Center-level trends in utilization of HCV-exposed donors for HCV-uninfected kidney and liver transplant recipients in the United States

Abstract

Several single-center reports of using HCV-viremic organs for HCV-uninfected (HCV-) recipients were recently published. We sought to characterize national utilization of HCV-exposed donors for HCV-recipients (HCV D+/R−) in kidney transplantation (KT) and liver transplantation (LT). Using SRTR data (April 1, 2015-December 2, 2018) and Gini coefficients, we studied center-level clustering of 1193 HCV D+/R− KTs and LTs. HCV-viremic (NAT+) D+/R− KTs increased from 1/month in 2015 to 22/ month in 2018 (LTs: 0/month to 12/month). HCV-aviremic (Ab+/NAT-) D+/R− KTs increased from < 1/month in 2015 to 26/month in 2018 (LTs: <1/month to 8/month). HCV-recipients of viremic and aviremic kidneys spent a median (interquartile range [IQR]) of 0.7 (0.2-1.6) and 1.6 (0.4-3.5) years on the waitlist versus 1.8 (0.5-4.0) among HCV D−/R−. HCV-recipients of viremic and aviremic livers had median (IQR) MELD scores of 24 (21-30) and 25 (21-32) at transplantation versus 29 (23-36) among HCV D−/R−. 12 KT and 14 LT centers performed 81% and 76% of all viremic HCV D+/R− transplants; 11 KT and 13 LT centers performed 76% and 69% of all aviremic HCV D+/R− transplants. There have been marked increases in HCV D+/R− transplantation, although few centers are driving this practice; centers should continue to weigh the risks and benefits of HCV D+/R− transplantation. K E Y W O R D S clinical research/practice, hepatitis C, infection and infectious agents -viral, infectious disease, kidney transplantation/nephrology, liver transplantation/hepatology, Organ Procurement and Transplantation Network (OPTN), Scientific Registry for Transplant Recipients (SRTR)

National Trends in Utilization and 1-Year Outcomes with Transplantation of HCV-Viremic Kidneys

“…Recipients with a history of HIV infection, recipients of a multiorgan transplant, and those transplanted at centers that did not perform any kidney transplants from donors with HCV viremia or anti-HCV antibody (Ab) during the study period were excluded. 24 Waitlisted patients must opt in to receive offers of kidneys from HCV Ab or HCV NAT-positive (viremic) kidneys. We examined temporal trends in this HCV-seropositive kidney eligibility defined as willingness to receive HCV Ab or HCV-viremic kidney offers or both.…”

Lessons from the real world: HCV-infected donor kidney transplantation as standard practice

“…Since the first two successful pilot trials, THINKER and EXPANDER, HCV D+/R− kidney transplantation has grown substantially, clustered at a few high‐utilizing centers . There is debate over whether this innovative practice should be restricted to research, as recommended in an American Society of Transplantation 2017 consensus statement, or whether it should become standard clinical care, given the organ shortage and high waitlist mortality …”

Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers

“…Recently, larger case series have confirmed these results. 5,9,12,17,18,[25][26][27][28][29][30][31][32] Despite the published outcomes in clinical studies, the development of safe and effective strategies to utilize DHCV NAT+ organs is challenging. 10 Safe transplantation requires coordination to ensure universal posttransplant testing, access to DAAs for viremic patients, and appropriate monitoring to ensure compliance and viral clearance.…”

“…2 Although DHCV exposed kidney utilization has been increasing, thousands of kidneys are gone unused over a 10-year period. [3][4][5] Since DHCV Ab+/NAT-kidneys reflect prior, rather than current infection, viral transmission to recipients would is unexpected. In contrast, DHCV NAT+ kidneys result in viral transmission to the majority of recipients.…”