Abstract and Introduction
Background: Given the success of direct-acting antivirals (DAAs) in treating hepatitis C (HCV), interest is growing in utilizing solid organs from allografts with active HCV to expand donor availability.
Aim: To review post-transplant outcomes and patient survival in HCV-negative recipients receiving solid organ transplants (SOT) from viraemic, that is, HCV+/NAT+ (nucleic acid testing) allografts.
Methods: A literature search was conducted on PubMed and EMBASE from 01/01/2007 to 4/17/2021 for articles matching eligibility criteria. Two authors independently screened titles and abstracts. Disagreements were solved by a third independent reviewer. Methodological quality assessment was done using a modified Newcastle-Ottawa scale (NOS). Data synthesis was done qualitatively using median, ranges and percentages.
Results: Thirty-five studies were included (or 852 SOTs): 343 kidney, 233 heart, 204 liver, and 72 lung transplants from viraemic allografts. Of the recipients eligible for sustained virological response at 12 weeks (SVR12) calculation, 100% achieved cure from HCV. No deaths/graft failures were reported to be related to HCV transmission. Seven SOT recipients had viral relapse, with all seven patients treated successfully. Four patients developed fibrosing cholestatic hepatitis with complete resolution post-treatment.
Conclusions: Transplanting viraemic organs into uninfected individuals can become the standard of care for patients who do not have contraindications to DAAs.
According to the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) 2018 Report, there is relative solid organ scarcity resulting in prolonged wait times on the United Network for Organ Sharing (UNOS) list.[1–5] Rising waitlist times have resulted in increased mortality. Thus, the transplant community is exploring other potential donors, including those with active HCV. The limiting factors for utilizing HCV allografts include patient scepticism about receiving infected organs and physician concerns about post-transplant complications.[6–8]
The literature on HCV viraemic allograft transplants to negative recipients emphasizes the excellent safety profile of such transplants. In 2015, UNOS released a mandate requiring nucleic acid testing (NAT) on all donors with chronic infections. NAT can identify HCV viraemia earlier (window 5–7 days), compared to serum antibody testing (window 60–70 days). In non-transplant patients, HCV treatment with direct-acting antiviral (DAA) agents results in high rates of sustained virological response at 12 weeks from the completion of DAA therapy (SVR12), or cure of hepatitis C infection. The therapeutic success rate with DAA agents has led some transplant centres to use HCV viraemic donors' organs. Some centres prophylactically/pre-emptively administer DAAs before or on the transplant day to prevent HCV infection, respectively. In contrast, others opt to wait for confirmation of HCV transmission to the recipient before initiation of DAAs ("reactive strategy").
Even though initial studies show success with utilizing HCV viraemic organs, concerns from physicians and patients are still prevalent. We systematically assessed the virological response and risks associated with SOT (kidney, heart, liver and lung) from HCV viraemic (NAT+) donors to HCV seronegative recipients. This literature review will provide background evidence and support for changes in national policies to increase SOT availability.
Aliment Pharmacol Ther. 2021;54(5):571-582. © 2021 Blackwell Publishing