The Lifesaving Potential of Less-Than-Perfect Donor Kidneys

Carrie Arnold

December 17, 2020

This story was co-produced with Scientific American.

"I have no reservations — none whatsoever — about getting a hepatitis C kidney," Price said in a follow-up phone call with Undark.

Still, there are lingering concerns. On the one hand, Roth, the University of Miami nephrologist, says that he embraces the idea of using hepatitis C-positive and other donor organs that function fine but aren't in pristine condition. It's one way to help partially ease the persistent organ shortage in the country, he says. But Roth is concerned that some patients may be so eager to escape the drudgeries of dialysis that they are willing to accept a sub-par kidney.

"When you have a population of patients who are vulnerable in that regard, it's really incumbent on us to paint a very clear picture," Roth said. "Many of them are so anxious to get off dialysis that they will accept a lot of things that maybe they're not 100 percent certain what they're accepting, and I think you have to be very careful about that."

While studies of the general population suggest that cure rates from direct-acting antivirals hover at over 95 percent — a high number, especially when compared to previous hepatitis C cure rates — it's still not 100 percent. Two participants in one of Sise's trials weren't cured after a single course of direct-acting antivirals, Sise acknowledged, though both were cured after a subsequent course. Another concern might be the development of antiviral resistance, especially as scientists try shorter courses of medications. "The more time the virus has to exist in someone's body or only exposing patients to extremely short courses of therapy could potentially breed resistance," Sise said.

In a 2018 review in the journal Clinical Liver Disease, a team of transplant surgeons and doctors from the University of Pennsylvania argued that organs from hepatitis C-positive donors should only be used as part of formal clinical studies at this time. The authors wrote that the procedures have too many unknowns, including the best protocols for what antivirals to take and for how long, as well as the long-term outcomes of those who have received these kidneys. Given how little researchers know about the use of kidneys from hepatitis C-positive donors, the authors wrote, "without sufficient knowledge to craft comprehensive post-transplant care plans, any further use of HCV‐infected donors, whether through a research protocol or so‐called standard of care, is arguably experimentation." The following year, hepatologist David Goldberg, one of the co-authors of that review, participated in a meeting that developed consensus opinions on the use of such organs, one of which suggested that transplanting hepatitis-C positive organs into hepatitis C-negative patients is permissible as long as there is "rigorous informed consent."

But all of the lingering qualifiers still make the decision to accept an imperfect organ a weighty one for patients living with kidney disease and the gauntlet of dialysis. Evans-Simmons says she contemplated the possibility of regret — both if she accepted a hepatitis C-positive kidney and if she didn't. But after additional conversations with her nephrologist and her family, she decided to add her name to the list for people willing to consider a kidney from a hepatitis C-positive donor.

It didn't remove her from the other, "regular" list, nor did it obligate her to accept the kidney. Her health insurance provider also still needs to agree to pay the high cost of the direct-acting antivirals before Evans-Simmons can receive a kidney from a hepatitis C-positive donor.

She's still not 100 percent sold on the idea, but as she waits for the day when the phone will ring with news of an available kidney — any kidney — Evans-Simmons says that she is keeping an open mind. "It's still very concerning for me," she said of the prospect of accepting a kidney from a hepatitis C-positive donor. "But at the same time, I'd rather try that than be on the dialysis."

This series was supported in part by the National Institute for Health Care Management Foundation.

Carrie Arnold is an award-winning freelance science journalist based in Virginia. In addition to Undark, her work has appeared with Scientific American, STAT, National Geographic, Wired, and The New York Times, among other publications.