Solid organ transplantation of viral hepatitis C positive donor organs into viral hepatitis C negative recipients

Revolution in the diagnosis and management of hepatitis C virus infection in current era

Chronic hepatitis C virus (HCV) infection is a major global public health problem, particularly in developing part of the world. Significant advances have been made in the early diagnosis and treatment of the disease. Its management has been particularly revolutionized during the past two decades. In this review, we summarize the major advances in the diagnostic and management armamentarium for chronic HCV infection. The focus of the present review is on the newer directly acting anti-viral agents, which have revolutionized the management of chronic HCV infection. Management of uncomplicated chronic HCV infection and of specific complications and special at-risk populations of patients will be covered in detail. Despite the advent and approval of highly effective and well tolerable oral agents, still many challenges remain, particularly the affordability, the equitable distribution and access to later drugs. The World Health Organization aims to eliminate viral hepatitis including HCV by 2030 since its poses a major public health threat. There is an urgent need to ensure uniform and early access to diagnostic and therapeutic facilities throughout the world if the later goal has to be realized.

Present and future management of viral hepatitis

Viral hepatitis can result in important morbidity and mortality, with its impact on health conditioned by the specific type of hepatitis, the geographical region of presentation and the development and access to new drugs, among other factors. Most acute presentation forms are self-limiting and may even go unnoticed, with just a small percentage of cases leading to acute liver failure that may necessitate transplantation or even cause the death of the patient. However, when they become chronic, as in the case of hepatitis B virus and C virus, unless they are diagnosed and treated adequately they may have severe consequences, like cirrhosis or hepatocarcinoma. Understanding of the mechanisms of transmission, the pathogenesis, the presence of vaccinations and the development over recent years of new highly-efficient, potent drugs have meant that we are now faced with a new scenario in the management of viral hepatitis, particularly hepatitis B virus and hepatitis C virus. The spectacular advances in hepatitis C virus treatment have led the World Health Organization to propose the objective of its eradication by 2030. The key aspect to achieving this goal is to ensure that these treatments reach all the more vulnerable population groups, in whom the different types of viral hepatitis have a high prevalence and constitute a niche that may perpetuate infection and hinder its eradication. Accordingly, micro-elimination programs assume special relevance at the present time.

Systematic review on potential brain dead donor estimations and conversion rates to actually realized organ donations

INTRODUCTION

Accurate estimations of potential organ donors (POTDs) are required to improve transplant systems. This systematic review analyses current studies on national estimations of potential donors for transplantation as well as the practical and policy implications of detected differences.

METHOD

A systematic review of literature published between 01.01.2010 and 01.04.2020 in PubMed was conducted. Data was extracted into a self-developed matrix, and further data retrieved on national population sizes, waiting lists and transplant activities.

RESULTS

Six studies were included. Investigated populations, underlying data collections and eligibility criteria for POTDs varied widely. Estimated POTDs per million population (p.m.p.) ranged from 25.8 to 333.6, conversion rates from 3.2% to 47.5% leading to 41.2 to 86.4 transplanted organs p.m.p.. Patients on the waiting lists varied from 66.7 to 338.9 p.m.p., defining gaps between organ supply and demand in countries. Not all studies adhered to the definitions and processes of the critical pathway for deceased donation which is the latest international consensus statement on deceased organ donation.

CONCLUSION

Differences in estimated POTDs and differences in supply and demand of donor organs between countries cannot be satisfactorily explained yet due to an obvious lack of evidence, consistent methodology, international consensus and robust underlying datasets. Future studies should be based on robust underlying data sets and aim for potential donor estimations that allow national comparisons due to the adherence to the international consensus on definitions, processes and methodology.

Outcomes of Lung Transplantation from HCV Viremic Donors

BACKGROUND

Direct-acting antiviral (DAA) therapy for hepatitis C (HCV) has encouraged lung transplantation with HCV+ donors. Early trials have been promising(1, 2), however nationwide data has not been previously examined.

METHODS

The United Network for Organ Sharing registry was queried for adult patients receiving lung transplants from 2016-2019. We excluded multiorgan transplants, incomplete data, and loss to follow-up. Nucleic acid testing (NAT) determined HCV status. Propensity matching was performed for comparison of outcomes.

RESULTS

HCV NAT+ lungs were transplanted in 189 patients, compared to 9511 recipients of NAT- lungs. HCV NAT+ donors were younger (mean: 33 vs 35 years, p=0.017) with higher rates of PaO2/FiO2 >300 (83.6% vs 76.5%, p=0.029). Recipients of NAT+ lungs had lower lung allocation scores (mean: 39.3 vs 42.4; p=0.009). Distance traveled was significantly further for HCV viremic donor lungs (mean: 416 vs 206 miles, p<0.001). Kaplan Meier survival analysis demonstrated no difference in survival (p=0.56). There were no differences in airway dehiscence (p-0.629), acute rejection (p>0.999) or reintubation (p=0.304). At mean follow-up of 395 days, 63 recipients of NAT+ lungs (40.0%) seroconverted, 14 with viremia. 1-year mortality rates among seroconverted patients was 6.0% and did not differ significantly from 14.0% in non-seroconverted patients or 13.2% in recipients of HCV-negative lungs.

CONCLUSIONS

Short-term outcomes of lung transplantation from HCV viremic donors are promising, with no difference in early complications or survival. The effects of seroconversion and long-term outcomes including chronic rejection and infection need to be further explored.

Balancing the risk and rewards of utilizing organs from hepatitis C viremic donors

PURPOSE OF REVIEW

Owing to long waitlist times and high waitlist morbidity and mortality, strategies to increase utilization of hepatitis C viremic-deceased donor organs are under investigation in kidney, liver, heart, and lung transplantation.

RECENT FINDINGS

Direct-acting antiviral medications for hepatitis C virus infection have high cure rates and are well tolerated. Small, single-center trials in kidney and heart transplant recipients have demonstrated that with early posttransplant direct-acting antiviral therapy, 100% of uninfected recipients of hepatitis C viremic organs have been cured of infection after transplantation.

SUMMARY

In this manuscript, we review the risks and rewards of utilizing hepatitis C viremic organs for transplantation.

Assessing the outcome of organ allocation: choosing metrics

PURPOSE OF REVIEW

Organ allocation is a highly complex process with significant impact on outcomes of donor organs and end-stage organ disease patients. Policies governing allocation must incorporate numerous factors to meet stated objective. There have been significant alterations and ongoing discussion about changes in allocation policy for all solid organs in the United States. As with any policy change, rigorous evaluation of the impact of changes is important.

RECENT FINDINGS

This manuscript discusses metrics to consider to evaluate the impact of organ allocation policy that may be monitored on an ongoing basis including examples of research evaluating current policies. Potential metrics to evaluate allocation policy include the effectiveness, efficiency, equity, costs, donor rates, and transparency associated with the system.

SUMMARY

Ultimately, policies will often need to adapt to secular changes in donor and patient characteristics, clinical and technological advances, and overarching healthcare polices. Providing objective empirical evaluation of the impact of policies is a critical component for assessing quality of the allocation system and informing the effect of changes. The foundation of organ transplantation is built upon public trust and the dependence on the gift of donor organs, as such the importance of the most appropriate organ allocation policies cannot be overstated.

Heart Transplantation in Systemic Sclerosis: New Impulses for Conventional Scleroderma Transplantation Regimen and Scleroderma Diagnostic Monitoring: 2 Case Reports

BACKGROUND

Although low (but increasing) rates of lung/lung-heart transplantations of scleroderma (systemic sclerosis [SSc]) patients have been reported, exclusive heart transplantation is a rare approach for treatment of heart failure due to SSc.

CASES

We report on 2 cases of SSc patients receiving a heart transplantation (HTx) due to severe and progressive right heart failure without pulmonary artery hypertension. One patient received a hepatitis C virus (HCV)-positive donor heart and recovered excellently from viral transmission after administration of a direct-acting antiviral (DAA) regimen. This is the first published case of an SSc patient who underwent HTx using an HCV-positive donor heart. The clinical course of both patients was monitored by different serum SSc biomarkers. Only xylosyltransferase activity proved to be a promising biomarker for disease stage determination and therapeutic monitoring, precisely reflecting fibrotic remodeling and successful organ recovery.

CONCLUSIONS

Successful implementation of the 2 cases described here demonstrates that HTx is a safe and effective therapeutic option for defined SSc sub-patient groups despite the progressive character of the underlying disease. In the future, xylosyltransferase activity might be conducive to simplify the identification of patients with low systemic involvement but a strong indication for single heart transplantation. Finally, we demonstrate that treatment of HCV viral transmission from HCV-positive donor to organ recipient using DAA gives us new opportunities to consider HCV-positive donor organs for HTx and might reveal new possibilities to ease the lack of donor organs.