Hepatitis C donor viremic cardiac transplantation: A practical approach

Abstract

Introduction Patients with end‐stage heart failure eligible for orthotopic heart transplantation (OHT) exceed the number of available donor organs. With highly effective hepatitis C virus (HCV) antiviral therapy now available, HCV+ organs are increasingly utilized. We seek to describe our experience with patients receiving HCV viremic organs as compared to non‐HCV transplant recipients. Methods Our center began utilizing HCV hearts in February 2018. We retrospectively reviewed baseline demographics, laboratory data and outcomes for those undergoing OHT with majority being from a viremic HCV donor. Results Twenty‐three of 25 HCV recipients received hearts from NAT+ donors with 22 of 23 seroconverting within 7 days. Fifteen recipients have completed HCV treatment, with the longest duration of follow‐up being 13 months. No differences in rates of rejection, hospitalizations or death were seen between non‐HCV and HCV transplant patients. Discussion With the advent of available direct‐acting antivirals (DAAs), viremic HCV hearts provide an opportunity to increase organ availability. Moreover, treatment for HCV in the setting of immunosuppression is well‐tolerated and results in sustained viremic response. Conclusion Viremic, discordant HCV OHT can be performed in a safe and effective manner utilizing a systematic, multidisciplinary approach without an effect on short‐term outcomes.

Systematic review: hepatitis C viraemic allografts to hepatitis C‐negative recipients in solid organ transplantation

“…Our initial search terms resulted in a set of 2186 articles, of which 35 studies satisfied the inclusion and exclusion criteria (Figure 1), 13‐46 including one paper identified with reference search 47 . There were 852 SOTs, which included 343 kidney, 233 heart, 204 liver and 72 lung transplants.…”

“…There was one case of viral relapse, successfully retreated and achieved SVR12 (Table 2). 25 A total of 12 deaths occurred. Five deaths were from primary graft failure, one death from graft dysfunction, 45 one from a pulmonary embolism, 26 one from disseminated bacteremia, 27 one from heart failure, 22 two deaths from necrotizing pancreatitis 39,46 and one death from multi‐organ failure with antibody‐mediated rejection 24 .…”

“…The study by Morris et al did not wait for insurance approval before transplantation and experienced significant delays in initiating treatment despite confirmed viraemia (Table S3). 25 …”

“…Still, in those studies that addressed insurance, some relied on third‐party payers, which sometimes led to reported delays in the initiation of DAAs. In Morris et al, one patient’s DAA initiation was delayed by 169 days due to insurance appeals 25 . Aslam et al mentioned delays averaging 30 days 22 .…”

New Approaches to Donor Selection and Preparation in Heart Transplantation

“…Given these promising findings, there has been rapidly growing interest in using hearts from HCV-positive donors. Several reports have demonstrated similar survival, as well as similar incidence of acute rejection and malignancy, in recipients of HCV-positive donor hearts who were treated with direct-acting antivirals after transplant, compared to those who received HCV-negative donor organs [37,38]. The largest study to date is a prospective observational cohort from Vanderbilt University that reported outcomes on 80 recipients of HCV-positive donor hearts from 2016 to 2019 [39••].…”