Use of HCV-infected organs increases transplants, but treatment questions remain
Transplanting organs from donors with hepatitis C virus may increase the number of transplants performed and reduce waitlist times, but the optimal treatment strategy for recipients requires further investigation, according to a speaker.
“Drug overdose became the leading cause of injury death in 2013, and hepatitis C is the most common chronic blood-borne infection in the United States with its prevalence only increasing,” Ann E. Woolley, MD, MPH, associate clinical director of solid organ transplant infectious diseases at Brigham and Women’s Hospital, told the audience at the virtual American Transplant Congress. “Fortunately, there have been many advances in hepatitis C and now, for the past 6 years, we’ve had direct acting antiviral agents [DAAs] which has transformed the way we think about and are able to manage hepatitis.”
Direct acting antivirals and increases in transplantation
Woolley outlined some reasons the medical community has been hesitant to utilize infected organs in the past, including concerns about acute and progressive hepatitis, a high transmission rate (more than 80%) and conflicting reports regarding graft and patient survival.
“However,” she said, “we have to keep in mind these studies were performed many years ago in the absence of a well-tolerated and highly effective antiviral treatment for hepatitis C ... Now, we have DAAs that make this inconceivable idea a true possibility.”
According to Woolley, 6.6% of all donor organs were hepatitis C positive in 2019 and utilizing these organs for transplant can expand the donor pool; studies have demonstrated that, since 2012, there has been an increase in the number of infected abdominal and thoracic organs utilized for transplant which has significantly decreased the median waitlist time and increased number of transplants that were able to be performed.
Uncertainty surrounds ideal treatment approach
“This is wonderful,” Woolley said, “but there’s many questions we need to answer. Should we be concerned about doing this more and making this a generalizable approach? Should we be using these pangenotypic regimens, which fortunately have limited drug-to-drug interactions, in a preemptive strategy or wait for the recipients to become viremic and use it as a reactive approach?”
Further research is required to fully answer these questions, according to Woolley, as it remains uncertain what the ideal approach is in terms of the timing of DAA initiation and the type of treatment regimen that should be used to allow the strategy to effectively be implemented by more centers.
“When we think about barriers, whether we do delayed treatment or preemptive/prophylaxis treatment comes down to cost,” Woolley said. “We need to think about this in the transplant community if we do think that the medical benefits of starting treatment earlier on outweigh the risks of delaying treatment. In order to have this be more accessible to more centers and be a more generalizable approach, we need to think about this in terms of costs and whether we can bundle this in insurance coverage for transplant.”
Once long-term outcomes and the ideal treatment approach are determined, Woolley said it will be possible to consider utilizing the strategy for other infections, such as hepatitis B.