Long-term outcomes of heart transplant recipients with hepatitis C positivity: the data from the U.S. transplant registry

The impact of hepatitis B and C positive serologies on the outcomes of non-hepatic solid organ transplantation in the United States

Chronic viral hepatitis B (HBV) and C (HCV) infection could negatively affect outcomes of non-hepatic solid organ transplantations due to the risk of viral reactivation in the presence of immunosuppression. This study aimed to determine post-transplant outcomes in patients with HBV or HCV positivity receiving non-hepatic solid-state organ transplant. Data was collected from the Scientific Registry of Transplant Recipients (SRTR) 2006-2021 for patients (≥18) who received a lung, heart, or kidney single organ transplant in the U.S. Hepatitis C positivity (HCV+) was determined as positive HCV Ab and hepatitis B positivity (HBV+) as positive HBsAg. We included N = 30,872 lung, N = 36,990 heart and N = 280,162 kidney transplant recipients. The prevalence of HBV+ was 1.3% in lung, 1.5% in heart and 1.7% in kidney patients, HCV+ was 2.2%, 2.2% and 5.0%, respectively. Post-transplant survival of patients with vs. without HBV+ was similar in all solid organ transplants (all p > .05). Similarly, there was no difference in post-transplant survival between lung transplant recipients with vs. without anti-HCV (all p > .05). Heart transplant recipients with HCV+ had higher crude post-transplant mortality (all p < .01). Similarly, there was higher post-transplant mortality in kidney transplant recipients with HCV+ (1-year: 6% vs. 3%; 5-year: 21% vs. 13%; 10-year: 47% vs. 31%; all p < .0001). In multivariate analysis controlling for confounders, only the association of HCV+ with higher post-kidney transplant mortality remained significant: adjusted hazard ratio (aHR) (95% CI) = 1.16 (1.12-1.20), p < .0001. There was no association of viral hepatitis seropositivity with the risk of graft failure in all groups (p > .05). In most cases, the presence of HBV or HCV serologies is not associated with adverse post-transplant outcomes in non-hepatic solid organ transplants. However, kidney transplant recipients who are positive for HCV serology have an increased risk for post-transplant mortality.

Hepatitis C and heart transplantation: An update

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.

Approaches and strategies to manage the hepatitis C virus-positive heart donor

PURPOSE OF REVIEW

Cardiac transplantation remains the treatment of choice for patients with advanced heart failure, but is limited by a donor organ shortage. Utilization of hepatitis C virus (HCV)-positive donors has been recently adopted to expand access to heart transplantation. We review the history of HCV heart transplantation, modern drug therapy, and recent outcomes.

RECENT FINDINGS

Since the advent of direct-acting antiviral (DAA) therapy, several single-center studies, and retrospective reviews have demonstrated good short-term outcomes, shorter waitlist times, and clearance of viremia with recipients of HCV-positive hearts. Two principle approaches to treatment of recipients of HCV viremic donors are utilized. In the prophylactic strategy, therapy is initiated before viremia is detected compared with the preemptive approach where initiation of DAA is delayed until after viremia is detected. Future studies are needed to address uncertainty about medium and long-term outcomes of using HCV-positive hearts and to determine the optimal treatment timing and duration.

SUMMARY

Utilization of HCV-positive donors has expanded the heart donor pool and appears safe through the early posttransplant period. We suggest that prophylactic administration of the shortest effective course of a DAA pangenotypic agent should be the current standard of care.

New Approaches to Donor Selection and Preparation in Heart Transplantation

Purpose of review

With increasing survival of patients with stage D heart failure, the demand for heart transplantation has increased. The supply of donor hearts remains relatively limited. Strategies have been investigated and new technologies have been developed to expand the current donor pool. These new approaches will be discussed herein.

Recent findings

Donor hearts are often considered “marginal” due to risk factors such as older age, size mismatch with the intended recipient, prolonged ischemic time, presence of left ventricular hypertrophy, and hepatitis B/C infection. We reviewed recent data regarding the use of donor hearts with these risk factors and suggest ways to safely liberalize current donor heart acceptance criteria. New technologies such as temperature-controlled transport systems and ex vivo cardiac perfusion methods have also demonstrated promising short-term and intermediate outcomes as compared with routine cold storage, by promoting heart preservation and enabling heart procurement from remote sites with shorter cold ischemic time. Recent use of hearts from donation after circulatory death donors has demonstrated comparable outcomes to conventional donation after brain death, which can further expand the current donor pool.

Summary

Careful selection of “marginal” donor hearts, use of ex vivo cardiac perfusion, and acceptance of hearts after circulatory death may expand our current cardiac donor pool with comparable outcomes to conventional donor selection and preparation methods.

Paradigm Shift in Utilization of Livers from Hepatitis C-Viremic Donors into Hepatitis C Virus-Negative Patients

Despite record-breaking numbers of liver transplants (LTs) performed in the United States in each of the last 7 years, many patients remain on the wait list as the demand for LT continues to exceed the supply of available donors. The emergence of highly effective and well-tolerated direct-acting antiviral therapy has transformed the clinical course and management of hepatitis C virus (HCV) in both the pretransplant and posttransplant setting. Historically, donor livers infected with HCV were either transplanted into patients already infected with HCV or discarded.

Effect of Hepatitis C Virus Infection on Heart Transplants in the Current Era

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.

Trends in Renal Function Among Heart Transplant Recipients of Donor-Derived Hepatitis C Virus

Donor-derived hepatitis C (dd-HCV) infection may increase the risk of renal impairment (RI) among heart transplantation (HT) recipients. Sofosbuvir, an integral component of HCV direct-acting antivirals (DAAs) has also been linked to RI. To date, no study has examined the trends in renal function for HT recipients of dd-HCV infection and assessed safety and efficacy of Sofosbuvir-based DAAs. Between September 2016 and June 2018, 46 HCV-naive patients and one patient with a history of HCV treated pretransplant, underwent HT from HCV-positive donors (follow-up available through October 10, 2018). Patients were treated with Ledipasvir-Sofosbuvir (genotype 1) or Sofosbuvir-Velpatasvir (genotype 3) for 12 or 24 weeks; no dose adjustments were made for renal function. Data on renal function were available for 23 patients who achieved a sustained virologic response at 12 weeks after the treatment (SVR12; cohort A) and 18 patients who completed 1 year of follow-up (cohort B). Treatment of dd-HCV infection was initiated at a median of 6 weeks post-HT. In both cohorts, a nonsignificant reduction in median estimated glomerular filtration rate (eGFR; ml/min/1.73 m) was noted (cohort A: pretransplant eGFR: 62 [interquartile range {IQR}: 1-84] to SVR12 eGFR: 49 [IQR: 37-82]; p = 0.43; cohort B: pretransplant eGFR: 65 [IQR: 54-84] to 1 year post-HT eGFR: 56 [IQR: 39-75]; p = 0.29). Pretreatment renal function had no significant impact on changes in renal function during treatment. All patients tolerated DAAs well with 100% completion rate to the assigned therapy and duration and 100% success at achieving SVR12. In this first and largest reported case series to date of HT recipients with dd-HCV infection, we observed that neither the dd-HCV infection nor its treatment with Sofosbuvir-based DAAs increased the risk of RI. Sofosbuvir-based DAAs appear safe, tolerable, and effective for HCV treatment even in presence of severe RI.

Utilization of hepatitis C virus-infected organ donors in cardiothoracic transplantation: An ISHLT expert consensus statement

The advent of therapies for successful treatment of hepatitis C virus has allowed the heart and lung transplant community to re-explore the use of hepatitis C virus-positive donors for organ transplantation, with a benefit for many terminally ill patients. The consensus statements provided herein represent the current state of knowledge and expertise in this area, which we expect will continue to rapidly evolve over the next few years.

Relationship Between Change in Heart Transplant Volume and Outcomes: A National Analysis

INTRODUCTION

Although volume-outcome relationships in transplantation have been well-defined, the effects of large changes in center volume are less well understood. The purpose of the current study was to examine the impact of changes in center volume on outcomes after heart transplantation.

METHODS

Retrospective analysis was performed of adult patients undergoing heart transplant between 2000 and 2017 identified in the United Network for Organ Sharing database. Exclusions included annual volume <10. Patients were grouped according to percentage change in center volume from the previous year. Multivariable Cox regression models were adjusted for the significant preoperative variance identified on univariate analyses.

RESULTS

Of the 29,851 transplants during the study period, 64% were at centers with stable volume (±25% annual change), whereas 10% were performed at contracting (-25% change or more) and 26% were performed at growing (+25% change or more) centers. Average volume was lower with contracting centers compared with stable or growing programs (21 vs 36, P< .001). Thirty-day mortality was greater in decreasing centers (6% vs 4%, P < .001), with more acute rejection treatments at 1y (27% vs 24% P < .001). The adjusted risk of mortality among contracting centers was 1.25 ([1.07-1.46], P= .004), whereas growing centers had unaffected risk (0.90 [0.79-1.02], P= .103). Causes of death were similar between groups.

CONCLUSIONS

Rapid growth of transplant center volume has occurred at select centers in the United States without decrement in programmatic outcomes. Decreasing center volume has been associated with poorer outcomes, although the causative nature of this relationship requires further investigation.

Sofosbuvir-based Interferon-Free Direct Acting Antiviral Regimens for Heart Transplant Recipients With Chronic Hepatitis C Virus Infection

We assessed the effectiveness and safety of sofosbuvir (SOF) combined with ledipasvir (LDV) or daclatasvir (DCV) in 12 heart transplant recipients with chronic hepatitis C virus (HCV). The sustained virologic response (SVR12) rate was 100% [95% confidence interval [CI]: 75.8%-100%]. All patients tolerated treatment well without interruption, death, or serious adverse events.

National Trends In Kidney, Heart And Liver Transplants Among Patients With And Without Chronic Obstructive Pulmonary Disease In Spain (2001-2015)

Background

To describe trends and outcomes during admission for solid organ transplants, excluding lungs, in people with or without COPD in Spain (2001–2015).

Methods

We used national hospital discharge data to select all hospital admissions for kidney, heart and liver transplants. We estimated admission rates stratified by COPD status. We analyzed the Charlson Comorbidity Index, therapeutic procedures and outcomes.

Results

We identified 52,020 admissions (33,293 for kidney transplant, 3,937 for heart transplant and 14,790 for liver transplant). Patients with COPD accounted for 2.5%, 4.2% and 3.5% of kidney, heart and liver transplant patients, respectively. The number of kidney and liver transplants increased among COPD patients over the study period, whereas the number of heart transplants remained stable. In all cases, COPD patients were significantly older and had more coexisting medical conditions than those without COPD. Among patients who underwent a kidney transplant, there were no significant differences in the clinical characteristics analyzed between the groups, but the overall in-hospital mortality (IHM) rate was significantly higher in COPD patients than in those without COPD (2.22% vs 0.58%, p=0.008). There were no differences for any of the study variables or for the IHM rate in patients who underwent a heart transplant (14.63% in both groups). Among patients who underwent a liver transplant, COPD patients had lower prevalences of infection and complications than those without COPD. The IHM rate was also significantly lower in COPD patients than in non-COPD controls who underwent a liver transplant (4.07% vs 8.91%, p=0.002).

Conclusion

COPD prevalence in patients undergoing renal, heart and liver transplants is lower than it has been described in the general population. However, we did not find differences in the clinical characteristics analyzed between COPD and non-COPD patients. Furthermore, the IHM rate was only higher in COPD patients who underwent a kidney transplant but not in those undergoing a heart or liver transplant.

A Downside to Hepatitis C Virus Cure? Vigilance Is Needed Regarding Hepatitis B Virus Reactivation, Organ Rejection, or Hepatocellular Carcinoma Progression

Cure of hepatitis C virus has become feasible in almost all patients. However, vigilance is needed in 3 scenarios: previous exposure to hepatitis B virus (HBV), history of organ transplantation, and history of cured hepatocellular carcinoma (HCC). The current data suggest that HBV reactivation occurs in about 10% of hepatitis B surface antigen (HBsAg)-positive patients and approximately 1% of hepatitis B core antibody-positive but HBsAg-negative patients. The risk of organ rejection is also around 1%, but can be fatal if not acted on immediately. Finally, the risk of early HCC recurrence may be increased but should not delay initiation of antiviral therapy in the setting of cured HCC; however, increased surveillance may be warranted.

Hepatitis C: Current Controversies and Future Potential in Solid Organ Transplantation

PURPOSE OF REVIEW

To highlight the changing landscape of hepatitis C virus (HCV) infection in the context of organ transplantation. This focuses on areas of controversy and future potential in the era of highly effective direct-acting antiviral (DAA) agents.

RECENT FINDINGS

Since the advent of safe and highly effective DAA therapy, HCV infection is now curable in virtually all cases, including organ transplant recipients. Excellent drug tolerability and safety combined with high cure rates across all organ groups means that HCV is no longer a barrier to transplantation or its outcomes. Mounting data demonstrate the safety of using organs from HCV-infected donors with subsequent treatment of HCV in the recipient and a potential to expand the donor pool. Historical data demonstrating inferior survival in transplant recipients with HCV is of limited relevance in the DAA era. Virtually all transplant recipients with HCV infection can be cured, while early data also suggest excellent outcomes in recipients of organs from HCV viremic donors. The optimal timing of HCV therapy in relation to transplantation and the optimal use of organs from HCV viremic donors remain areas of controversy and ongoing research efforts.

Prevalence and risk factors for prehypertension and hypertension among adults in Central China from 2000-2011

BACKGROUND

Hypertension is frequently studied in surveys; however, prehypertension, a new blood pressure status between normotension and hypertension, is rarely reported.

METHODS

All data were derived from the China Health and Nutrition Survey (CHNS) and were analysed by logistic regression for correlation.

RESULTS

The prehypertension prevalence was 27.4%, with a hypertension rate of 36.9%. The awareness, treatment, and uncontrolled rates among all hypertension participates were 19.8%, 83.6%, and 55.0%, respectively. The epidemic rate of hypertension increased with increasing age (p < 0.001), and prehypertension appeared to have an epidemic peak in the age group of 38-57 years (p < 0.001). In general, the incidence of hypertension in urban participants was higher than in rural subjects (p < 0.001), and prehypertension in urban subjects was lower than that in rural subjects (p < 0.001). According to the results of logistic regression, hypertension and prehypertension were associated with age, gender, location, body mass index (BMI), body fat rate (BFR), waist circumference (WC), education, and the intake of energy-yielding nutrients<0.05).

CONCLUSION

The current study reveals a high epidemic rate of hypertension and prehypertension in Central China. These results indicate the urgent need to develop strategies to improve the prevention of hypertension and prehypertension in Central China.

Donor selection in the modern era

The growing disparity between the supply of donor hearts for transplantation and the demand for such organs has led to liberalization of the criteria for donor heart acceptance over the past few decades. The upper age limit and size restrictions for donor heart acceptance continue to be revised and hearts are being routinely used from donors with left ventricular dysfunction, left ventricular hypertrophy (LVH), cocaine use, multiple medical co-morbidities and after cardiopulmonary resuscitation. This article reviews recent data for use of such "expanded criteria" donor hearts and suggests ways to further increase the donor pool, including use of hearts from donors with hepatitis C and after circulatory determination of death. Donor biomarkers and risk scores may eventually aid in heart acceptance decisions, while ethical issues surrounding information sharing with transplant recipients remain a topic of great debate.

The American Society of Transplantation Consensus Conference on the Use of Hepatitis C Viremic Donors in Solid Organ Transplantation

The availability of direct-acting antiviral agents for the treatment of hepatitis C virus (HCV) infection has resulted in a profound shift in the approach to the management of this infection. These changes have affected the practice of solid organ transplantation by altering the framework by which patients with end-stage organ disease are managed and receive organ transplants. The high level of safety and efficacy of these medications in patients with chronic HCV infection provides the opportunity to explore their use in the setting of transplanting organs from HCV-viremic patients into non-HCV-viremic recipients. Because these organs are frequently discarded and typically come from younger donors, this approach has the potential to save lives on the solid organ transplant waitlist. Therefore, an urgent need exists for prospective research protocols that study the risk versus benefit of using organs for hepatitis C-infected donors. In response to this rapidly changing practice and the need for scientific study and consensus, the American Society of Transplantation convened a meeting of experts to review current data and develop the framework for the study of using HCV viremic organs in solid organ transplantation.