Changes in Utilization and Discard of Hepatitis C–Infected Donor Livers in the Recent Era

Abstract

The impact of interferon (IFN)-free direct acting antiviral (DAA) hepatitis C virus treatments on utilization and outcomes associated with HCV+ deceased-donor liver transplantation (DDLT) is largely unknown. Using SRTR, we identified 25,566 HCV+ DDLT recipients from 2005 to 2015, and compared practices according to the introduction of DAA therapies using modified Poisson regression. The proportion of HCV+ recipients who received HCV+ livers increased from 6.9% in 2010 to 16.9% in 2015. HCV+ recipients were 61% more likely to receive an HCV+ liver after 2010 (early DAA/IFN era) [aRR:1.451.611.79, p<0.001] and almost three times more likely to receive one after 2013 (IFN-free DAA era) [aRR:2.582.853.16, p<0.001]. Compared to HCV− livers, HCV+ livers were 3 times more likely to be discarded from 2005–2010 [aRR:2.692.993.34, p<0.001], 2.2 times more likely after 2010 [aRR:1.802.162.58, p<0.001], and 1.7 times more likely after 2013 [aRR:1.371.682.04, p<0.001]. Donor HCV status was not associated with increased risk of all-cause graft loss (p=0.1), and this did not change over time (p=0.8). Use of HCV+ livers has increased dramatically, coinciding with the advent of DAAs. However, the discard rate remains nearly double that of HCV− livers. Further optimization of HCV+ liver utilization is necessary to improve access for all candidates.

Use of Hepatitis C Positive Organs: Patient Attitudes in Urban Chicago

“…HCV positivity has been observed in 5.6% of all potential donors, and in 18% of potential PHS (public health safety) increased risk donors, who are defined as being "at a higher than average risk for transmitting viruses such as HIV, HCV, and hepatitis B (HBV)" [7,22]. were discarded [5,6,23]. This percentage has dramatically decreased (from 28% in 2010 to 11% in 2015) with the advent of the DAAs, with corresponding increase of HCV-positive liver grafts to HCV-positive recipients [5].…”

“…In addition to organ shortages, hepatitis C virus (HCV) positivity, in patients and grafts, has historically been another factor preventing transplant candidates from receiving an organ in some cases. The incidence of HCV positivity -the transmission of which in most cases occurred on dialysis -in kidney transplant recipients is estimated between 1.8 and 8%, and roughly 43% of the liver waitlist is HCV antibody positive [4,5]. Further, 28% of HCV-positive livers were discarded yearly from 2005 to 2010 and 63% of good quality kidneys were discarded from 2005 to 2014 due to HCV positivity [4][5][6].…”

“…HCV-positive donor organs are now increasingly being transplanted in HCV-positive patients safely and successfully [5,[12][13][14][15]. Additionally, some medical centers are transplanting HCV-positive solid organs in HCVnegative recipients with expectant treatment early in the post-transplant period [16,17].…”

“…Researchers are studying different methods of both prevention, with DAA prophylaxis given pre-transplant and continued in the post-transplant setting, and cure, with DAA therapy administered post-transplant based upon a positive HCV viral load [16][17][18]. This practice would likely increase the number of organs available for transplantation, given the shorter waitlist times seen on the kidney transplant list for patients receiving HCV-positive kidneys and the significant number of HCV-positive organs that are discarded yearly [5,6,19].…”

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“…The number of patients dying or too ill for LT has risen from 11.1 per 100 in 2009 to 12.3 per 100 in 2014. 10 To help improve Abbreviations: DCD, donation after cardiac death; HCC, hepatocellular carcinoma; LT, liver transplant; SD, standard deviation 21 An attempt is made to match HCV-positive donors to HCV-positive recipients. When an HCV-positive recipient receives an HCV-negative or HCV-positive graft, infection of the graft occurs almost instantly, with viral titers often reaching pretransplant levels as early as a few days, sometimes with changing of genotype of the disease in favor of the donor's HCV genotype.…”