HCV-positive Organ Donations Could Expand in Era of Direct Acting Antivirals

The American Society of Transplantation has reached consensus on how treatment of hepatitis C virus (HCV) with direct acting antivirals (DAAs) could enable organ transplantations to HCV naive recipients and potentially save the lives of many on transplant waitlists.

Organ transplantation between HCV-positive donor and recipient is already accepted practice, and the consensus conference report lead author Josh Levitsky, MD, Professor of Medicine and Surgery, Northwestern University, Chicago, IL and co-authors explained the purpose of the January 2017 conference.

"The meeting participants thought that the availability of DAA therapy makes expansion of transplanting HCV-viremic organs into nonviremic recipients a possibility,” Levitsky and colleagues wrote. “This could result in saving a significant number of lives per year among organ failure patients.”

However, the researchers agreed unanimously that more research was needed before the practice became routine.

In an editorial accompanying the consensus report, Jay Fishman, MD, Transplant Center and Infectious Disease Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA and Xavier Forns, MD, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain, pointed out that research will need to include an assessment of the limitations of DAA therapies.

"Each new application of DAA therapy requires evaluation for drug interactions with transplant immunosuppressive and other common medications," Fishman and Forns wrote. "The benefits of early access to transplantation using organs from HCV-positive donors must be carefully balanced against the risk of unknown effects of drugs and therapies."

The consensus conference report acknowledged that current barriers in obtaining DAA treatment could also impede the expanded use of HCV-viremic organs.

"DAAs are normally approved for use in chronic HCV infection but may be restricted to patients with advanced hepatic fibrosis,” Fishman and Forns wrote. “In contrast, the transplantation of HCV-viremic organs into nonviremic recipients involves treatment for acute, donor-derived infection before the development of liver injury or infection-related comorbidities, raising concerns that coverage may be denied.”

It would be necessary for transplantation protocols to ensure that the recipient would be guaranteed access to DAA therapy — with rare exceptions made for emergency lifesaving transplantations, according to the consensus conference report.

Even with this guaranteed access, however, Fishman and Forns note that outcomes could be complicated by limitations of the transplant sites.

"Not all clinical centers will have the expertise to manage newer DAA therapies or relapses, viral resistance, or infections with multiple viral strains," Fishman and Forns wrote.

Levitsky and colleagues echoed that concern, and suggested a procedure to address it.

"Due to the increased complexity of decision-making involved as well as with public health service increased risk organs in general, the group thought that organ procurement organizations (OPOs) should consider contracting with transplant physicians knowledgeable about DAAs to provide real-time consultation regarding the appropriateness of allocating these organs, for both the OPO and transplant center considerations," Levitsky and colleagues wrote.

The report from the American Society of Transplantation Consensus Conference on use of HCV Viremic donors in solid organ transplantation was published in the November issue of the American Journal of Transplantation.