Use of HCV‐infected organs in solid organ transplantation: An ethical challenge but plausible option

Abstract

Due to the unfortunate epidemic of opioid overdose deaths among people who inject drugs (PWID) in North America, there has been an increase in the availability of hepatitis C (HCV)‐positive organs for transplantation and consequently the potential to decrease waiting times for solid organ transplantation if an HCV‐uninfected recipient is willing to accept an HCV‐positive donor. The confidence in this potential new strategy comes as a result of the advent of safe and highly effective pan‐genotypic direct‐acting antivirals (DAAs). This promising strategy has been the most widely studied in kidney transplantation. Liver transplantation has positive results preliminarily, but has even less available data because viable HCV‐infected donor livers are typically transplanted into HCV‐infected individuals. Further, while HCV‐infected heart and lung transplantation, which face additional post‐transplant issues, have shown encouraging results, these studies are small scale and are limited by short‐term follow‐up. Thus, it would be premature to implement this strategy as standard of care without large scale clinical and real‐world trials and longer‐term follow‐up studies. Further, the ethics of this practice need to be considered. While some transplant professionals argue that more harm will be done by not utilizing HCV‐infected organs, others contend that cautiously conducted multi‐centre studies involving extensive post‐transplant follow‐up are paramount prior to endorsing widespread implementation of this strategy. The ethical permissibility of this practice hinges on whether access to DAA therapy can be secured in advance, and prospective recipients understand and accept all the risks associated with acquiring HCV.

Advances in resection and transplantation for hepatocellular carcinoma

“…If donors are HCV RNA positive, the transmission rate is 100%, however early DAA treatment led to sustained virological response. 107 These are promising results, but larger prospective studies are needed, as well as an understanding by payors that DAAs will be provided.…”

Post‐transplant survey to assess patient experiences with donor‐derived HCV infection

“…Additionally, there is concern regarding the level of patient understanding at time of acceptance of HCV-V organ transplant as well as the potential social and ethical implications for the patient. 19,20 Physicians and policy makers want to ensure patients are receiving appropriate and thorough education to allow for informed consent, and that high treatment costs and/or other patient perceptions and experiences are not barriers to care. While all agree that HCV-V organs should only be transplanted with explicit patient consent, 21 no standardization of consent forms or guidance regarding content has been developed to date.…”

Nierentransplantation

“…Der nachhaltige Mangel an Spenderorganen und die damit rückläufigen Transplantationszahlen bedürfen nicht nur gesellschaftlicher und politischer Diskussionen sowie systemrelevanter Verbesserungen, wie sie mit dem "Zweiten Gesetz zur Änderung des Transplantationsgesetzes -Verbesserung der Zusammenarbeit und der Strukturen bei der Organspende" auf dem Weg gebracht wurden, auch neue wissenschaftliche Konzepte sind zu untersuchen. So bedürfen Untersuchungen zum Stellenwert der Maschinenperfusion [34], der Verwendung Hepatitis C positiver Spenderorgane für Hepatitis C negative Empfänger [35,36] oder Aspekte der Xenotransplantation [37] einer kritischen ebenso wie konstruktiven Analyse und Fortentwicklung.…”