COMMENTARY

Discarded No More: HCV-Infected Organs Advance Transplantation

William F. Balistreri, MD

Disclosures

May 03, 2019

In This Article

As we scan the list of patients waiting for liver transplants during our weekly team meeting, we deliberate the ongoing problem of donor organ availability. The demand for organs greatly exceeds the supply, limiting the number of transplants performed. Only half of the 14,000 patients on the national transplant list actually received a liver in 2016.[1] As our discussion shifts to the controversial option of using hepatitis C virus (HCV)-positive donor organs, we wonder whether this could bridge the gap between supply and demand.

Many of the HCV-positive donor organs are from drug overdose deaths, which have increased from 7 to 21 per 100,000 persons between 1999 and 2016.[2,3] But if these potential donors otherwise meet the standard criteria for donation, this could dramatically tilt the supply-demand balance. The use of these organs might not only expand the donor pool for our patients but also affect waitlist mortality.

Game-Changing Antivirals

The Public Health Service established criteria to identify increased risk donors to reduce the unintended transmission of infectious diseases, such as HCV, through organ transplantation.[4] This allows transplant centers to lessen the risk for transmission and also to ensure the appropriate treatment of recipients in the event of posttransplant infection. However, broader acceptance of these organs (including those from drug overdose-related deaths) could substantially improve transplant rates. Their discard rate is significant: For kidneys obtained from increased risk donors, the proportion of organs retrieved but not transplanted reached 20% in 2016.[5]

But the tide is turning. In the past, HCV-positive organs were discarded or offered only to HCV-positive patients. However, the efficacy and tolerability of direct-acting antiviral (DAA) therapy has created a rationale for the judicious use of organs from HCV-infected donors, including transplantation into HCV-negative recipients. In fact, a growing number of hospitals are now offering HCV-positive organs to patients without HCV infection.[6] Their reported experiences demonstrate noninferior outcomes after transplantation of overdose-death donor organs that were HCV-infected. Throughout most of 2018, a total of 1631 HCV-positive organs were transplanted, of which 1058 went to patients without HCV infection.[1] The increased rates of organ recovery from these donors have also been associated with shorter transplant waiting lists.[7]

As we continued to debate the merits of this option, a Wall Street Journal article, The Transplant Surgeon Needed a New Heart—Even if It Had Hepatitis C, caught our attention.Robert Montgomery, MD, a renowned kidney-transplant surgeon who long advocated for his patients to accept transplanted organs infected with HCV, now serves as a living example, having received a heart from a heroin user infected with HCV who died of an overdose. Although Dr Montgomery tested positive for HCV shortly after his transplant, he was successfully treated with DAA therapy to clear the infection. "This was an opportunity to both use an organ that we probably wouldn't have used and to kind of morally align myself with what I believed and had been telling people," he said.

It may be time for the transplant community at large to define the logistics surrounding the use of HCV-positive organs and also to document the outcomes of these transplants.

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