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Transplant

Hepatitis C-positive donor organs and lung transplantation: Are we there yet?

The field of lung transplantation continues to be encumbered by the mismatch between organ supply and demand. Only approximately 15% of potential donor lungs are currently being used for transplantation, resulting in unacceptably high wait list mortality (17.2 deaths per 100 wait list years).

To counter this, the transplant community continues to invest in innovations such as ex vivo lung perfusion (EVLP) to increase the availability of suitable lungs for transplantation. At the same time, efforts to modify some of the existing practices are also underway. One area of interest has been the potential use of hepatitis C virus antibody positive (HCV +) donors in solid organ transplantation. Traditionally, the use of HCV + organs, especially when the donor is nucleic acid test (NAT)-positive, which indicates presence of HCV RNA, has been considered a contra-indication for solid organ transplantation. However, this has resulted in the exclusion of a significant number of potential HCV + donors (including young and otherwise healthy donor organs), the increased availability of which has been fueled by the opioid epidemic in the United States.

While kidney transplantation programs have been relatively more liberal with utilizing this subset of donors (due to requiring lesser degree of immunosuppression), heart and lung transplantation programs have shied away from this practice due to concerns for disease transmission and unfavorable outcomes, including reduced survival of the recipient (Englum BR, et al. J Heart Lung Transplant. 2016 Feb;35[2]:228).

Hepatitis C infection is one of the medical conditions for which the treatment of disease has changed substantially in the last decade. The advent of new classes of medications, direct acting antiviral agents (DAA), has ensured that a sustained virologic response (SVR), across all genotypes, is now possible in up to 98% of those who undergo treatment. Further, DAAs have a comparatively favorable pharmacokinetic profile and are well tolerated. Since the initial reports of success in the use of HCV + donor organs for lung transplantation, the results of a recently published trial lend further support to the continued use of these organs (Khan B, et al. Am J Transplant. 2017 Apr;17[4]:1129). One hundred percent of patients (n=35, 28 lung and 7 heart) who received organs from HCV + donors (NAT +) and were treated with DAA for 4 weeks (started immediately after transplantation) had an undetectable viral load and excellent graft function at 6 months posttransplantation (Woolley AE, et al. N Engl J Med. 2019 Apr 25;380[17]:1606). Similar studies with greater power and longer follow-up need to be conducted to instill greater confidence in the use of HCV + organs in potential lung recipients. In addition, ethical issues surrounding the use of HCV + organs should be carefully vetted, as the long-term outcomes regarding use of DAAs are not yet known. It is imperative that transplant centers ensure that patients who consent to receipt of HCV + organs fully comprehend the implications of doing so and have systematic posttransplant surveillance. It is also critical that ready access to the entire planned course of DAA is secured for recipients, since these agents could be cost-prohibitive in nonresearch settings. Willingness to comply with intense surveillance and therapy should also be assessed. While the notion of using HCV + donors has gained ground as a promising strategy, transplant centers have been rightfully cautious in its liberal use, until long-term outcomes are better characterized.

Anupam Kumar, MD
Fellow-in-Training Member

J. W. Awori Hayanga, MD, MPH, FCCP
Steering Committee