Liver Transplantation of HCV-viremic Donors Into HCV-negative Recipients in the United States: Increasing Frequency With Profound Geographic Variation

Abstract

Background. Direct-acting antiviral therapy made possible the novel practice of utilizing hepatitis C virus (HCV)-viremic (HCV RNA-positive) donors into HCV-negative recipients in the United States. Although initial reports of outcomes have been satisfactory, higher-quality longer-term outcomes remain to be elucidated. Methods. National data were examined from the Organ Procurement and Transplantation Network on adult patients in the United States who underwent a primary, single organ, deceased donor liver transplant from January 1, 2016 to March 31, 2020. Outcomes of HCV-negative recipients (R−) who received an allograft from donors who were HCV RNA-positive (D HCV+) donors were compared with HCV RNA-negative (D HCV−) donors. Results. There has been a 35-fold increase in D HCV+/R− liver transplants over the past 4 y in the United States, from 8 in 2016 to 280 in 2019. There was an almost 6-fold difference in this practice among UNOS geographic regions. Graft survival following D HCV+/R− liver transplantation was excellent, with 1-y rates being 91% and 90% and 2-y rates being 88.5% and 87% for D HCV+/R− and D HCV−/R−, respectively (P = 0.672). In multivariate analysis, adjusting for other donor and recipient attributes, D HCV+/R− was not associated with patient or graft survival. Conclusions. The practice of D HCV+/R− continues to increase without discernible impact on medium-term outcomes. Notable geographic variation exists, suggesting inconsistent perceptions about the impact of D HCV+/R− transplantation on outcomes. These results strengthen the perceived safety in utilizing HCV-viremic donor organs as a donor pool expansion strategy, not only in the United States, but also worldwide.

Innovations in liver transplantation in 2020, position of the Belgian Liver Intestine Advisory Committee (BeLIAC)

“…It was concluded that similar graft survival and equivalent if not increased patient survival rates were evident in the HCV+ donor compared with the HCV-donor for HCV+ recipients. This observation also seems to hold true in the relatively rare situations where NAT+ grafts have been transplanted into HCV-recipients in the pre-DAA era (58)(59)(60). Recent studies confirmed this trend with excellent short-and medium-term graft and patient survival (61)(62)(63).…”

Hepatitis C viraemic organs in solid organ transplantation

“…All patients were treated with G/P and 13/16 achieved SVR12 (3 in various stages of treatment at time of publication) with 100% patient and graft survival at median follow-up of 8 to 11 months 30,35 . Two recent reviews of the OPTN registry from 2015 to 2020 confirmed these excellent short-term outcomes hold true in real world experience using HCVviremic livers in nonviremic recipients 52,53 .…”

“…Similarly, the percentage of anti-HCV-positive livers discarded in the U.S. steadily decreased from over 20% in 2011 to 7.6% in 2018 with comparable discard rates between anti-HCV-positive and anti-HCV-negative livers since 2016 due mainly to the decrease discard rate in anti-HCV-positive nonviremic donors 51,52 . However, there has been a 35-fold increase in transplantation of HCV-viremic livers into nonviremic recipients from 2016 to 2019, greatly expanding the use of HCV-viremic livers 53 . Similarly, national utilization rates of anti-HCV-positive viremic and nonviremic donor hearts in 2019 was the same as anti-HCV-negative donor hearts 54.55 .…”

“…Similarly, national utilization rates of anti-HCV-positive viremic and nonviremic donor hearts in 2019 was the same as anti-HCV-negative donor hearts 54.55 . Lastly, significant regional and center variation in discard and transplant rates J o u r n a l P r e -p r o o f of anti-HCV-positive and viremic organs has been described, suggesting that more uniform national and international policies may increase utilization even further 53,55,56 .…”

Usage of HCV Positive Donors Among Non-HCV Infected Liver Transplant Recipients

“…The type and duration of the DAA therapy after LT depends on the genotype of the acquired virus from the donor 10 .DAA's have made HCV positive donor to HCV positive recipient LT, a common practice, and has led to a spike in using similar donors for uninfected recipients as well. A 2021 study showed a 35 fold increase in HCV positive donor to HCV negative recipient LT in the past 4 years in the United States, from 8 in 2016 to 280 in 11 study showed how DAA had led to a threefold increase in LT from HCV positive to HCV negative recipients from 2015 to 2016 12 . This trend is backed by multiple studies which are giving favourable outcomes for this strategy.…”