AMSTERDAM — While hepatitis C virus-positive liver donation into HCV-positive recipients solves a number of public health problems, donation into HCV-negative recipients remains controversial, according to a presenter at the International Liver Congress.
Didier Samuel, MD, PhD, professor of hepatology and gastroenterology at Université Paris-Sud, Villejuif, said that the most convincing argument for using positive livers is the organ shortage. “Also, seroprevalence of HCV is higher in donors than in the overall population,” he said.
The U.S. is leading the way in HCV-positive graft usage, according to Samuel. “The rate was up to 15% in 2015,” he said. “Accordingly, we are seeing a decrease in the discarding of HCV-positive livers in the U.S.”
The dilemma is to balance the risk of transmission of the disease with the potential benefit to patients. “We are trying to minimize risk and maximize the benefit,” Samuel said.
This can be most effectively achieved by carefully selecting both donors and recipients, controlling risk factors and optimizing prophylaxis and treatment.
In donor selection, it is recommended to screen for HCV RNA positivity and liver fibrosis, according to Samuel. “The risk of transmission is 48% for the kidney, 25% for the heart, but in the liver, it depends on viral replication,” he said. “With no donor replication, the transmission rate is 0%, but with viral replication, the transmission rate is 100%. If HCV RNA information is unavailable, the donor should be considered positive.”
Samuel added that it is also important to know the strain of HCV in the donor, and to understand that donor age has an impact on outcomes. “Donor age over 55 years is associated with lower survival,” he said. “We recommend using HCV-positive grafts in HCV-positive recipients, and grafts with stage 2 fibrosis or less.”
There are a number of reasons to use positive livers beyond limiting the organ shortage, Samuel suggested. “We can use our screening methods to match donors and recipients with the same genotype of HCV,” he said. “We have seen similar survival of all patients except HIV-HCV coinfected patients. Also, we have effective DAA therapies.”
Arguments against this practice include increases in fibrosis progression in these patients, Samuel noted. “Also, access to DAAs is limited,” he added.
Samuel said that there is not yet sufficient evidence to assess the safety of positive to negative donation. “We suggest limited use of positive grafts in negative patients, but there are no solid data to support this statement,” he said. “It should be restricted except in cases of high clinical need. Also, graft quality should be cautiously evaluated. Initiation of DAA therapy should begin as soon as possible, usually within 3 to 6 months.”
There are legal and ethical issues involved in this procedure, as well. “In France, for example, it is illegal,” he said.
Data are also limited for managing graft after transplantation, according to Samuel. “We suggest that the patient should be treated with interferon-negative DAA therapy as soon as possible after transplantation,” he said. “The timing and modality of post-transplant treatment is critical. Keep in mind the patient’s genotype, but a pangenotypic regimen is recommended.” – by Rob Volansky
Samuel D. PGC on Liver Transplantation: Liver transplantation for viral hepatitis. Presented at: International Liver Congress; April 19-24, 2017; Amsterdam.
: Samuel reports consulting for Astellas, BioTest, BMS, Cilag, Gilead, Janssen, LFB, MSD, Novartis and Roche.