Background: Hepatitis C virus (HCV) is a leading cause for liver cirrhosis and one of the commonest indications for liver transplantation. The introduction of direct acting antiviral (DAA) medications have revolutionized the treatment for HCV. Prior to 2014, the treatment for HCV consisted of interferon and ribavirin which yielded a sustained virologic response (SVR) of around 55%. In comparison to interferon and ribavirin, DAA’s have improved rates of SVR. Since 2014, DAA’s are increasingly being used in hepatitis C positive patients while on the transplant waiting list, leading to a smaller number of patients on the transplant list with hepatitis C. Decreased numbers of hepatitis C positive recipients raised concerns that the utilization of hepatitis C positive deceased liver donors would decline. This study was conducted to evaluate if discard rate of hepatitis C positive donor livers has changed with the introduction of DAA’s.
Methods: A retrospective observational study using a local organ procurement organization (OPO) database was performed. The study time frame was from 2008 to 2017 and was divided into two eras: a time before widespread use of DAA’s (2008-2013) and a time where DAA’s were common practice (2014-2017). A total of 96 patients who had positive HCV antibody serology or nucleic acid amplification techniques were included. The organ discard rates in these two eras were compared using Chi-square analysis with statistical significance considered at a p-value of less than 0.05. Analysis was also performed by employing binary logistic regression to evaluate for differences between patient factors, such as age, hypertension, and alcohol use. A secondary analysis was performed to determine how these organs were used: locally or regionally shared.
Results: There were 96 organ donors who tested positive for hepatitis C in the study time frame of which 75 livers were transplanted. In the pre-DAA era (2008 to 2013), a total of 47 organ donors tested positive for hepatitis C, of which 31.9% were discarded. In the post-DAA era (2014-2017), a total of 49 HCV positive organs were identified, of which 12.2% were discarded. The results showed that the discard rate was significantly higher in the pre-DAA era compared to the post-DAA era [p=0.026]. Secondary analysis shows that there was a trend to increased regional sharing of hepatitis C donor organs in the post-DAA era compared to the pre-DAA era; however this finding was not statistically significant [p=0.106].
Conclusions: The decrease in discard rate of hepatitis C organs in the OPO is related to the introduction of highly efficacious DAA’s. The results of the secondary analysis are likely related to center derived variation in utilizing HCV positive organs and wait list HCV management. Treating patients who would have been eligible for an HCV positive donor liver makes them no longer eligible, transitioning them to a different, and longer, wait list. Treatment results in an improvement in liver function, but does not reverse cirrhosis or the sequelae of portal hypertension – including ascites and encephalopathy. It is suggested that transplant centers abstain from treating HCV positive wait list patients so they can be transplanted with HCV positive donor organs, and to treat recipients with DAA’s post-transplant. This will potentially allow patients to receive organ transplants sooner and at a lower MELD score, and reduce the discard rate of HCV positive organs.