The New Direct Antiviral Agents and Hepatitis C in Thoracic Transplantation: Impact on Donors and Recipients

Promising Long-Term Outcomes of Lung Transplantation With Hepatitis C Positive Donors: Insights From the UNOS Registry

BACKGROUND

The development of effective direct-acting antiviral treatment (DAAT) for hepatitis C virus (HCV) has opened the possibility of using HCV+ donors. We aimed to assess the long-term feasibility of lung transplantation using organs from HCV+ donors.

METHODS

We used the UNOS database to evaluate adult lung transplant recipients between 2000 and 2023. HCV+ organs were further divided into those positive for both antibody and nucleic acid testing (NAT) or antibody testing alone. Baseline recipient and donor characteristics were compared. The Kaplan-Meier method was used to assess 30-day, 1-year, and 5-year survival. We performed risk analyses using multivariate Cox regression analyses.

RESULTS

41,797 lung transplants were performed, among which 945 used HCV+ donors. Recipients of HCV+ lungs had higher FEV1 (P < .001), older (P < .001), and had higher BMI (P < .001). While 5-year survival did not differ between recipients of HCV+ and HCV- donor lungs (P = .093), graft survival was superior among recipients of HCV+ lungs (P = .038). Acute rejection rates were also lower for recipients of HCV+ lungs (P = .018). However, recipients of HCV+ lungs required significantly higher time on the ventilator post-transplant (P = .033). Donor HCV+ status, regardless of whether they were NAT- (HR 1.03, P = .766) or NAT+ (HR 0.89, P = .24), was not associated with adverse outcomes.

CONCLUSIONS

Lung transplantation with HCV+ donor lungs demonstrates promising outcomes up to 5 years post-transplant. With careful preoperative screening, DAAT treatments, and postoperative management, recipients of HCV+ lungs may expect minimal additional complications.

Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion

Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Pre-emptive pangenotypic direct acting antiviral therapy in donor HCV-positive to recipient HCV-negative heart transplantation: an open-label study

BACKGROUND

Low donor heart availability underscores the need to identify all potentially transplantable organs. We sought to determine whether pre-emptive administration of pangenotypic direct-acting antiviral therapy can safely prevent the development of chronic hepatitis C virus (HCV) infection in uninfected recipients of HCV-infected donor hearts.

METHODS

Patients were recruited for this an open-label, single-centre, proof-of-concept study from Nov 1, 2017, to Nov 30, 2018. Following enrolment, the recipient's status on the heart transplantation waiting list was updated to reflect a willingness to accept either an HCV-positive or HCV-negative heart donor. Patients who underwent transplantation with a viraemic donor heart, as determined by nucleic acid testing (NAT), received pre-emptive oral glecaprevir-pibrentasvir before transport to the operating room followed by an 8-week course of glecaprevir-pibrentasvir after transplantation. Patients receiving HCV antibody-positive donor hearts without detectable circulating HCV RNA were followed using a reactive approach and started glecaprevir-pibrentasvir only if they developed viraemia. The primary outcome was achievement of sustained virological response 12 weeks after completion of glecaprevir-pibrentasvir therapy (SVR12). Patients were followed from study enrolment to 1 year after transplantation. This is an interim analysis, initiated after all enrolled patients reached the primary outcome. Results reflect data from Nov 1, 2017, to May 30, 2019. This trial is registered with ClinicalTrials.gov, number NCT03208244.

FINDINGS

55 patients were assessed for eligibility and 52 consented to enrolment. 25 patients underwent heart transplantation with HCV-positive donor hearts (20 NAT-positive, five NAT-negative), three of whom underwent simultaneous heart-kidney transplantation. All 20 recipients of NAT-positive hearts tolerated glecaprevir-pibrentasvir and showed rapid viral suppression (median time to clearance 3·5 days, IQR 0·0-8·3), with the subsequent achievement of SVR12 by all 20. The five recipients of NAT-negative grafts did not become viraemic. Median pre-transplant waiting time for patients following enrolment in the HCV protocol was 20 days (IQR 8-57). Patient and allograft survival were 100% at a median follow-up of 10·7 months (range 6·5-18·0).

INTERPRETATION

Pre-emptive administration of glecaprevir-pibrentasvir therapy results in expedited organ transplantation, rapid HCV suppression, prevention of chronic HCV infection, and excellent early allograft function in patients receiving HCV-infected donor hearts. Long-term outcomes are not yet known.

FUNDING

American Association for the Study of Liver Diseases, National Institutes of Health, and the Massachusetts General Hospital.

Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation

Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.