Trends in utilization of deceased donor kidneys based on hepatitis C virus status and impact of public health service labeling on discard

Abstract

Background Kidneys from deceased donors infected with hepatitis C virus (HCV) are underutilized. Most HCV virus‐infected donors are designated as Public Health Service increased donors (PHS‐IR). Impact of PHS and HCV designations on discard is not well studied. Methods We queried the UNOS data set for all deceased donor kidneys between January 2015 and December 2018. The final study cohort donors (n = 38 702) were stratified into three groups based on HCV antibody (Ab) and NAT status: (a) Ab−/NAT− (n = 35 861); (b) Ab+/NAT− (n = 973); and (c) Ab±/NAT+ (n = 1868). We analyzed utilization/discard rates of these organs, the impact of PHS‐IR and HCV designations on discard using multivariable two‐level hierarchical logistic regression models, forecasted number of HCV viremic donors/kidneys by 2023. Results During the study period, (a) the number of viremic donor kidneys increased 2 folds; (b) the multilevel mixed‐effects logistic regression models showed that, overall, the PHS labeling (OR 1.20, CI 95% CI 1.15‐1.29) and HCV designation (OR 2.29; 95% CI 2.15‐2.43) were independently associated with increased risk of discard; (c) contrary to the general perception, PHS‐IR kidneys across all HCV groups, compared to PHS‐IR kidneys were more likely to be discarded; (d) we forecasted that the number of kidneys from HCV viremic donor kidneys might increase from 1376 in 2019 to 2092 in 2023. Conclusion Hepatitis C virus viremic kidneys might represent 10%‐15% of deceased donor organ pool soon with the current rate of the opioid epidemic. PHS labeling effect on discard requires further discussion of the utility of this classification.

Pancreas transplantation from hepatitis C viremic donors to uninfected recipients

“…20 Kidneys from donors identified as PHS IR are less likely to be utilized, despite the fact that posttransplant graft and patient survival with PHS IR kidneys is equal to or better than that of nonincreased risk kidneys. [25][26][27] The PHS IR designation was seen in 31% of nontransplanted HCV-negative potential ideal pancreas donors compared to only 25% in transplanted HCVnegative pancreas donors. However, this same HCV-negative cohort also had higher KDPIs and lipase levels compared to HCV-negative transplanted pancreata donors.…”

“…HCV-positive designation has also been shown to be an independent risk factor for increased risk of kidney discard. 28 Given the predicted increase in HCV viremeic organ donors in the next decade, 27 it is possible that this could further contribute to the reduced utilization of otherwise appropriate donor pancreata.…”

Hepatitis C viraemic organs in solid organ transplantation

“…In this DAA-era, the percentage of anti-HCV-positive kidneys discarded peaked in 2013 around 55% and has since decreased to ~35% in 2018 49 ; however, anti-HCV-positive kidneys were still 3.7-times more likely to be discarded than anti-HCV-negative kidneys 46 . As of 2017, discard rates for anti-HCV-positive nonviremic kidneys are approaching anti-HCV-negative nonviremic kidney rates, though HCV-viremic kidneys are still being discarded at nearly 2-times more frequently 50 . 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 .…”

Best practice recommendations for the use of hepatitis C viremic donor organs for hepatitis C virus naïve recipients

“…In the era of highly efficacious HCV therapies, the ongoing organ shortage coupled with increasing numbers of HCV NAT+ potential organ donors due to the opioid crisis has led to a significant increase in the utilization of HCV NAT+ organs into HCV negative recipients. [31][32][33][34] However, there remains a dearth of best practice guidelines for the implementation of HCV NAT+ organ transplantation. The recommendations summarized here will provide a safe foundation upon which to expand the utilization of these organs while maximizing patient safety and outcomes.…”