Lung Transplant With HCV-Viremic Organ Does Not Increase Rejection, Allograft Dysfunction

Kamyar Afshar, DO

Credit: UC Providers

Findings from a recent single-center study are highlighting the feasibility and success of using hepatitis C virus (HCV)-positive donor organs for lung transplantation, showing no increase in acute or chronic lung allograft rejection compared to HCV-negative donor organs.¹

Due to the insufficient number of donor organs available to patients in need of a transplant, the US Centers for Disease Control and Prevention has said intentional transplantation of organs from HCV-infected donors is accepted medical practice. However, many programs still do not accept HCV organs, and their use in lung transplantation as well as the potential implications on acute and chronic lung rejection require further investigation.^1,2

“To address measures to increase the allocation of donor lungs, particularly for the patients showing signs of decompensation, there is an increased acceptance of the safety and viability of HCV donor lung acquisition,” wrote Kamyar Afshar, DO, clinical professor and medical director of the lung transplant program at UC San Diego, and colleagues.¹

Investigators sought to assess differences in acute or chronic rejection rates at 1 year following lung transplantation from HCV-viremic versus uninfected donors. To do so, they retrospectively reviewed outcomes for all lung transplant recipients at a single institution from April 1, 2017, to October 1, 2020, comparing HCV-positive donor organ recipients to HCV-negative donor organ recipients.¹

Patients ≥18 years of age who were waitlisted for a lung transplant, either single or combined with other organs, and were able to provide informed consent were included in the study. Investigators noted patients with pre-existing HIV infection and those with active hepatitis B virus (HBV) infection were excluded from the present study. Additionally, donors with concomitant positive nucleic acid testing for HBV or HIV.¹

Patients on the transplant waitlist who fulfilled the study inclusion and exclusion criteria underwent a detailed discussion using a standardized patient information form. If the patient agreed to accept HCV+ organs, their United Network for Organ Sharing status was changed to reflect this decision – once an HCV+ organ was available, detailed informed consent was obtained before proceeding with the lung transplant.¹

The study’s outcomes were the rate of HCV transmission from HCV+ donors; the percentage of patients achieving SVR12 with DAA therapy; graft and patient survival of HCV+ donors compared to HCV− donors; rates of rejection episodes between HCV+ donors and HCV− donors; and adverse events related to HCV infection.¹

A total of 135 patients were transplanted during the study period, including 18 from HCV-viremic donors. The majority of transplant recipients in both cohorts were male with a median age of 57 years.¹

Investigators noted all 18 patients who received HCV-viremic organs developed acute HCV infection, demonstrating a 100% transmission rate. In the postoperative period, all patients were treated with 12 weeks of direct antiviral agent (DAA) therapy with glecaprevir/pibrentasvir, sofosbuvir/velpatasvir, or ledipasvir/sofosbuvir and monitored for response to treatment using quantitative HCV PCRs every 4 weeks for a total of 24 weeks.¹

SVR 12 was achieved in all (100%) HCV-viremic donor organ recipients, and no patient had a serious adverse event related to HCV infection. Investigators also pointed out there were no cases of chronic lung allograft dysfunction at 1 year in the HCV-positive donor group, compared to 5.9% of patients in the HCV-negative donor group.¹

Among the HCV nonviremic group, investigators noted an increased rate of clinically significant rejection, acute cellular rejection A2 or higher, or antibody-mediated rejection (12.8% vs 5.6% HCV-viremic group) as well as a greater combined outcome of rejection/chronic lung allograft dysfunction within the first post-transplant year (16.2% vs 5.6% HCV-viremic group), though these differences were not statistically significant. Survival at 1 year was 100% in the lung transplant recipient HCV-viremic donors compared to 95.8% among lung transplant recipient HCV-nonviremic donors.¹

“Larger studies with longer-term follow-up will be needed to substantiate the feasibility and success that we have found with the use of HCV+ lung donation in uninfected recipients to allow for this to be a more widely accepted practice for lung transplant programs and payors,” investigators concluded.¹

References:

1. ^{Afshar K, Schonhoft E, Kozuch J, et al. Using HCV-viremic organs for lung transplantation does not confer higher rejection rates compared to HCV-negative organs. Clinical Transplantation. https://doi.org/10.1111/ctr.15260}
2. ^{US Centers for Disease Control and Prevention. Donor Screening and Testing. Transplant Safety. October 13, 2022. Accessed February 23, 2024. https://www.cdc.gov/transplantsafety/protecting-patient/screening-testing.html}