1
|
Hollander SA, Chen S, Dykes J, Kaufman BD, Lee E, Wujcik K, Profita E, Schmidt J, Rosenthal DN. A comprehensive, multifaceted strategy to increase pediatric donor heart utilization. J Heart Lung Transplant 2024:S1053-2498(24)01707-8. [PMID: 38945282 DOI: 10.1016/j.healun.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND In 2016, we initiated a quality improvement endeavor to increase pediatric heart offer acceptance. This study assessed the effect of these interventions at our center. METHODS We evaluted pre- and postimplementation cohorts (January 1, 2008-December 31, 2016 vs January 1, 2017-July 1, 2023) comparing donor heart utilization. Six interventions were iterated over time to increase offer acceptance ("extended criteria"): ABO-incompatible transplant, ex vivo perfusion for distanced donors, 3-dimensional total cardiac volume (TCV) assessment, acceptance of hepatitis-C or Severe Acute Respiratory Syndrome Coronavirus 2 infected donors, and institutional culture change favoring consideration of donors previously considered unacceptable. Outcomes studied included annual HT volume, median waitlist duration, sequence number at acceptance, and post-transplant clinical outcomes. RESULTS During the study period, annual transplant volume increased from 16/year to 25/year pre- and postimplementation. Three hundred thirteen of 389 (80%) listed patients were transplanted. Waitlist duration shortened postimplementation (p = 0.01), as did the percentage of accepted heart offers utilizing at least 1 extended criterion (p < 0.001). Institutional culture change and TCV assessment had the largest impact on donor heart utilization (p = 0.04 and p < 0.001). There was no difference in post-HT intubation or intensive care unit days (p = 0.05-0.9), though post-transplant hospitalization duration (p < 0.001) increased. Post-transplant survival was unaffected by the use of extended criteria hearts (p = 0.3). CONCLUSIONS We report a successful longitudinal, multifaceted effort to increase organ offer utilization, with institutional culture change and TCV assessments most impactful. The use of extended criteria hearts was not associated with inferior survival.
Collapse
Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California.
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - John Dykes
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Ellen Lee
- Procurement Services, Stanford Medicine Children's Health, Palo Alto, California
| | - Kari Wujcik
- Solid Organ Transplant Services, Stanford Medicine Children's Health, Palo Alto, California
| | - Elizabeth Profita
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Julie Schmidt
- Solid Organ Transplant Services, Stanford Medicine Children's Health, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
2
|
Hannan HA, Goldberg DS. Racial and Gender Disparities in Transplantation of Hepatitis C+ Hearts and Lungs. J Heart Lung Transplant 2024; 43:780-786. [PMID: 38163451 DOI: 10.1016/j.healun.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/15/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Transplanting organs from hepatitis C virus (HCV)-infected donors into HCV-negative recipients has led to thousands of more transplants in the United States since 2016. Studies have demonstrated disparities in utilization of kidneys from these donors due to gender and education. It is still unknown, however, if the same disparities are seen in heart and lung transplantation. METHODS We used Organ Procurement and Transplantation/United Network for Organ Sharing data on all isolated heart and lung transplants from November 1, 2018, to March 31, 2023, classifying donors based on their HCV nucleic acid test (NAT) result: HCV-NAT- vs HCV-NAT+. We fit separate mixed-effects logistic regression models (outcome: HCV-NAT+ donor) for heart and lung transplants. Primary covariates included (1) race/ethnicity, (2) sex, (3) education level, (4) insurance type, and (5) transplant year. RESULTS The study included 26,108 adults (14,189 isolated heart transplant recipients and 11,919 isolated lung transplant recipients). A total of 993 (7.0%) heart transplants involved an HCV-NAT+ donor, compared to 457 (3.8%) lung transplants. In multivariable models among all isolated heart transplant recipients, women were significantly less likely to receive an HCV-NAT+ donor heart (odds ratio [OR]: 0.79, 95% confidence interval [CI]: 0.67-0.92, p = 0.003), as were Asian patients (OR: 0.52, 95% CI: 0.31-0.86, p = 0.01). In multivariable models among all isolated lung transplant recipients, Asians were significantly less likely to receive HCV-NAT+ transplants (OR: 0.31, 95% CI: 0.12-0.77, p = 0.01). CONCLUSIONS There are disparities in utilization of heart and lungs from HCV-NAT+ donors, with women and Asian patients being significantly less likely to receive these transplants.
Collapse
Affiliation(s)
- Helen A Hannan
- University of Michigan College of Literature, Science, and the Arts, Ann Arbor, Michigan
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida.
| |
Collapse
|
3
|
Kadosh BS, Birs AS, Flattery E, Stachel M, Hong KN, Xia Y, Gidea C, Aslam S, Razzouk L, Saraon T, Goldberg R, Rao S, Pretorius V, Moazami N, Smith DE, Adler ED, Reyentovich A. Cardiac allograft vasculopathy in heart transplant recipients from hepatitis C viremic donors. Clin Transplant 2024; 38:e15294. [PMID: 38545881 DOI: 10.1111/ctr.15294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 02/19/2024] [Accepted: 03/08/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non-HCV infected donors (NAT-). METHODS We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease. RESULTS Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT- group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45-1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58-1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS. CONCLUSION Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short-term safety of this strategy to maximize the pool of available donor hearts.
Collapse
Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Antoinette S Birs
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Erin Flattery
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Maxine Stachel
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Kimberly N Hong
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Yuhe Xia
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Claudia Gidea
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Saima Aslam
- Division of Infectious Disease, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Louai Razzouk
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Tajinderpal Saraon
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Randal Goldberg
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Shaline Rao
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Victor Pretorius
- Department of Cardiothoracic Surgery, University of California San Diego, La Jolla, California, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
4
|
Vanterpool KB, Diallo K, Kim E, Van Pilsum Rasmussen SE, Johnson MA, Predmore Z, Brundage J, Barnaba B, Desai N, Levan ML, Sung HC, Kates O, Sugarman J, Durand CM. Patient Perspectives on Solid Organ Transplantation From Donors With Hepatitis C Viremia to Recipients Without Hepatitis C Viremia. Open Forum Infect Dis 2024; 11:ofae015. [PMID: 38434612 PMCID: PMC10906703 DOI: 10.1093/ofid/ofae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/08/2024] [Indexed: 03/05/2024] Open
Abstract
Background Organ transplantation from donors with hepatitis C viremia (HCV) to recipients without HCV (HCV D+/R-) has excellent medical outcomes. Less is known about the psychosocial impact and experiences of HCV D+/R- recipients, particularly outside of clinical trials. Methods We conducted in-depth, semistructured interviews with 24 HCV D+/R- recipients (kidney, n = 8; lung, n = 7; liver, n = 5; heart, n = 3; simultaneous heart and kidney, n = 1) who received transplants outside of clinical trials and were treated for HCV after transplant to assess their experiences and perspectives. We used thematic analysis to analyze the interviews. Results Interviewees' reasons for accepting an HCV D + organ were based on perceived benefits and confidence in the effectiveness of HCV treatment. The majority (62%) received HCV treatment within 1 month after transplant (range, 1 day-2 months). Most interviewees reported positive transplant outcomes, including reduced wait times and improved survival, health, physical activity, and quality of life. Overall, themes and experiences did not differ significantly between different organ transplant types. Generally, interviewees did not perceive stigma from those aware of the HCV D+ transplant; yet, disclosure was selective and a few recipients reported concerns from family members about posttransplant HCV transmission risk. Other common concerns included treatment costs and delays, which were not always anticipated by recipients. Conclusions Our findings suggest that HCV D+/R- kidney, liver, and heart and lung transplant recipients outside of clinical trials had overall positive experiences. However, HCV transmission risk, treatments costs, and treatment delays were a source of concern that might be mitigated with targeted pretransplant education.
Collapse
Affiliation(s)
- Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Kadiatou Diallo
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellie Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Morgan A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zachary Predmore
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Janetta Brundage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj Desai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Hannah C Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivia Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Jeremy Sugarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
5
|
Nunez M, Kelkar AA. Hepatitis C and heart transplantation: An update. Clin Transplant 2023; 37:e15111. [PMID: 37650430 DOI: 10.1111/ctr.15111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
There are limited data regarding heart transplantation in the setting of hepatitis C virus (HCV) infection in either recipients or donors, as the practice was infrequent, given concerns of worse post-transplant outcomes. This changed dramatically after the development of highly effective HCV therapies, namely direct-acting antivirals (DAAs). Additionally, nucleic acid testing currently in use establishes more precisely the risk of HCV transmission from donors. As a result, chronic HCV infection in itself is no longer a barrier for heart transplant candidates, and the use of HCV-positive organs for HCV-infected and non-infected transplant candidates has increased dramatically. A review of the literature revealed that in the pre-DAA era, HCV seropositive heart transplant patients had a higher mortality than their seronegative counterparts. However, short-term data suggest that the differences in survival have been erased in the DAA era. Heart transplantation from HCV-viremic donors to HCV-uninfected recipients has become increasingly common as the number of deceased donors with HCV viremia has increased over the past years. Preliminary outcome reports are very encouraging, although further data are needed with regard to long-term safety. New information continues to be incorporated to optimize protocols that guide this practice.
Collapse
Affiliation(s)
- Marina Nunez
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, North Carolina, USA
| | - Anita A Kelkar
- U.S. Department of Veterans Affairs, Kernersville VA Health Care System, Kernesville, North Carolina, USA
| |
Collapse
|
6
|
Torres-Díaz JA, Jasso-Baltazar EA, Toapanta-Yanchapaxi L, Aguirre-Valadez J, Martínez-Matínez L, Sánchez-Cedillo A, Aguirre-Villarreal D, García-Juárez I. Hepatitis C virus-positive donors in HCV-negative recipients in liver transplantation: Is it possible in Mexico? REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:392-403. [PMID: 38097433 DOI: 10.1016/j.rgmxen.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 01/01/2024]
Abstract
Hepatitis C virus (HCV) infection is a worldwide public health problem associated with significant morbidity and mortality. In the context of liver transplantation, the demand for organs continues to exceed the supply, prompting the consideration of using organs from HCV-positive donors in HCV-negative recipients. The introduction of direct-acting antivirals (DAAs), which have demonstrated great efficacy in eradicating the virus, has made transplantation of organs from donors with HCV infection possible. The present article provides a brief review of the current evidence on the use of organs from HCV-infected patients.
Collapse
Affiliation(s)
- J A Torres-Díaz
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E A Jasso-Baltazar
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L Toapanta-Yanchapaxi
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Departamento de Gastroenterología, Hospital Ángeles Pedregal, Mexico City, Mexico
| | - J Aguirre-Valadez
- Departamento de Gastroenterología, Hospital Ángeles Pedregal, Mexico City, Mexico
| | - L Martínez-Matínez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - A Sánchez-Cedillo
- Departamento de trasplante, Hospital General de México, Mexico City, Mexico
| | - D Aguirre-Villarreal
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I García-Juárez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| |
Collapse
|
7
|
Salas J, Storm K, Durand CM. Organ Donors with Human Immunodeficiency Virus and Hepatitis C Virus: Expanding the Donor Pool. Infect Dis Clin North Am 2023:S0891-5520(23)00039-9. [PMID: 37258326 DOI: 10.1016/j.idc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Using organs from donors with treatable infections is a strategy to increase the quality and number of organs for transplantation. For HIV, pilot studies of kidney and liver transplantation from donors with HIV to recipients with HIV demonstrate excellent early outcomes. However, the number of donors and transplants per year remains lower than projected due to several barriers. For HCV, the use of organs from donors with HCV has expanded to recipients without HCV due to safe, effective direct-acting antivirals for HCV, which are well-tolerated in transplant recipients. Studies across organ types demonstrate good outcomes and shorter wait times.
Collapse
Affiliation(s)
- Jordan Salas
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA; Department of Medicine, Oregon Health & Science University School of Medicine, 3181 Southwest Sam Jackson Park Road, Portland, OR, USA
| | - Kaitlyn Storm
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA.
| |
Collapse
|
8
|
Kwon JH, Hill MA, Patel R, Tedford RJ, Hashmi ZA, Shorbaji K, Huckaby LV, Welch BA, Kilic A. Outcomes of Over 1000 Heart Transplants Using Hepatitis C-Positive Donors in the Modern Era. Ann Thorac Surg 2023; 115:493-500. [PMID: 36368348 DOI: 10.1016/j.athoracsur.2022.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/10/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Advances in hepatitis C virus (HCV) treatment and the ongoing opioid epidemic have made HCV-positive donors increasingly available for heart transplantation (HT). This analysis reports outcomes of over 1000 HCV-positive HTs in the United States in the modern era. METHODS The United Network of Organ Sharing registry was used to identify HTs between 2015 and 2021. Recipients were grouped by donor HCV status and by nucleic acid amplification test (NAT) positivity. The primary outcome was 1-year mortality, and secondary outcomes included 3-year mortality. A subanalysis compared HCV-positive HT outcomes between NAT-positive and NAT-negative donors. Risk adjustment was performed using Cox regression. Kaplan-Meier analysis was used to estimate survival. RESULTS The frequency of HCV-positive HT increased from 0.12% of HTs in 2015 to 12.9% in 2021 (P < .001). Of 16,648 HTs, 1170 (7.0%) used an organ from an HCV-positive donor. Recipients of HCV-positive organs were more likely to be HCV seropositive, older, and White. Unadjusted 1- and 3-year survival rates were not significantly different between recipients of HCV-negative and HCV-positive organs. After risk adjustment HCV-positive donor status was not associated with an elevated risk for 1-year (hazard ratio, 0.92; 95% CI, 0.71-1.19; P = .518) or 3-year mortality. Among HCV-positive HTs 772 (61.7%) were NAT positive. After risk adjustment NAT positivity did not impact 1-year mortality. CONCLUSIONS The proportion of HCV-positive HTs has increased over 100-fold in recent years. This analysis of the US experience demonstrates that recipients of HCV-positive hearts, including those that are NAT positive, have acceptable outcomes with similar early to midterm survival as recipients of HCV-negative organs.
Collapse
Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Morgan A Hill
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Raj Patel
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan J Tedford
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
| |
Collapse
|
9
|
Copeland H, Knezevic I, Baran DA, Rao V, Pham M, Gustafsson F, Pinney S, Lima B, Masetti M, Ciarka A, Rajagopalan N, Torres A, Hsich E, Patel JK, Goldraich LA, Colvin M, Segovia J, Ross H, Ginwalla M, Sharif-Kashani B, Farr MA, Potena L, Kobashigawa J, Crespo-Leiro MG, Altman N, Wagner F, Cook J, Stosor V, Grossi PA, Khush K, Yagdi T, Restaino S, Tsui S, Absi D, Sokos G, Zuckermann A, Wayda B, Felius J, Hall SA. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant 2023; 42:7-29. [PMID: 36357275 PMCID: PMC10284152 DOI: 10.1016/j.healun.2022.08.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023] Open
Abstract
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.
Collapse
Affiliation(s)
- Hannah Copeland
- Department of Cardiovascular and Thoracic Surgery Lutheran Hospital, Fort Wayne, Indiana; Indiana University School of Medicine-Fort Wayne, Fort Wayne, Indiana.
| | - Ivan Knezevic
- Transplantation Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David A Baran
- Department of Medicine, Division of Cardiology, Sentara Heart Hospital, Norfolk, Virginia
| | - Vivek Rao
- Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Pham
- Sutter Health California Pacific Medical Center, San Francisco, California
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois
| | - Brian Lima
- Medical City Heart Hospital, Dallas, Texas
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, Katholieke Universiteit Leuven, Leuven, Belgium; Institute of Civilisation Diseases and Regenerative Medicine, University of Information Technology and Management, Rzeszow, Poland
| | | | - Adriana Torres
- Los Cobos Medical Center, Universidad El Bosque, Bogota, Colombia
| | | | | | | | | | - Javier Segovia
- Cardiology Department, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Heather Ross
- University of Toronto, Toronto, Ontario, Canada; Sutter Health California Pacific Medical Center, San Francisco, California
| | - Mahazarin Ginwalla
- Cardiovascular Division, Palo Alto Medical Foundation/Sutter Health, Burlingame, California
| | - Babak Sharif-Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MaryJane A Farr
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luciano Potena
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | | | | | | | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - Susan Restaino
- Division of Cardiology Columbia University, New York, New York; New York Presbyterian Hospital, New York, New York
| | - Steven Tsui
- Department of Cardiothoracic Surgery Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Daniel Absi
- Department of Cardiothoracic and Transplant Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina
| | - George Sokos
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Brian Wayda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joost Felius
- Baylor Scott & White Research Institute, Dallas, Texas; Texas A&M University Health Science Center, Dallas, Texas
| | - Shelley A Hall
- Texas A&M University Health Science Center, Dallas, Texas; Division of Transplant Cardiology, Mechanical Circulatory Support and Advanced Heart Failure, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
10
|
Patel P, Patel N, Ahmed F, Gluck J. Review of heart transplantation from hepatitis C-positive donors. World J Transplant 2022; 12:394-404. [PMID: 36570408 PMCID: PMC9782687 DOI: 10.5500/wjt.v12.i12.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/03/2022] [Accepted: 11/23/2022] [Indexed: 12/16/2022] Open
Abstract
Significant scarcity of a donor pool exists for heart transplantation (HT) as the prevalence of patients with end-stage refractory heart failure is increasing exceptionally. With the discovery of effective direct-acting antiviral and favorable short-term outcomes following HT, the hearts from hepatitis C virus (HCV) patient are being utilized to increase the donor pool. Short-term outcomes with regards to graft function, coronary artery vasculopathy, and kidney and liver disease is comparable in HCV-negative recipients undergoing HT from HCV-positive donors compared to HCV-negative donors. A significant high incidence of donor-derived HCV transmission was observed with great success of achieving sustained viral response with the use of direct-acting antivirals. By accepting HCV-positive organs, the donor pool has expanded with younger donors, a shorter waitlist time, and a reduction in waitlist mortality. However, the long-term outcomes and impact of specific HCV genotypes remains to be seen. We reviewed the current literature on HT from HCV-positive donors.
Collapse
Affiliation(s)
- Palak Patel
- Department of Cardiology, West Roxbury VA Center, West Roxbury, MA 02132, United States
| | - Nirav Patel
- Department of Cardiology, University of Connecticut, Harford Hospital, Hartford, CT 06102, United States
- Department of Cardiology, University of California, CA 90065, United States
| | - Fahad Ahmed
- Department of Internal Medicine, Hartford Hospital, Hartford, CT 06106, United States
| | - Jason Gluck
- Advanced Heart Failure, Hartford Hospital, Hartford, CT 06102, United States
| |
Collapse
|
11
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
12
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
13
|
Lushniak SA, Durand CM. Donors with human immunodeficiency virus and hepatitis C virus for solid organ transplantation: what's new. Curr Opin Infect Dis 2022; 35:321-329. [PMID: 35849522 PMCID: PMC9718437 DOI: 10.1097/qco.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF THE REVIEW Passage of the HOPE Act and the advent of direct-acting antiviral (DAA) therapies have allowed for expansion of the donor organ pool to include donors with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), thus providing new opportunities for waitlist candidates. This article provides updates on recent studies in solid organ transplantation (SOT) utilizing donors with HIV and HCV. RECENT FINDINGS The first pilot studies of kidney and liver transplantation from donors-with-HIV to recipients-with-HIV (HIV D+/R+) show robust patient survival, comparable graft survival to transplantation from donors without HIV (HIV D-/R+) and no increased rates of HIV breakthrough. The number of HIV D+ organs utilized has been lower than initial estimates due to several potential factors. With high numbers of overdose deaths from the opioid epidemic, there have been more HCV D+ organs available, leading to transplantation in recipients without HCV (HCV D+/R-) in combination with DAAs. Outcomes in both abdominal and thoracic HCV D+/R transplantation are excellent. SUMMARY With recent findings of good outcomes in both HIV D+/R+ and HCV D+/R- SOT, we feel the evidence supports both practices as standard clinical care options to mitigate organ shortage and reduce waitlist mortality.
Collapse
Affiliation(s)
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
14
|
Czarnecka P, Czarnecka K, Tronina O, Baczkowska T, Durlik M. Utilization of HCV viremic donors in kidney transplantation: a chance or a threat? Ren Fail 2022; 44:434-449. [PMID: 35260039 PMCID: PMC8920354 DOI: 10.1080/0886022x.2022.2047069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Kidney transplantation is the treatment of choice in end-stage renal disease. The main issue which does not allow to utilize it fully is the number of organs available for transplant. Introduction of highly effective oral direct-acting antivirals (DAAs) to the treatment of chronic hepatitis C virus infection (HCV) enabled transplantation of HCV viremic organs to naive recipients. Despite an increasing number of reports on the satisfying effects of using HCV viremic organs, including kidneys, they are more often rejected than those from HCV negative donors. The main reason is the presence of HCV viremia and not the quality of the organ. The current state of knowledge points to the fact that a kidney transplant from an HCV nucleic acid testing positive (NAT+) donor to naive recipients is an effective and safe solution to the problem of the insufficient number of organs available for transplantation. It does not, however, allow to draw conclusions as to the long-term consequence of such an approach. This review analyzes the possibilities and limitations of the usage of HCV NAT + donor organs. Abbreviations: DAA: direct-acting antivirals; HCV: hepatitis C virus; NAT: nucleic acid testing; OPTN: Organ Procurement and Transplantation Network; KDIGO: Kidney Disease: Improving Global Outcomes; Ab: antigen; eGFR: estimated glomerular filtration rate; D: donor; R: recipient; CMV: cytomegalovirus; HBV: hepatitis B virus; UNOS: United Network for Organ Sharing; PHS: Public Health Service; EBR/GZR: elbasvir/grazoprevir; SVR: sustained virologic response; RAS: resistance-associated substitutions; SOF: soforbuvir; GLE/PIB: glecaprevir/pibrentasvir; ACR: acute cellular rejection; AR: acute rejection; DSA: donor-specific antibodies; KTR: kidney transplant recipients; AASLD: American Association for the Study of Liver Disease; IDSA: Infectious Diseases Society of America; PPI: proton pump inhibitors; CKD: chronic kidney disease; GN: glomerulonephritis; KAS: The Kidney Allocation system.
Collapse
Affiliation(s)
- Paulina Czarnecka
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Kinga Czarnecka
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Olga Tronina
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Teresa Baczkowska
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
15
|
Sise ME, Goldberg DS, Schaubel DE, Fontana RJ, Kort JJ, Alloway RR, Durand CM, Blumberg EA, Woodle ES, Sherman KE, Brown RS, Friedewald JJ, Desai NM, Sultan ST, Levitsky J, Lee MD, Strohbehn IA, Landis JR, Fernando M, Gustafson JL, Chung RT, Reese PP. One-Year Outcomes of the Multi-Center StudY to Transplant Hepatitis C-InfeCted kidneys (MYTHIC) Trial. Kidney Int Rep 2022; 7:241-250. [PMID: 35155863 PMCID: PMC8820987 DOI: 10.1016/j.ekir.2021.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Transplanting kidneys from hepatitis C virus (HCV) viremic donors into HCV-negative patients (HCV D-RNA-positive/R-negative) has evolved from experimental to “standard-of-care” at many centers. Nevertheless, most data derive from single centers and provide only short-term follow-up. Methods The Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC) study was a multicenter (7 sites) trial of HCV D-RNA-positive/R-negative kidney transplantation (KT) followed by 8 weeks of glecaprevir/pibrentasvir (G/P) initiated 2 to 5 days post-KT. Prespecified outcomes included probability of KT (vs. matched waitlist comparators) and 1-year safety outcomes, allograft function, and survival. Results Among 63 enrolled patients, 1-year cumulative incidence of KT was approximately 3.5-fold greater for the MYTHIC cohort versus 2055 matched United Network for Organ Sharing (UNOS) comparators who did not opt-in to receive a kidney from an HCV-viremic donor (68% vs. 19%, P < 0.0001). Of 30 HCV D-RNA-positive/R-negative KT recipients, all achieved HCV cure. None developed clinically significant liver disease or HCV-related kidney injury. Furthermore, 1-year survival was 93% and 1-year graft function was excellent (median creatinine 1.17; interquartile range [IQR]: 1.02–1.38 mg/dl). There were 4 cases of cytomegalovirus (CMV) disease among 10 CMV-negative patients transplanted with a kidney from an HCV-viremic/CMV-positive donor. Conclusion The 1-year findings from this multicenter trial suggest that opting-in for HCV-viremic KT offers can increase probability of KT with excellent 1-year outcomes. Trial Registration: NCT03781726
Collapse
|
16
|
Transplantation of Organs from Hepatitis C Virus-Positive Donors under Direct-Acting Antiviral Regimens. J Clin Med 2022; 11:jcm11030770. [PMID: 35160222 PMCID: PMC8836390 DOI: 10.3390/jcm11030770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/28/2021] [Accepted: 01/27/2022] [Indexed: 01/27/2023] Open
Abstract
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.
Collapse
|
17
|
Ushiro-Lumb I, Thorburn D. Risk of Transmission of Infections to Others After Donor-Derived Infection Transmissions. Transpl Infect Dis 2022; 24:e13791. [PMID: 35023237 DOI: 10.1111/tid.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ines Ushiro-Lumb
- National Health Service Blood and Transplant, Organ and Tissue Donation and Transplantation, London, UK
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, Royal Free NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
Wayda B, Sandhu AT, Parizo J, Teuteberg JJ, Khush KK. Cost-effectiveness and system-wide impact of using Hepatitis C-viremic donors for heart transplant. J Heart Lung Transplant 2022; 41:37-47. [PMID: 34635381 PMCID: PMC8973316 DOI: 10.1016/j.healun.2021.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The advent of direct-acting antiviral therapy for Hepatitis C (HCV) has made using HCV-viremic donors a viable strategy to address the donor shortage in heart transplantation. We employed a large-scale simulation to evaluate the impact and cost-effectiveness of using HCV-viremic donors for heart transplant. METHODS We simulated detailed histories from time of listing until death for the real-world cohort of all adults listed for heart transplant in the United States from July 2014 to June 2019 (n = 19,346). This population was imputed using historical data and captures "real-world" heterogeneity in geographic and clinical characteristics. We estimated the impact of an intervention in which all candidates accept HCV+ potential donors (n = 472) on transplant volume, waitlist outcomes, and lifetime costs and quality-adjusted life years (QALYs). RESULTS The intervention produced 232 more transplants, 132 fewer delistings due to deterioration, and 50 fewer waitlist deaths within this 5-year cohort and reduced wait times by 3% to 11% (varying by priority status). The intervention was cost-effective, adding an average of 0.08 QALYs per patient at a cost of $124 million ($81,892 per QALY). DAA therapy and HCV care combined account for 11% this cost, with the remainder due to higher costs of transplant procedures and routine post-transplant care. The impact on transplant volume varied by blood type and region and was correlated with donor-to-candidate ratio (ρ = 0.71). CONCLUSIONS Transplanting HCV+ donor hearts is likely to be cost-effective and improve waitlist outcomes, particularly in regions and subgroups experiencing high donor scarcity.
Collapse
Affiliation(s)
- Brian Wayda
- Division of Cardiology; Stanford Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Alexander T Sandhu
- Division of Cardiology; Stanford Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Justin Parizo
- Division of Cardiology; Stanford Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jeffrey J Teuteberg
- Division of Cardiology; Stanford Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Division of Cardiology; Stanford Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
19
|
Clinical outcomes of heart transplantation using hepatitis c-viremic donors: a systematic review with meta-analysis. J Heart Lung Transplant 2022; 41:538-549. [DOI: 10.1016/j.healun.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 11/18/2022] Open
|
20
|
Kim M, Stern J, Robalino R, Weldon EP, Ali N, Mehta SA, Stewart ZA, Lonze BE. Caregiver exposure to hepatitis C virus following transplantation with hepatitis C viremic donor organs: A case series. Transpl Infect Dis 2021; 24:e13775. [PMID: 34910839 DOI: 10.1111/tid.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Direct acting antiviral (DAA) therapeutics have ushered in an era in which transplanting organs from donors infected with hepatitis C virus (HCV+) into recipients without (HCV-) is an increasingly common practice. Rare but potentially life-threatening events have been reported in recipients of HCV+ organs. METHODS Since 2018 at our institution, 182 HCV- patients have received HCV+ donor organs. Here, we retrospectively reviewed cases in which recipients' family member caregivers reported sustaining needlestick exposures at home following discharge of the transplant recipient from the hospital. RESULTS Caregiver needlestick exposures were passively reported in three cases of HCV+ into HCV- transplants (1.64% of such cases at our center). In all instances, the exposed individuals were aiding in diabetic management and the exposure occurred via lancets or insulin needles. In one case, the recipient viral load was undetectable at the time of the exposure but in the other two, recipients were viremic, putting their family members at risk to contract HCV infection. Surveillance for the exposed individuals was undertaken and no transmissions occurred. DISCUSSION For centers performing HCV+ into HCV- transplants, it is important that informed consent includes discussion of potential secondary risks to family members and caregivers. Further, protocols for post-exposure surveillance and for the acquisition of DAA treatment in the event of a secondary transmission should be in place. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Michelle Kim
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Jeffrey Stern
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Ryan Robalino
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Elaina P Weldon
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - NicoleM Ali
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Sapna A Mehta
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Zoe A Stewart
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Bonnie E Lonze
- Transplant Institute, New York University Langone Health, New York, NY, USA
| |
Collapse
|
21
|
Huckaby LV, Seese LM, Handzel R, Wang Y, Hickey G, Kilic A. Center-level Utilization of Hepatitis C Virus-positive Donors for Orthotopic Heart Transplantation. Transplantation 2021; 105:2639-2645. [PMID: 33988340 PMCID: PMC9015733 DOI: 10.1097/tp.0000000000003674] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of hepatitis C virus-positive (HCV+) donors has expanded the donor pool for orthotopic heart transplantation (OHT). This study evaluated center-level trends and utilization of HCV+ donors for OHT. METHODS Data were extracted from the Scientific Registry of Transplant Recipients on adults (≥18 y) undergoing OHT between January 1, 2016 and December 31, 2019. Centers performing <10 OHTs during the study period were excluded. Donor utilization rates were evaluated at the center level. Center-level characteristics were compared between centers performing HCV+ donor hepatitis C virus-negative (HCV-) recipient OHTs and those not utilizing HCV+ donors for HCV- recipients. RESULTS A total of 10 134 patients underwent OHT, including 613 (6.05%) HCV+ donors transplanted into HCV- recipients. The number of HCV+ OHTs increased from 15 of 2512 (0.60%) in 2016 to 285 of 2490 (11.45%) in 2019 (P < 0.001). In 2016, among 105 centers performing OHTs, 7 (6.67%) utilized HCV+ donors compared to 2019 during which 55 (52.89%) of 104 centers utilized HCV+ donors (P < 0.001). In total, 57 of 107 (53.27%) centers utilized HCV+ donors during the study period. Centers utilizing HCV+ donors had higher overall donor utilization rates (7376/24 378 [30.26%] versus 3463/15 335 [22.58%], P < 0.001) and were higher volume as compared to nonutilizing centers (mean annual OHT volume 30.72 ± 1.21 versus 16.2 ± 1.40, P < 0.001). CONCLUSIONS Although the use of HCV+ donors for OHT is rapidly expanding in the United States, almost half of transplant centers remain nonutilizers. Broader education and implementation of HCV+ donor protocols may be important in expanding OHT to more patients with end-stage heart failure.
Collapse
Affiliation(s)
- Lauren V. Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Laura M. Seese
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert Handzel
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gavin Hickey
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
22
|
Siddiqi HK, Schlendorf KH. Hepatitis C Positive Organ Donation in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2021; 8:359-367. [PMID: 34786324 PMCID: PMC8579730 DOI: 10.1007/s40472-021-00350-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 01/05/2023]
Abstract
Purpose of Review To summarize outcomes to date, as well as important considerations and unanswered questions related to the use of hepatitis C virus (HCV) positive donors for heart transplantation. Recent Findings Outcomes from single-center studies and registry data to date suggest that among patients who develop donor-transmitted HCV after heart transplantation, direct-acting antiviral therapies (DAAT) are effective and well-tolerated, and that short-term survival is similar to that of patients transplanted with HCV - donors. Summary In an era marked by increasing numbers of HCV positive deceased donors and a growing imbalance between the demand and supply of donor hearts, utilization of HCV + donors is a feasible strategy to expand the donor pool and reduce waitlist times. Ongoing work is needed to clarify longer-term outcomes with the use of this strategy.
Collapse
Affiliation(s)
- Hasan K Siddiqi
- Division of Cardiology, Vanderbilt University Medical Center, 1215 21, St Avenue South, Suite 5307, Nashville, TN 37232 USA
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, 1215 21, St Avenue South, Suite 5307, Nashville, TN 37232 USA
| |
Collapse
|
23
|
Edmonds C, Carver A, DeClercq J, Choi L, Peter M, Schlendorf K, Perri R, Forbes RC, Concepcion BP. Access to hepatitis C direct-acting antiviral therapy in hepatitis C-positive donor to hepatitis C-negative recipient solid-organ transplantation in a real-world setting. Am J Surg 2021; 223:975-982. [PMID: 34548142 DOI: 10.1016/j.amjsurg.2021.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Emerging data supports expanding the solid organ donor pool with transplantation from hepatitis C virus (HCV)-positive donors into HCV-negative recipients. However, concerns exist regarding the ability to access direct-acting antivirals (DAAs) post-transplant in a real-world setting. METHODS This single-center, retrospective study evaluated DAA access rates, time to first dose, and patient cost in donor-derived HCV solid-organ transplant recipients utilizing an integrated specialty pharmacy process. RESULTS Among 91 patients, all accessed DAAs through prescription insurance (97%) or patient assistance programs (3%). Of those who received DAAs through insurance, only 65% received approval on initial insurance submission. Median time from transplant to first dose was 45d [IQR 34-66]. The on-site specialty pharmacy was used by 69% of patients. Copay assistance programs reduced the median monthly patient cost from $1914 [range $7-7536] to $0 [range $0-5]. CONCLUSION Our findings indicate that access to DAAs in donor-derived HCV post-transplant is achievable and affordable; however, significant added administrative efforts may be required for insurance approval as well as obtaining copay assistance, which is a limited resource.
Collapse
Affiliation(s)
- Cori Edmonds
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Alicia Carver
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Megan Peter
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kelly Schlendorf
- Section of Heart Failure and Cardiac Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Roman Perri
- Department of Medicine, Division of Hepatology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
24
|
Kidney Transplantation From Hepatitis C Viremic Deceased Donors to Aviremic Recipients in a Real-world Setting. Transplant Direct 2021; 7:e761. [PMID: 34514116 PMCID: PMC8425827 DOI: 10.1097/txd.0000000000001217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background. Transplantation of hepatitis C viremic (HCV+) deceased donor kidney transplants (DDKT) into aviremic (HCV–) recipients is a strategy to increase organ utilization. However, there are concerns around inferior recipient outcomes due to delayed initiation of direct-acting antiviral (DAA) therapy and sustained HCV replication when implemented outside of a research setting. Methods. This was a retrospective single-center matched cohort study of DDKT recipients of HCV+ donors (cases) who were matched 1:1 to recipients of HCV– donors (comparators) by age, gender, race, presence of diabetes, kidney donor profile index, and calculated panel-reactive antibody. Data were analyzed using summary statistics, t-tests, and chi-square tests for between-group comparisons, and linear mixed-effects models for longitudinal data. Results. Each group consisted of 50 recipients with no significant differences in baseline characteristics. The 6-mo longitudinal trajectory of serum creatinine and estimated glomerular filtration rate did not differ between groups. All recipients had similar rates of acute rejection and readmissions (all P > 0.05). One case lost the allograft 151 d posttransplant because of acute rejection, and 1 comparator died on postoperative day 7 from cardiac arrest. HCV+ recipients initiated DAA on average 29 ± 11 d posttransplant. Ninety-eight percent achieved sustained virologic response at 4 and 12 wks with the first course of therapy; 1 patient had persistent HCV infection and was cured with a second course of DAA. Conclusions. Aviremic recipients of HCV+ DDKT with delayed DAA initiation posttransplant had similar short-term outcomes compared with matched recipient comparators of HCV– donors.
Collapse
|
25
|
Raasikh T, Jamali T, Flores A, Cotton RT, Ramanathan V, Tan HP, Hernaez R. Systematic review: hepatitis C viraemic allografts to hepatitis C-negative recipients in solid organ transplantation. Aliment Pharmacol Ther 2021; 54:571-582. [PMID: 34265111 DOI: 10.1111/apt.16508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/14/2021] [Accepted: 06/16/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Given the success of direct-acting antivirals (DAAs) in treating hepatitis C (HCV), interest is growing in utilizing solid organs from allografts with active HCV to expand donor availability. AIM To review post-transplant outcomes and patient survival in HCV-negative recipients receiving solid organ transplants (SOT) from viraemic, that is, HCV+/NAT+ (nucleic acid testing) allografts. METHODS A literature search was conducted on PubMed and EMBASE from 01/01/2007 to 4/17/2021 for articles matching eligibility criteria. Two authors independently screened titles and abstracts. Disagreements were solved by a third independent reviewer. Methodological quality assessment was done using a modified Newcastle-Ottawa scale (NOS). Data synthesis was done qualitatively using median, ranges and percentages. RESULTS Thirty-five studies were included (or 852 SOTs): 343 kidney, 233 heart, 204 liver, and 72 lung transplants from viraemic allografts. Of the recipients eligible for sustained virological response at 12 weeks (SVR12) calculation, 100% achieved cure from HCV. No deaths/graft failures were reported to be related to HCV transmission. Seven SOT recipients had viral relapse, with all seven patients treated successfully. Four patients developed fibrosing cholestatic hepatitis with complete resolution post-treatment. CONCLUSIONS Transplanting viraemic organs into uninfected individuals can become the standard of care for patients who do not have contraindications to DAAs.
Collapse
Affiliation(s)
- Taaj Raasikh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Taher Jamali
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Avegail Flores
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Venkat Ramanathan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Henkie P Tan
- Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, VA Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| |
Collapse
|
26
|
Altshuler PJ, Helmers MR, Schiazza AR, Hu R, Han JJ, Herbst DA, Iyengar A, Atluri P. HCV-Positive Allograft Use in Heart Transplantation Is Associated With Increased Access to Overdose Donors and Reduced Waitlist Mortality Without Compromising Outcomes. J Card Fail 2021; 28:32-41. [PMID: 34314824 DOI: 10.1016/j.cardfail.2021.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Because of ongoing shortages of donors for heart transplantation, the use of donor candidates whose availabilities are the result of drug overdoses (ODs) has become increasingly prevalent, even though these donors carry a high preponderance of the now curable hepatitis C virus (HCV). This study investigated temporal trends and regional variabilities in HVC-positive (HCV+) allograft use in heart transplantation and assessed the relationship between the use of HCV+ graft donors and the use of OD donors as well as assessing waitlist and post-transplant outcomes. METHODS AND RESULTS A retrospective review of the United Network for Organ Sharing database assessed adults listed for heart transplantation. Patients were stratified both temporally into pre-HCV and HCV eras related to HCV+ graft use trends and regionally by degree of HCV+ allograft use. Regions of high HCV+ donor use were associated with an increase in OD donor access by 7.8% across eras compared to 0.4% in low HCV+ donor-use regions. One-year waitlist mortality decreased from 4.7% to 2.5% across eras in high HCV+ donor-use regions (P= 0.001) and remained roughly the same as before in low HCV+ donor-use regions (3.0% vs 2.4%; P= 0.244.). Post-transplant survival at 1 year remained similar across eras. CONCLUSIONS HCV+ donor allograft use can help to optimize donor use, decreasing waitlist mortality without compromising early survival. Ongoing assessment is essential to ensure long-term safety and efficacy of using HCV+ donors.
Collapse
Affiliation(s)
- Peter J Altshuler
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexis R Schiazza
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robin Hu
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - D Alan Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
27
|
Stewart ZA, Shah SA, Rolls JA, Guarrera JV, Kandaswamy R, Axelrod DA. Best practice recommendations for the use of hepatitis C viremic donor organs for hepatitis C virus naïve recipients. Clin Transplant 2021; 35:e14381. [PMID: 34086371 DOI: 10.1111/ctr.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/22/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
The combination of the transplant organ deficit, the increase in HCV nucleic acid positive donors (HCV NAT+), and the development of direct-acting antiviral agents (DAAs) has resulted in a rapid increase in HCV NAT+ organ transplants into HCV naïve recipients. Early clinical experience with HCV NAT+ donor organs has shown promising outcomes; however, best practices are lacking to guide transplant programs during all phases of patient care. Transplant programs developing protocols for the utilization of HCV NAT+ organs will need a multidisciplinary team to address all aspects of pre-transplant and post-transplant patient care. Reports of fibrosing cholestatic hepatitis in HCV NAT+ organ transplant recipients receiving delayed DAA initiation highlight the need for the transplant community to develop safe and effective protocols. A failure to do so will inevitably lead to the erosion of public trust from cases of missed or inadequately treated donor-derived HCV infections. Herein, we provide best practice guidelines for the utilization of HCV NAT+ organs into HCV-negative recipients based on literature review and expert opinion from the faculty of the ASTS Standards and Quality Committee.
Collapse
Affiliation(s)
- Zoe A Stewart
- Transplant Institute, NYU Langone Health, New York, NY, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason A Rolls
- Division of Transplantation, Christiana Hospital, Newark, DE, USA
| | - James V Guarrera
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Raja Kandaswamy
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
28
|
Altshuler PJ, Helmers MR, Atluri P. Organ allocation and procurement in cardiac transplantation. Curr Opin Organ Transplant 2021; 26:282-289. [PMID: 33938464 DOI: 10.1097/mot.0000000000000872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a critical shortage of organs in cardiac transplantation. Recent advancements in both organ allocation and donor utilization have intended to address this shortage and optimally allocate allografts. This review evaluates several important aspects of recipient and donor management. For recipients, the focus is placed on the evolving mechanical circulatory support population and its bidirectional impact on organ allocation. From the donor standpoint, organ utilization is assessed with respect to increasing access to previously unused allografts. RECENT FINDINGS Implementation of the new heart allocation system in the United States has better stratified waitlist candidates by illness acuity. Compared to the prior system, those requiring venoarterial extracorporeal membrane oxygenation support are less likely to die on the waitlist, although conflicting data exists whether this has improved their posttransplant survival. The use of pretransplant intra-aortic balloon pumps has markedly increased, whereas transplantation of patients with dischargeable left ventricular assist devices has decreased. Although some studies have reported inferior short- to mid-term posttransplant survival in the new system compared to its predecessor, others report similar outcomes.Several recent advancements in donor utilization have also been noted. Coinciding with the global increase in drug overdose deaths, efforts have been made to increase use of these donors who are frequently considered 'increased risk' and are hepatitis C-positive. Grafts from these donors appear safe to use. These, alongside donation after circulatory death donors, represent potentially underutilized populations that may effectively expand the donor pool. SUMMARY Recent changes in organ allocation, alongside efforts to expand the donor pool, have attempted to improve cardiac allograft utilization and reduce the imbalance between organ supply and demand. Ongoing monitoring and continuous re-evaluation of these efforts will help guide future practice.
Collapse
Affiliation(s)
- Peter J Altshuler
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
29
|
Terrault NA, Burton J, Ghobrial M, Verna E, Bayer J, Klein C, Victor D, Mohan S, Trotter J, Dodge J, Niemann CU, Rubin RA. Prospective Multicenter Study of Early Antiviral Therapy in Liver and Kidney Transplant Recipients of HCV-Viremic Donors. Hepatology 2021; 73:2110-2123. [PMID: 32926749 DOI: 10.1002/hep.31551] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Organs from hepatitis C virus (HCV)-viremic donors have been used in HCV-uninfected recipients (D+/R-), but the optimal treatment approach has not been defined. We evaluated the kinetics of HCV infection following transplant in D+/R- kidney-transplant (KT) and liver-transplant (LT) recipients when a preemptive antiviral strategy was used. APPROACH AND RESULTS Six US transplant programs prospectively treated D+/R- primary LT and KT recipients with sofosbuvir-velpastasvir for 12 weeks starting once viremia was confirmed following transplant and the patients were judged to be clinically stable, including estimated glomerular filtration rate >30 mL/min. Primary endpoints were sustained virologic response at 12 weeks following transplant and safety (assessed by proportion of treatment-related adverse and serious adverse events). Of the 24 patients transplanted (13 liver, of whom 2 had prior-treated HCV infection; 11 kidney), 23 became viremic after transplant. The median (interquartile range) time from transplant to start of antiviral therapy was 7.0 (6.0, 12.0) versus 16.5 (9.8, 24.5) days, and the median (interquartile range) HCV-RNA level 3 days after transplant was 6.5 (3.9, 7.1) versus 3.6 (2.9, 4.0) log10 IU/mL in LT versus KT recipients, respectively. By week 4 of treatment, 10 of 13 (77%) LT, but only 2 of 10 (20%) KT, had undetectable HCV RNA (P = 0.01). At the end of treatment, all LT recipients were HCV RNA-undetectable, whereas 3 (30%) of the kidney recipients still had detectable, but not quantifiable, viremia. All achieved sustained virologic response at 12 weeks following transplant (lower 95% confidence interval bound: 85%). Serious adverse events considered possibly related to treatment were antibody-mediated rejection, biliary sclerosis, cardiomyopathy, and graft-versus-host disease, with the latter associated with multiorgan failure, premature treatment discontinuation, and death. CONCLUSIONS Despite differing kinetics of early HCV infection in liver versus non-liver recipients, a preemptive antiviral strategy is effective. Vigilance for adverse immunologic events is warranted.
Collapse
Affiliation(s)
- Norah A Terrault
- Keck Medicine, University of Southern California, Los Angeles, CA
| | - James Burton
- Department of Medicine, University of Colorado, Denver, CO
| | - Mark Ghobrial
- J C Walter Jr Transplant Center, Houston Methodist Hospital, Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX
| | - Elizabeth Verna
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Christina Klein
- Department of Transplantation, Piedmont Transplant Institute, Atlanta, GA
| | - David Victor
- J C Walter Jr Transplant Center, Houston Methodist Hospital, Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - James Trotter
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Jennifer Dodge
- Keck Medicine, University of Southern California, Los Angeles, CA
| | - Claus U Niemann
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Raymond A Rubin
- Department of Transplantation, Piedmont Transplant Institute, Atlanta, GA
| |
Collapse
|
30
|
The use of organs from hepatitis C virus-viremic donors into uninfected recipients. Curr Opin Organ Transplant 2021; 25:620-625. [PMID: 33105203 DOI: 10.1097/mot.0000000000000826] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW There has been an ongoing disparity between the number of organs available for solid organ transplantation (SOT) relative to the need. This has resulted in significant waitlist mortality, may affect transplant outcomes due to transplants being performed on sicker patients and may even increase healthcare costs due to extended hospital stays. Transplanting organs from hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-) is now a reality, due to the advent of highly affective direct-acting antivirals (DAAs) which not only have very high efficacy, but also a favorable side effect and drug-drug interaction profile. RECENT FINDINGS Data from multiple centers reporting outcomes of kidney, liver, heart, lung and liver-kidney transplant during the past few years reveal that SOT from HCV-infected donors into noninfected recipients is safe, efficacious and can result in excellent recipient outcomes, with an opportunity to decrease the time on the waitlist, waitlist mortality and to improve outcomes after transplant due to less morbidity at the time of surgery. When livers are the transplanted organ, 8-12 weeks of DAA treatment will be required. For other organs, 2-4 weeks is likely sufficient. The available DAAs have profiles such that patients with all genotypes, with or without renal insufficiency an on renal replacement therapy and those who fail treatment may be successfully treated, with a sustained virologic response rate of more than 95%. Based upon the available data, starting DAAs shortly after transplant will likely limit posttransplant complications. that This will require cooperation between the transplant team, transplant hospital and insurer providing medication coverage. SUMMARY SOT from HCV infected recipients is safe, is associated with excellent outcomes and should be considered for recipients who would benefit from receiving an organ earlier than they would if they waited for an organ from an uninfected donor.
Collapse
|
31
|
Hepatitis C-Positive Donors in Cardiac Transplantation: Problems and Opportunities. Curr Heart Fail Rep 2021; 17:106-115. [PMID: 32474734 DOI: 10.1007/s11897-020-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C-infected donors as well as the recent advancements that are making the use of these organs possible. RECENT FINDINGS With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.
Collapse
|
32
|
Innovations in liver transplantation in 2020, position of the Belgian Liver Intestine Advisory Committee (BeLIAC). Acta Gastroenterol Belg 2021; 84:347-359. [PMID: 34217187 DOI: 10.51821/84.2.347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) remains the only curative option for patients suffering from end-stage liver disease, acute liver failure and selected hepatocellular carcinomas and access to the LT-waiting list is limited to certain strict indications. However, LT has shown survival advantages for patients in certain indications such as acute alcoholic hepatitis, hepatocellular carcinoma outside Milan criteria and colorectal cancer metastases. These newer indications increase the pressure in an already difficult context of organ shortage. Strategies to increase the transplantable organ pool are therefore needed. We will discuss here the use of HCV positive grafts as the use of normothermic isolated liver perfusion. Belgian Liver Intestine Advisory Committee (BeLIAC) from the Belgian Transplant Society (BTS) aims to guarantee the balance between the new indications and the available resources.
Collapse
|
33
|
Kappus MR, Wolfe CR, Muir AJ. Direct-Acting Antivirals and Organ Transplantation: Is There Anything We Can't Do? J Infect Dis 2021; 222:S794-S801. [PMID: 33245347 DOI: 10.1093/infdis/jiaa420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The opioid epidemic has resulted in an increase in organ donors with hepatitis C virus (HCV) infection in the United States. With the development of direct-acting antiviral regimens that offer high sustained virologic response rates even in the setting of immunosuppression after transplantation, these HCV-viremic organs are now being offered to transplant candidates with or without preexisting HCV infection. Strategies for HCV treatment with HCV-viremic organs have included delayed and preemptive approaches. This review will discuss key studies in the different solid organ transplants, recent reports of adverse events, and ethical and regulatory considerations. The efficacy of current HCV therapies has created this important opportunity to improve survival for patients with end-organ failure through greater access to organ transplantation and decreased waitlist mortality rate.
Collapse
Affiliation(s)
- Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cameron R Wolfe
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
34
|
Weinfurtner K, Reddy KR. Hepatitis C viraemic organs in solid organ transplantation. J Hepatol 2021; 74:716-733. [PMID: 33212088 DOI: 10.1016/j.jhep.2020.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
Although rates of organ donation and solid organ transplantation have been increasing over the last few decades, demand for organs still greatly exceeds supply. Several strategies have been utilised to increase organ supply, including utilisation of high-risk (e.g. HCV antibody-positive) donors. In this context, organs from HCV antibody-positive donors have been used in recipients with chronic HCV since the early 1990s. Recently, transplantation of HCV-viraemic organs into HCV-naïve recipients has garnered significant interest, owing to the development of safe and highly effective direct-acting antivirals and increased experience of treating HCV in the post-transplant setting. Preliminary studies based largely in the US have shown excellent outcomes in kidney, liver, heart, and lung transplantation. This practice has the potential to significantly increase transplantation rates and decrease waitlist mortality; however, intentionally transmitting an infectious disease to recipients has important practical and ethical implications. Further, the generalisability of the US experience to other countries is limited by significant differences in HCV-viraemic donor populations. This review summarises the current data on this practice, discusses barriers to implementation, and highlights areas that warrant further study.
Collapse
Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
35
|
Logan C, Yumul I, Cepeda J, Pretorius V, Adler E, Aslam S, Martin NK. Cost-effectiveness of using hepatitis C viremic hearts for transplantation into HCV-negative recipients. Am J Transplant 2021; 21:657-668. [PMID: 32777173 PMCID: PMC8216294 DOI: 10.1111/ajt.16245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/08/2020] [Accepted: 07/25/2020] [Indexed: 01/25/2023]
Abstract
Outcomes following hepatitis C virus (HCV)-viremic heart transplantation into HCV-negative recipients with HCV treatment are good. We assessed cost-effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV-viremic hearts. Markov model simulated long-term outcomes among HCV-negative patients on the transplant waitlist. We compared costs (2018 USD) and health outcomes (quality-adjusted life-years, QALYs) between cohorts willing to accept any heart and those willing to accept only HCV-negative hearts. We assumed 4.9% HCV-viremic donor prevalence. Patients receiving HCV-viremic hearts were treated, assuming $39 600/treatment with 95% cure. Incremental cost-effectiveness ratios (ICERs) were compared to a $100 000/QALY gained willingness-to-pay threshold. Sensitivity analyses included stratification by blood type or region and potential negative consequences of receipt of HCV-viremic hearts. Compared to accepting only HCV-negative hearts, accepting any heart gained 0.14 life-years and 0.11 QALYs, while increasing costs by $9418/patient. Accepting any heart was cost effective (ICER $85 602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost effective provided posttransplant mortality and costs among those receiving HCV-viremic hearts were not >7% higher compared to HCV-negative hearts. Willingness to accept HCV-viremic hearts for transplantation into HCV-negative recipients is cost effective and improves clinical outcomes.
Collapse
Affiliation(s)
- Cathy Logan
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Ily Yumul
- Division of Cardiology, Department of Medicine, University of Iowa
| | - Javier Cepeda
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Diego
| | - Eric Adler
- Division of Cardiology, Department of Medicine, University of California San Diego
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
- Population Health Sciences, University of Bristol, UK
| |
Collapse
|
36
|
Prakash K, Aslam S. New updates in the world of hepatitis C virus infected organ transplantation. Curr Opin Organ Transplant 2021; 25:364-370. [PMID: 32520787 DOI: 10.1097/mot.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With the advent of direct acting antiviral (DAA) therapy, the use of organs from hepatitis C virus infected (HCV+) donors is gaining more traction. In this review, we aim to: provide an overview of recent literature that supports the use of HCV+ organs, outline ongoing challenges to the use of these organs, and highlight the areas within this field where active investigation is ongoing. RECENT FINDINGS The present review describes clinical outcomes related to the transplantation of both HCV+ nonviremic and viremic organs and the distinction between hepatic and nonhepatic transplants. It also discusses the current debate pertaining to the ideal treatment strategy for donor-derived HCV infection, that is pre-emptive therapy versus prophylaxis therapy. SUMMARY Data suggest that the use of HCV+ organs is an effective and relatively well tolerated strategy to combat the organ scarcity. However, clinicians must be vigilant to a signal of increased inflammation as HCV+ organ transplantation becomes more universal. Recent studies suggest that shorter courses of DAA may sufficiently treat donor-derived HCV infection, however the best treatment approach to minimize risk, cost, and toxicity is still under investigation.
Collapse
Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | | |
Collapse
|
37
|
Abstract
BACKGROUND The effect of hepatitis C virus (HCV) infection in recipients or donors on heart transplants is less known in the current era after the introduction of direct-acting antiviral agents (DAAs) in 2011. METHODS Using the United Network for Organ Sharing registry, 24 871 adult heart transplant recipients between 2005 and 2019 were identified. The trend in prevalence of HCV infected recipients and in utilization of HCV infected donors and their effect on the transplant outcomes were investigated in the past era versus the current era separated by 2011, using Cox proportional hazard regression. RESULTS HCV antibody positive recipients (n=520, 2.1%) had stable prevalence (P=0.18). They had a lower survival estimate when compared to HCV antibody negative recipients in the past era (55.3% versus 70.9% at 7 years; hazard ratio (HR), 1.56; 95% confidence interval (CI), 1.27-1.91; P<0.001), however not in the current era (73.1% versus 71.5% at 7 years; HR, 1.00; 95% CI, 0.75-1.32; P=0.98) (Pinteraction<0.001). Organ use from HCV antibody positive donors (n=371, 1.5%) was concentrated in the recent years (P<0.001) and provided the similar survival estimate up to 2 years (84.2% versus 87.6%; HR, 0.97; 95% CI, 0.65-1.44; P=0.87). The similar findings were confirmed with a subgroup cohort with positive nucleic acid amplification test (NAT). CONCLUSIONS Positive HCV antibody in recipients did not adversely affect the long-term transplant outcomes in the current era. Graft utilization from positive HCV antibody or NAT positive donors are rapidly more prevalent and appeared to be promising up to 2 years posttransplant.
Collapse
|
38
|
Doulamis IP, Tzani A, Moustakidis S, Kampaktsis PN, Briasoulis A. Effect of Hepatitis C donor status on heart transplantation outcomes in the United States. Clin Transplant 2021; 35:e14220. [PMID: 33420730 DOI: 10.1111/ctr.14220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/20/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent studies demonstrated safety and efficacy of heart transplantation (HT) from hepatitis C virus (HCV)-positive donors. We sought to evaluate the impact of HCV donor status on the outcomes of patients undergoing HT in the United States. METHODS We analyzed a retrospective cohort of adult patients from the United Network for Organ Sharing (UNOS) database who underwent isolated HT from 2015 until present. Primary outcomes were 30-day and 1-year overall mortality. Secondary outcomes included risk for graft failure and overall survival, incident stroke and need for dialysis during the available follow-up period. All end points were evaluated according to HCV status. RESULTS All-cause 30-day and 1-year mortality was similar between the two groups (3.4% vs 3.2%, P = .973 and 6.9% vs 7.8%, P = .769, respectively, for patients receiving heart grafts from HCV+ vs. HCV- donors). Graft failure was 12.8% (95% CI: 8%-19%) and 15.2% (95 CI: 15%-16%) in the HCV+ and HCV- groups, respectively (P = .92 and P = .68). Competing risk regression analysis for re-operation showed a non-significant trend for higher risk for re-transplantation in the HCV+ group (HR: 2.71; 95% CI: 0.83, 8.80, P = .097). CONCLUSION HCV donor status does not seem to negatively affect the outcomes of HT in the U.S population.
Collapse
Affiliation(s)
- Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aspasia Tzani
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| |
Collapse
|
39
|
Wang SJ, Huang CF, Yu ML. Elbasvir and grazoprevir for the treatment of hepatitis C. Expert Rev Anti Infect Ther 2021; 19:1071-1081. [PMID: 33428488 DOI: 10.1080/14787210.2021.1874351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Hepatitis C is one of the leading causes of chronic liver disease. The direct-acting-antivirals has revolutionized the chronic hepatitis C treatment. DAAs can achieve a sustained virological response rate >95% in different populations.Area covered: This review summarizes the pharmacokinetics, pharmacodynamics, efficacy, and safety of Elbasvir/Grazoprevir (EBR/GZR).Expert opinion: EBR/GZR is a combination of NS5A and NS3/4A inhibitors. The performance in the EBR/GZR combination's safety and tolerability is appreciated in clinical treatment. EBR/GZR also has a higher barrier to resistance-associated substitutions. Based on clinical trials and real-world experience, elbasvir/grazoprevir is effective in the HCV GT1, 4 infections.
Collapse
Affiliation(s)
- Szu-Jen Wang
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
40
|
Schlendorf KH, Zalawadiya S, Shah AS, Perri R, Wigger M, Brinkley DM, Danter MR, Menachem JN, Punnoose LR, Balsara K, Sacks SB, Ooi H, Awad JA, Sandhaus E, Schwartz C, O'Dell H, Carver AB, Edmonds CL, Ruzevich-Scholl S, Lindenfeld J. Expanding Heart Transplant in the Era of Direct-Acting Antiviral Therapy for Hepatitis C. JAMA Cardiol 2021; 5:167-174. [PMID: 31851352 DOI: 10.1001/jamacardio.2019.4748] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance For patients awaiting heart transplant, hepatitis C-positive donors offer an opportunity to expand the donor pool, shorten wait times, and decrease wait-list mortality. While early reported outcomes among few heart transplant recipients have been promising, knowledge of 1-year outcomes in larger cohorts of patients is critical to shared decision-making with patients about this option. Objective To better define the association of hepatitis C-positive donors with heart transplant volumes, wait-list duration, the transmission and cure of donor-derived hepatitis C, and morbidity and mortality at 1 year. Design, Setting, and Participants This was a prospective, single-center observational study of 80 adult (age 18 years or older) patients who underwent heart transplant using hearts from hepatitis C-positive donors between September 2016 and April 2019 at a large academic medical center. Among donors, who were considered hepatitis C-positive if results from hepatitis C antibody and/or nucleic acid testing were positive, 70 had viremia and 10 were seropositive but did not have viremia. Follow-up was available through May 15, 2019. Comparisons were drawn with patients who underwent transplant with hearts from hepatitis C-negative donors during the same period. Exposures In addition to standard posttransplant management, transplant recipients who developed donor-derived hepatitis C infection were treated with direct-acting antivirals. Main Outcomes and Measures The main outcomes included wait-list duration and 1-year survival in all patients, and for those who developed donor-derived hepatitis C, the response to direct-acting antiviral treatment. Results Of 80 patients, 57 (71.3%) were men, 55 (68.7%) were white, and 17 (26.3%) were black; the median age at transplant was 54.5 years (interquartile range, 46-62 years). Following consent to accept hearts from hepatitis C-exposed donors, the median days to heart transplant was 4 (interquartile range, 1-18). No recipients of donors with negative nucleic acid testing results (10 [12.5%]) developed donor-derived hepatitis C. Of 70 patients who were recipients of donors with positive nucleic acid testing results, 67 (95.7%) developed donor-derived hepatitis C over a median follow-up of 301 days (interquartile range, 142-617). Treatment with direct-acting antivirals was well tolerated and yielded sustained virologic responses in all treated patients. Within the cohort with infection, 1-year patient survival was 90.4%, which was not significantly different compared with the cohort without infection or with patients who received transplants from hepatitis C-negative donors during the same period. Conclusions and Relevance In the era of direct-acting antivirals, hepatitis C-positive donors are a viable option to expand the donor pool, potentially reducing wait-list duration and mortality. In heart transplant recipients with donor-derived hepatitis C, infection is well-tolerated and curable, and 1-year survival is equivalent to that in recipients of hepatitis C-negative donors.
Collapse
Affiliation(s)
| | | | - Ashish S Shah
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roman Perri
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | - Keki Balsara
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Henry Ooi
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph A Awad
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily Sandhaus
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Heather O'Dell
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Cori L Edmonds
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | |
Collapse
|
41
|
Nangia G, Vierling JM, Kwo P, Brown DD, Klopfer SO, Robertson MN, Haber BA, Reddy KR. Safety and tolerability of elbasvir/grazoprevir in chronic hepatitis C virus therapy: Integrated analysis from clinical trials. J Viral Hepat 2020; 27:1222-1233. [PMID: 32594612 DOI: 10.1111/jvh.13357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Direct-acting antiviral treatments for chronic hepatitis C virus (HCV) infection are generally safe; however, understanding the safety profile of each regimen is essential for their continued use. Safety data were pooled from 12 clinical trials of elbasvir/grazoprevir (EBR/GZR) that enrolled adult participants with HCV infection. Pooled analyses are presented for participants receiving EBR/GZR for 12 weeks and those receiving EBR/GZR plus ribavirin (RBV) for 16-18 weeks. Safety data are also presented for participants with comorbidities receiving EBR/GZR for 12 weeks in individual clinical trials (chronic kidney disease [CKD] stage 4/5, inherited blood disorders [IBLD] or receiving opioid agonist therapy [OAT]). Among 1743 participants receiving EBR/GZR for 12 weeks, 1068 (61.3%) reported ≥1 adverse event (AE) and 491 had AEs (28.2%) considered drug-related. The most frequent AEs were headache (10.6%), fatigue (8.7%), nasopharyngitis (5.8%), nausea (5.1%) and diarrhoea (5.0%). Serious AEs were reported by 37 participants (2.1%), and 12 (0.7%) discontinued treatment due to an AE. In populations with CKD 4/5 or IBLD or receiving OAT, safety was similar in participants receiving EBR/GZR for 12 weeks and those receiving placebo. Some AEs occurred at higher frequencies in participants receiving RBV compared with those receiving EBR/GZR alone: fatigue (32.7% vs 8.7%); headache (21.6% vs 10.6%); and nausea (15.8% vs 5.1%). Safety was similar in participants with and those without cirrhosis. Grade 3/4 alanine aminotransferase elevations were reported in 0.7% participants. EBR/GZR is a safe treatment option for individuals with HCV genotype (GT) 1 or GT4 infections, even those with challenging comorbidities such as CKD or IBLD and those receiving OAT.
Collapse
Affiliation(s)
- Gayatri Nangia
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Paul Kwo
- Department of Medicine-Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | | | - K Rajender Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
42
|
Prakash K, Wainana C, Trageser J, Hahn A, Lay C, Pretorius V, Adler E, Aslam S. Local and regional variability in utilization and allocation of hepatitis C virus-infected hearts for transplantation. Am J Transplant 2020; 20:2867-2875. [PMID: 32185860 DOI: 10.1111/ajt.15857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 01/25/2023]
Abstract
With the advent of direct-acting antiviral agents, there has been a rapid rise in hepatitis C virus-infected (HCV+) heart transplantation. We aimed to understand local and regional differences in utilization and allocation of HCV+ hearts. Using United Network for Organ Sharing (UNOS) de-identified data from January 1, 2016 to September 30, 2019 we compared trends in the utilization rates (hearts transplanted/donors recovered) of HCV-uninfected (HCV-) to those of HCV+ nonviremic (HCV-NV) and viremic (HCV-V) hearts nationally and by UNOS region. We also evaluated allocation rates (hearts successfully allocated/donors recovered) by organ procurement organization (OPO). We found that (1) in 2019, national utilization rates for HCV-NV and HCV-V hearts were the same as HCV- hearts (27.6% for HCV-NV, 30.9 for HCV-V, and 31.7% for HCV-, P = .277); (2) utilization rates of HCV-NV hearts were low in regions 3 and 4 and of HCV-V hearts in regions 3, 4, and 8 even in the contemporary period since 2018; and (3) there was marked variability in allocation of HCV+ hearts at the OPO level even within the same UNOS region. We conclude that despite national strides in the utilization of HCV+ hearts for transplantation, more aggressive allocation of HCV+ hearts at the OPO level may still significantly affect the organ shortage.
Collapse
Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases, University of California, San Diego, California, USA
| | | | | | | | - Cecilia Lay
- Clinical Research, University of California, San Diego, California, USA
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, University of California, San Diego, California, USA
| | - Eric Adler
- Division of Cardiology, University of California, San Diego, California, USA
| | - Saima Aslam
- Division of Infectious Diseases, University of California, San Diego, California, USA.,Clinical Research, University of California, San Diego, California, USA
| |
Collapse
|
43
|
Liver and Kidney Recipient Selection of Hepatitis C Virus Viremic Donors: Meeting Consensus Report From the 2019 Controversies in Transplantation. Transplantation 2020; 104:476-481. [PMID: 31634329 DOI: 10.1097/tp.0000000000003014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The development of multiple highly effective and safe direct-acting antivirals to treat hepatitis C virus (HCV) has resulted in greater ease and confidence in managing HCV infection in transplant recipients that in turn has impacted the solid organ transplant community as well. In the United States, the opioid epidemic has increased the number of overdose deaths with a concomitant increase in younger HCV viremic donors after brain death being identified. At the same time, a decrease in HCV viremic transplant candidates has led to a growing interest in exploring the use of HCV viremic liver and kidney donor allografts in HCV-negative recipients. To date, experience with the use of HCV viremic liver and kidney allografts in HCV-negative recipients is limited to a few small prospective research trials, case series, and case reports. There are also limited data on recipient and donor selection for HCV viremic liver and kidney allografts. In response to this rapidly changing landscape in the United States, experts in the field of viral hepatitis and liver and kidney transplantation convened a meeting to review current data on liver and kidney recipient selection and developed consensus opinions related specifically to recipient and donor selection of HCV viremic liver and kidney allografts.
Collapse
|
44
|
Reyentovich A, Gidea CG, Smith D, Lonze B, Kon Z, Fargnoli A, Pavone J, Rao S, Saraon T, Lewis T, Qian Y, Jacobson I, Moazami N. Outcomes of the Treatment with Glecaprevir/Pibrentasvir following heart transplantation utilizing hepatitis C viremic donors. Clin Transplant 2020; 34:e13989. [DOI: 10.1111/ctr.13989] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Alex Reyentovich
- Division of Cardiology Department of Medicine NYU Langone Medical Center New York NY USA
| | - Claudia G. Gidea
- Division of Cardiology Department of Medicine NYU Langone Medical Center New York NY USA
| | - Deane Smith
- Department of Cardiothoracic Surgery NYU Langone Medical Center New York NY USA
| | - Bonnie Lonze
- Department of Renal Transplant Surgery NYU Langone Medical Center New York NY USA
| | - Zachary Kon
- Department of Cardiothoracic Surgery NYU Langone Medical Center New York NY USA
| | - Anthony Fargnoli
- Department of Cardiothoracic Surgery NYU Langone Medical Center New York NY USA
| | - Jennifer Pavone
- Division of Cardiology Department of Medicine NYU Langone Medical Center New York NY USA
| | - Shaline Rao
- Division of Cardiology Department of Medicine NYU Langone Medical Center New York NY USA
| | - Tajinderpal Saraon
- Division of Cardiology Department of Medicine NYU Langone Medical Center New York NY USA
| | - Tyler Lewis
- Department of Pharmacy NYU Langone Medical Center New York NY USA
| | - Yingzhi Qian
- Department of Population Health Biostatistics Division NYU Langone Medical Center New York NY USA
| | - Ira Jacobson
- Department of Gastroenterology NYU Langone Medical Center New York NY USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery NYU Langone Medical Center New York NY USA
| |
Collapse
|
45
|
Lewis TC, Gidea C, Reyentovich A, Angel L, Lesko M, Pavone J, Sureau K, Smith DE, Kon Z, Moazami N. Management and tolerability of glecaprevir-pibrentasvir pharmacotherapy in hepatitis C viremic heart and lung transplant recipients. Clin Transplant 2020; 34:e14030. [PMID: 32632929 DOI: 10.1111/ctr.14030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 12/12/2022]
Abstract
We conducted a retrospective review of thoracic transplant recipients (22 heart and 16 lung transplant recipients) prospectively enrolled in a single-center observational study of HCV NAT+ organ transplantation in HCV NAT- recipients. All recipients were treated with 8 weeks of glecaprevir-pibrentasvir (GP) for HCV viremia in addition to standard triple immunosuppression post-transplant. Thoracic transplant recipients of HCV NAT- organs were used as a control (24 heart and 22 lung transplant recipients). Our primary outcome was to assess the effect of GP on tacrolimus dose requirements. Secondary objectives included assessing drug interactions with common post-transplant medications, adverse effects, and the need to hold or discontinue GP therapy. The median tacrolimus concentration-to-dose ratio (CDR) in the cohort was 184 (99-260) during GP therapy and 154 (78-304) over the first month after GP (P = .79). Trends in median tacrolimus CDR were similar on a per-week basis and per-patient basis. In three instances, concomitant posaconazole and GP led to hyperbilirubinemia and interruption of posaconazole. GP therapy was held in one heart transplant recipient and discontinued in another due to unresolving hyperbilirubinemia. Utilization of GP to treat HCV viremia post-thoracic transplant is feasible and safe, but requires modifications to post-transplant pharmacotherapy and careful monitoring for adverse effects.
Collapse
Affiliation(s)
- Tyler C Lewis
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | - Claudia Gidea
- Department of Cardiology, NYU Langone Health, New York, New York, USA
| | - Alex Reyentovich
- Department of Cardiology, NYU Langone Health, New York, New York, USA
| | - Luis Angel
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Melissa Lesko
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Jennifer Pavone
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Kimberly Sureau
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Zachary Kon
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| |
Collapse
|
46
|
Prakash K, Ramirez-Sanchez C, Ramirez SI, Logan C, Law N, Mekeel K, Pretorius V, Aslam S. Post-transplant survey to assess patient experiences with donor-derived HCV infection. Transpl Infect Dis 2020; 22:e13402. [PMID: 32634289 PMCID: PMC10084045 DOI: 10.1111/tid.13402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/24/2020] [Accepted: 06/29/2020] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Katya Prakash
- Department of Medicine, University of California, San Diego, California, USA
| | | | - Sydney I Ramirez
- Department of Medicine, University of California, San Diego, California, USA
| | - Cathy Logan
- Department of Medicine, University of California, San Diego, California, USA
| | - Nancy Law
- Department of Medicine, University of California, San Diego, California, USA
| | - Kristin Mekeel
- Department of Surgery, University of California, San Diego, California, USA
| | - Victor Pretorius
- Department of Surgery, University of California, San Diego, California, USA
| | - Saima Aslam
- Department of Medicine, University of California, San Diego, California, USA
| |
Collapse
|
47
|
Thuluvath PJ, Bruno DA, Alukal J, Satapathy SK, Thuluvath AJ, Zhang T. Use of HCV-Positive Livers in HCV-Negative Recipients. Am J Gastroenterol 2020; 115:1045-1054. [PMID: 32618655 DOI: 10.14309/ajg.0000000000000583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION There are only limited data on the survival outcomes after transplanting HCV RNA-positive liver into HCV RNA-negative recipients. The objective of our study was to determine whether there were graft and patient survival differences when HCV-negative patients received HCV RNA (nucleic acid amplification testing [NAT] positive)-positive liver grafts. METHODS We queried the United Network for Organ Sharing data sets from January 2014 to December 2018, and recipients (N = 24,724) were stratified into 6 groups based on the status of HCV antibody and RNA of recipients and donors. The Cox proportional hazard regression was used to estimate the relationship between groups and 1-year post-LT graft or patient survival. RESULTS During the study period, 1,358 recipients received NAT-positive liver grafts. Two hundred ten of the recipients were HCV negative. During the same period, 707 HCV antibody-positive but NAT-negative grafts were transplanted into 516 HCV-positive and 191 HCV-negative recipients. There were no differences in survival in HCV-positive recipients whether they received NAT-positive grafts (n = 1,148) or HCV antibody-negative/NAT-negative grafts (n = 6,321). Recipients of grafts from HCV antibody-positive/NAT-negative donors had similar survival whether recipients were HCV-negative patients (n = 191) or HCV-positive patients (n = 516), and their survival probabilities were similar to those of HCV-negative recipients (n = 6,321) receiving grafts from HCV antibody-negative/NAT-negative donors. Patient survival was lower (P = 0.049) when HCV-negative recipients (n = 210) received NAT-positive grafts compared with HCV-positive patients (n = 1,148) receiving NAT-positive grafts; however, when adjusted for recipient and donor characteristics, the difference was not significant. DISCUSSION HCV-negative recipients receiving HCV-positive liver grafts (NAT positive) have excellent 1-year survival outcomes.
Collapse
Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David A Bruno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| | - Sanjaya K Satapathy
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Avesh J Thuluvath
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Talan Zhang
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
48
|
Kapila N, Menon KVN, Al-Khalloufi K, Vanatta JM, Murgas C, Reino D, Ebaid S, Shaw JJ, Agrawal N, Rhazouani S, Navas V, Sheffield C, Rahman AU, Castillo M, Lindenmeyer CC, Miller C, Quintini C, Zervos XB. Hepatitis C Virus NAT-Positive Solid Organ Allografts Transplanted Into Hepatitis C Virus-Negative Recipients: A Real-World Experience. Hepatology 2020; 72:32-41. [PMID: 31659775 DOI: 10.1002/hep.31011] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/22/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Hepatitis C virus (HCV)-viremic organs are underutilized, and there is limited real-world experience on the transplantation of HCV-viremic solid organs into recipients who are HCV negative. APPROACH AND RESULTS Patients listed or being evaluated for solid organ transplant after January 26, 2018, were educated and consented by protocol on the transplantation of HCV-viremic organs. All recipients were HCV nucleic acid test and anti-HCV antibody negative at the time of transplant and received an HCV-viremic organ. The primary outcome was sustained virological response (SVR) at 12 weeks after completion of direct-acting antiviral (DAA) therapy (SVR12 ). Seventy-seven patients who were HCV negative underwent solid organ transplantation from a donor who was HCV viremic. No patients had evidence of advanced hepatic fibrosis. Treatment regimen and duration were at the discretion of the hepatologist. Sixty-four patients underwent kidney transplant (KT), and 58 KT recipients had either started or completed DAA therapy. Forty-one achieved SVR12 , 10 had undetectable viral loads but are not eligible for SVR12 , and 7 remain on treatment. One KT recipient was a nonresponder because of nonstructural protein 5A resistance. Four patients underwent liver transplant and 2 underwent liver-kidney transplant. Three patients achieved SVR12 , 1 has completed DAA therapy, and 2 remain on treatment. Six patients underwent heart transplant and 1 underwent heart-kidney transplant. Six patients achieved SVR12 and 1 patient remains on treatment. CONCLUSIONS Limited data exist on the transplantation of HCV-viremic organs into recipients who are HCV negative. Our study is the largest to describe a real-world experience of the transplantation of HCV-viremic organs into recipients who are aviremic. In carefully selected patients, the use of HCV-viremic grafts in the DAA era appears to be efficacious and well tolerated.
Collapse
Affiliation(s)
- Nikhil Kapila
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL.,Department of Gastroenterology and Hepatology, Duke University, Durham, NC
| | | | | | - Jason M Vanatta
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Carla Murgas
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Diego Reino
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Samer Ebaid
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Joshua J Shaw
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Neerja Agrawal
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Salwa Rhazouani
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Viviana Navas
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | | | - Asad Ur Rahman
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL
| | | | | | - Charles Miller
- Department of Transplant, Cleveland Clinic, Cleveland, OH
| | | | | |
Collapse
|
49
|
Yu ML, Chen PJ, Dai CY, Hu TH, Huang CF, Huang YH, Hung CH, Lin CY, Liu CH, Liu CJ, Peng CY, Lin HC, Kao JH, Chuang WL. 2020 Taiwan consensus statement on the management of hepatitis C: Part (II) special populations. J Formos Med Assoc 2020; 119:1135-1157. [PMID: 32354689 DOI: 10.1016/j.jfma.2020.04.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/05/2020] [Indexed: 12/13/2022] Open
Abstract
Hepatitis C virus (HCV) infection is a silent killer that leads to rapid progression of liver cirrhosis and hepatocellular carcinoma (HCC). High prevalence of HCV infection has been reported in Taiwan, especially in high-risk populations including people who inject drugs (PWID) and patients requiring dialysis. Besides, certain populations merit special considerations due to suboptimal outcome, potential drug-drug interaction, or possible side effect. Therefore, in the second part of this 2-part consensus, the Taiwan Association for the Study of the Liver (TASL) proposes the treatment recommendations for the special population in order to serve as guidance to optimizing the outcome in the direct-acting antiviral (DAA) era. Special populations include patients with acute or recent HCV infection, previous DAA failure, chronic kidney disease, decompensated cirrhosis, HCC, liver and other solid organ transplantations, receiving an HCV viremic organ, hepatitis B virus (HBV) and HCV dual infection, HCV and human immunodeficiency virus (HIV) coinfection, active tuberculosis infection, PWID, bleeding disorders and hemoglobinopathies, children and adolescents, and pregnancy. Moreover, future perspectives regarding the management of hepatitis C are also discussed and summarized in this consensus statement.
Collapse
Affiliation(s)
- Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research and Center for Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Pei-Jer Chen
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research and Center for Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research and Center for Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chao-Hung Hung
- Division of Hepato-Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Yen Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Hua Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Jen Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Yuan Peng
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research and Center for Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
50
|
Jones JM, Kracalik I, Levi ME, Bowman JS, Berger JJ, Bixler D, Buchacz K, Moorman A, Brooks JT, Basavaraju SV. Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020. MMWR Recomm Rep 2020; 69:1-16. [PMID: 32584804 PMCID: PMC7337549 DOI: 10.15585/mmwr.rr6904a1] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.
Collapse
|