Temporal Changes and Regional Variation in Acceptance of Hepatitis C Virus–Viremic Livers

Abstract

The high efficacy of current hepatitis C virus (HCV) therapy and increased numbers of HCV‐infected deceased donors have changed the paradigm of HCV in liver transplantation (LT). Modeling studies have been performed to evaluate the optimal timing of HCV treatment (before versus after LT) in HCV‐infected patients and to assess the cost‐effectiveness of transplanting HCV‐infected livers into HCV− patients. However, these models rely on historical data and have not quantified the temporal changes in the median Model for End‐Stage Liver Disease (MELD) score at transplant of recipients of an HCV‐infected liver across geographic areas. We performed a retrospective cohort study of Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) data of nonstatus 1 deceased donor LT recipients from January 1, 2016, to December 31, 2018, and we calculated the difference in allocation MELD score in recipients of HCV nucleic acid test (NAT)− versus NAT+ livers by year and UNOS region. We used Pearson correlation coefficients to assess the relationship between MELD score difference in recipients of HCV NAT+ versus HCV NAT− livers and the proportion of non‐HCV recipients of HCV NAT+ livers. Nationally, the allocation MELD score difference at LT in recipients of HCV NAT+ versus NAT− livers did not change (4‐point difference). This stability was seen in regions 3, 5, and 10. In regions 1, 7, 8, 9, and 11, the MELD score difference decreased, which is a diminishing advantage. However, in regions 2 and 4, it increased, which is a rising advantage. In 2018, recipients of HCV NAT+ livers had a lower MELD score in 9/11 regions, and the MELD score advantage of accepting HCV NAT+ livers had a moderate inverse correlation with the regional use in non‐HCV patients (r = −0.53). These data should be used to inform clinicians of the pre‐ and post‐LT trade‐offs of HCV treatment.

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

“…This is particularly important for hepatocellular carcinoma with the implementation of "cap and delay policy" in 2015 and further capping to median MELD score at transplant minus 3 in 2019. 13 As these organs become more widely utilized, the waitlist time for recipients has also decreased, previously observed to be an average of 400 d, 5 our study shows this now to be a median of 95 d. This indicates that the option of HCV-viremic donor livers is being considered more expeditiously rather than being primarily offered to liver transplant candidates languishing on the transplant waitlist. Although the median waitlist time in the D HCV+/ R− group remains longer than in the D HCV−/R− group, this disparity will likely continue to decrease as the practice of D HCV+/R− continues to increase in the coming years.…”

“…Previously, both of these regions had a ≥10% higher absolute difference in the proportion of patients transplanted in 2018 among those willing to accept an HCV-infected liver. 13 Regions 1 and 10 had a decrease in their median MELD over the time period suggesting a potential causal effect with the embracing of this innovative transplant strategy. There were a number of regions (4, 5, 6, 7) who were among the regions with the lowest rates of HCV+/R− practice (<5% of all HCV-negative transplants), largely consistent with previous studies.…”

“…There were a number of regions (4, 5, 6, 7) who were among the regions with the lowest rates of HCV+/R− practice (<5% of all HCV-negative transplants), largely consistent with previous studies. 13 Some possible reasons for this practice trend include the smaller centers who may be more risk averse particularly with sicker patients, recipients who are unwilling to consent, or less competition from other local centers. Notably, regions 4 and 7 have many of the states with higher waitlist mortality rates (≈20 deaths per 100 patient waitlist-y).…”

“…This is particularly important for hepatocellular carcinoma with the implementation of “cap and delay policy” in 2015 and further capping to median MELD score at transplant minus 3 in 2019. 13…”

Can HCV Viremic Organs Be Used in Liver Transplantation to HCV Negative Recipients?

“…Regional variations on the MELD score for accepting HCV positive grafts for transplantation in HCV negative liver recipients have been reported. [29] Recent publication from Cotter, et al have suggested the usage of Hepatitis C viremic organs among patients with and without Hepatitis C, after reviewing Scientific Registry of Transplant Recipients database. They reported 87 HCV RNA positive donor being used among Hepatitis C negative recipients, with 2-year graft survival being similar in all groups.…”