last 7 years. Willingness to accept kidneys from HCV-infected donors and timing/duration of DAA therapy have been evolving.

RECENT FINDINGS

By 2021, most of the HCV NAT+ kidneys (92.6%) were transplanted to HCV-naive recipients. Despite the availability of effective DAA therapy, the discard rate of HCV NAT kidneys has been stagnant around 25%. The proportion of wait-listed patients willing to accept a deceased donor kidney from HCV Ab+ and HCV NAT+ donors increased 20-fold between 2015 and 2022. Wait-listed time to receive HCV NAT+ kidneys has been rising and most of the kidneys are transplanted to HCV-naive recipients. The proportion of deceased donor kidney transplants performed in recipients with HCV seropositivity decreased from 5.1 to 2.8% during the same period. Relatively short courses of DAA therapy (7-8 days) appear to be effective to decrease HCV transmission (<5%) and achieve sustained virological response at 12 weeks if administered prior to revascularization.

SUMMARY

Further studies are needed to evaluate long-term outcomes of HCV NAT D+/R- transplantation and the best course of DAA treatment.