Use of Hepatitis C-Positive Donor Livers in Liver Transplantation

Abstract

Purpose of review The purpose of this article is to review recent literature regarding the use of Hepatitis C virus (HCV) positive donor livers in liver transplantation. Given the prevalence of HCV-positive patients on the waitlist coupled with high waitlist mortality, use of HCV-positive livers may be a means to meet patient needs. This review seeks to primarily answer the following questions: can HCV-positive livers be used safely and effectively? Are new direct acting antiviral medications safe and effective in HCV-positive liver recipients? Recent findings Use of HCV-positive donor livers for liver transplantation in HCV-positive recipients is increasing. These donor livers have equivalent patient and graft survival when compared to HCV-negative donor livers in HCV-positive liver transplant recipients. Recent studies suggest that use of direct acting antiviral medications in HCV-positive liver transplant recipients can be successful, although there is insufficient data for their use in recipients of HCV-positive donor livers. Summary HCV-positive donor livers may be safely and effectively used in HCV-positive liver transplant recipients. Direct acting antiviral medications appear safe and effective in HCV-positive liver transplant recipients, but data on their efficacy in HCV-positive liver transplant recipients are limited. Future research should focus on the use of HCV-positive donor livers in HCV-negative liver transplant recipients.

Balancing the risk and rewards of utilizing organs from hepatitis C viremic donors

“…Two published studies exist that have explored this strategy in HCV-uninfected kidney transplant patients. The THINKER-1 and 2 trials showed that HCV virus could be eradicated with a 12 week course of DAAs begun shortly after transplant (early reactive approach) of HCV RNA positive organs into recipients who do not have HCV infection 46 . Twenty patients without HCV were transplanted with kidneys from HCV genotype 1-infected donors and began elbasvir-grazoprevir at day 3 post-transplant.…”

Changes in practice and perception of hepatitis C and liver transplantation: Results of a national survey

“…As clinical trials of HCV+ to HCV− kidney transplantation demonstrate the potential of this approach in the DAA era and new guidelines emerge for LT candidates, [39][40][41] institutional protocols to expand the use of HCV+ donor livers for HCV− LT candidates may also deserve further review. [42][43][44][45] This study has several limitations that merit consideration. First, we relied on our contacts at each LT center to identify an individual to represent the views of their center as a whole.…”

“…After these centers were surveyed, this practice grew from 6 centers with 12 HCV+ to HCV− LTs (2012‐2014) to 26 centers with 129 HCV+ to HCV− LTs (2016‐2018). As clinical trials of HCV+ to HCV− kidney transplantation demonstrate the potential of this approach in the DAA era and new guidelines emerge for LT candidates, institutional protocols to expand the use of HCV+ donor livers for HCV− LT candidates may also deserve further review …”

Use of HCV‐infected organs in solid organ transplantation: An ethical challenge but plausible option

“… As such, the evidential burden appears to rest on those who oppose this standard‐of‐care approach to prove that the potential risks posed by HCV‐infected organs warrant further investigation prior to their widespread use. Acknowledging the limitations of the existing data collectively, these cautious opponents insist that carefully monitored multi‐centre studies involving extensive post‐transplant follow‐up evaluations are necessary in order to validate safety, develop policy framework and establish recipient selection criteria prior to endorsing HCV‐infected organ transplantation as standard‐of‐care . The regulatory oversight and controlled context of clinical trials offer the safest setting in which to utilize infected organs in uninfected recipients; continued study will enable investigators to fill existing gaps in the evidence supporting the safety of this practice, and thus ameliorate informed consent discussions.…”

“…It is crucial that these risks are discussed alongside the risks of refusing to be listed for an HCV‐infected organ (eg disease progression and associated morbidity and mortality on the waiting list). One way to facilitate the comprehensive disclosure of risks and benefits of HCV‐infected organ transplantation is through offering patient education sessions on which the foundation of the informed consent discussion is formed . A team‐based approach, inclusive of patients’ hepatologists, surgeons and primary care providers, along with nurses, coordinators, pharmacists and independent advocates may aid in the dissemination and comprehension of risk information.…”