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Endo Y, Sasaki K, Munir MM, Woldesenbet S, Tsilimigras DI, Katayama E, Yang J, Limkemann A, Schenk A, Washburn K, Pawlik TM. Effect of the opioid crisis on the liver transplantation donor pool: A national analysis. Clin Transplant 2024; 38:e15290. [PMID: 38545890 DOI: 10.1111/ctr.15290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/22/2024] [Accepted: 03/03/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Over the last decade there has been a surge in overdose deaths due to the opioid crisis. We sought to characterize the temporal change in overdose donor (OD) use in liver transplantation (LT), as well as associated post-LT outcomes, relative to the COVID-19 era. METHODS LT candidates and donors listed between January 2016 and September 2022 were identified from the Scientific Registry of Transplant Recipients database. Trends in LT donors and changes related to OD were assessed pre- versus post-COVID-19 (February 2020). RESULTS Between 2016 and 2022, most counties in the United States experienced an increase in overdose-related deaths (n = 1284, 92.3%) with many counties (n = 458, 32.9%) having more than a doubling in drug overdose deaths. Concurrently, there was an 11.2% increase in overall donors, including a 41.7% increase in the number of donors who died from drug overdose. In pre-COVID-19 overdose was the 4th top mechanism of donor death, while in the post-COVID-19 era, overdose was the 2nd most common cause of donor death. OD was younger (OD: 35 yrs, IQR 29-43 vs. non-OD: 43 yrs, IQR 31-56), had lower body mass index (≥35 kg/cm2, OD: 31.2% vs. non-OD: 33.5%), and was more likely to be HCV+ (OD: 28.9% vs. non-OD: 5.4%) with lower total bilirubin (≥1.1 mg/dL, OD: 12.9% vs. non-OD: 20.1%) (all p < .001). Receipt of an OD was not associated with worse graft survival (HR .94, 95% CI .88-1.01, p = .09). CONCLUSIONS Opioid deaths markedly increased following the COVID-19 pandemic, substantially altering the LT donor pool in the United States.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Kazunari Sasaki
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashley Limkemann
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Kenneth Washburn
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Vanterpool KB, Diallo K, Kim E, Van Pilsum Rasmussen SE, Johnson MA, Predmore Z, Brundage J, Barnaba B, Desai N, Levan ML, Sung HC, Kates O, Sugarman J, Durand CM. Patient Perspectives on Solid Organ Transplantation From Donors With Hepatitis C Viremia to Recipients Without Hepatitis C Viremia. Open Forum Infect Dis 2024; 11:ofae015. [PMID: 38434612 PMCID: PMC10906703 DOI: 10.1093/ofid/ofae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/08/2024] [Indexed: 03/05/2024] Open
Abstract
Background Organ transplantation from donors with hepatitis C viremia (HCV) to recipients without HCV (HCV D+/R-) has excellent medical outcomes. Less is known about the psychosocial impact and experiences of HCV D+/R- recipients, particularly outside of clinical trials. Methods We conducted in-depth, semistructured interviews with 24 HCV D+/R- recipients (kidney, n = 8; lung, n = 7; liver, n = 5; heart, n = 3; simultaneous heart and kidney, n = 1) who received transplants outside of clinical trials and were treated for HCV after transplant to assess their experiences and perspectives. We used thematic analysis to analyze the interviews. Results Interviewees' reasons for accepting an HCV D + organ were based on perceived benefits and confidence in the effectiveness of HCV treatment. The majority (62%) received HCV treatment within 1 month after transplant (range, 1 day-2 months). Most interviewees reported positive transplant outcomes, including reduced wait times and improved survival, health, physical activity, and quality of life. Overall, themes and experiences did not differ significantly between different organ transplant types. Generally, interviewees did not perceive stigma from those aware of the HCV D+ transplant; yet, disclosure was selective and a few recipients reported concerns from family members about posttransplant HCV transmission risk. Other common concerns included treatment costs and delays, which were not always anticipated by recipients. Conclusions Our findings suggest that HCV D+/R- kidney, liver, and heart and lung transplant recipients outside of clinical trials had overall positive experiences. However, HCV transmission risk, treatments costs, and treatment delays were a source of concern that might be mitigated with targeted pretransplant education.
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Affiliation(s)
- Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Kadiatou Diallo
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellie Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Morgan A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zachary Predmore
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Janetta Brundage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj Desai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Hannah C Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivia Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Jeremy Sugarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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3
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Heald-Sargent T, Michaels MG, Ardura MI. Pre-Transplantation Strategies for Infectious Disease Mitigation and Prevention. J Pediatric Infect Dis Soc 2024; 13:S3-S13. [PMID: 38417081 DOI: 10.1093/jpids/piad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/22/2023] [Indexed: 03/01/2024]
Abstract
Pediatric Infectious Disease (ID) clinicians play a critical role in helping prevent and mitigate infectious risks in children peri- and post-transplantation. Prevention starts during the pre-transplant evaluation and persists throughout the solid organ transplant and hematopoietic cell transplant continuum. The pre-transplant evaluation is an opportunity to screen for latent infections, plan preventative strategies, optimize immunizations, and discuss risk mitigation practices. An ideal pre-transplant evaluation establishes a relationship with the family that further promotes post-transplant infectious risk reduction. This manuscript builds on shared pediatric ID prevention strategies, introduces updated ID testing recommendations for transplant donors/candidates, highlights emerging data, and identifies ongoing knowledge gaps that are potential areas of research.
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Affiliation(s)
- Taylor Heald-Sargent
- Department of Pediatrics, Division of Infectious Diseases, Northwestern University, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica I Ardura
- Division of Pediatric Infectious Diseases & Host Defense Program, Nationwide Children's Hospital and Department of Pediatrics, The Ohio University College of Medicine, Columbus, Ohio, USA
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4
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Fox DK, Waken RJ, Wang F, Wolfe JD, Robbins K, Fanous E, Vader JM, Schilling JD, Joynt Maddox KE. The Association of the UNOS Heart Allocation Policy Change With Transplant and Left Ventricular Assist Device Access and Outcomes. Am J Cardiol 2023; 204:392-400. [PMID: 37586314 PMCID: PMC10950424 DOI: 10.1016/j.amjcard.2023.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
In October 2018, the allocation policy for adult orthotopic heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. This study aimed to assess the association of this policy change with changes in access to OHTx versus left ventricular assist devices (LVADs), overall and in key sociodemographic subgroups, in the United States from 2016 to 2019. We identified all patients receiving OHTx or LVAD between 2016 and 2019 using the National Inpatient Sample. Controlling for medical co-morbidities, prepolicy trends, and within-hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx versus LVAD before versus after policy change. We also examined the frequency of temporary mechanical circulatory support in the same fashion. We identified 2,264 patients who received OHTx and 3,157 who received LVADs during the study period. In its first year of implementation, the United Network for Organ Sharing policy change of 2018 was associated with no overall change utilization of OHTx versus LVAD. In OHTx recipients, the frequency of use of temporary mechanical circulatory support changed from 15.6% in the before period to 42.6% in the after period (p <0.001). Although the policy change was associated with differences in the odds of receiving an OHTx versus LVAD between different regions of the country, there were no significant changes based on age, gender, race/ethnicity, insurance status, or rurality. In conclusion, the United Network for Organ Sharing policy change on access to OHTx was associated with no overall change in OHTx versus LVAD use in its first year of implementation although we observed small changes in relative odds of transplant based on rurality. Shifts in regional allocation were not significant overall, although certain regions appeared to have a relative increase in their use of OHTx.
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Affiliation(s)
- Daniel K Fox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - R J Waken
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Fengxian Wang
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Jonathan D Wolfe
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keenan Robbins
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Erika Fanous
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Vader
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Joel D Schilling
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis.
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5
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Torres-Díaz JA, Jasso-Baltazar EA, Toapanta-Yanchapaxi L, Aguirre-Valadez J, Martínez-Matínez L, Sánchez-Cedillo A, Aguirre-Villarreal D, García-Juárez I. Hepatitis C virus-positive donors in HCV-negative recipients in liver transplantation: Is it possible in Mexico? REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:392-403. [PMID: 38097433 DOI: 10.1016/j.rgmxen.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 01/01/2024]
Abstract
Hepatitis C virus (HCV) infection is a worldwide public health problem associated with significant morbidity and mortality. In the context of liver transplantation, the demand for organs continues to exceed the supply, prompting the consideration of using organs from HCV-positive donors in HCV-negative recipients. The introduction of direct-acting antivirals (DAAs), which have demonstrated great efficacy in eradicating the virus, has made transplantation of organs from donors with HCV infection possible. The present article provides a brief review of the current evidence on the use of organs from HCV-infected patients.
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Affiliation(s)
- J A Torres-Díaz
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E A Jasso-Baltazar
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L Toapanta-Yanchapaxi
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Departamento de Gastroenterología, Hospital Ángeles Pedregal, Mexico City, Mexico
| | - J Aguirre-Valadez
- Departamento de Gastroenterología, Hospital Ángeles Pedregal, Mexico City, Mexico
| | - L Martínez-Matínez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - A Sánchez-Cedillo
- Departamento de trasplante, Hospital General de México, Mexico City, Mexico
| | - D Aguirre-Villarreal
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I García-Juárez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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6
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Sharma P, Sawtell R, Wang Q, Sise ME. Management of Hepatitis C Virus and Hepatitis B Virus Infection in the Setting of Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:343-355. [PMID: 37657881 PMCID: PMC10479952 DOI: 10.1053/j.akdh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 09/03/2023]
Abstract
Treatment of chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection poses unique challenges in patients with kidney disease. Direct-acting antivirals have been a major breakthrough in eradicating HCV infection, and several pangenotypic regimens are available for patients with chronic kidney disease or end-stage kidney disease requiring dialysis with high cure rates and no need for dose adjustment. Direct-acting antiviral therapy alone can treat HCV-associated cryoglobulinemic glomerulonephritis; concurrent antiviral and immunosuppressive therapy is needed for cases of severe, organ-threatening manifestations of cryoglobulinemia. Immunosuppression may be needed for HBV-associated kidney disease (polyarteritis nodosa or membranous nephropathy) when there is evidence of severe immune-mediated injury while weighing the risk of potential viral activation. Most HBV antiviral agents need to be dose-adjusted in patients with chronic kidney disease or end-stage kidney disease requiring dialysis, and drug-drug interactions need to be carefully evaluated in patients with kidney transplants. Considerations for accepting HCV- and HBV-infected donors for kidney transplantation are discussed.
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Affiliation(s)
- Purva Sharma
- Department of Medicine, Division of Nephrology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Glomerular Disease Center at Northwell Health, Hempstead, NY
| | - Rani Sawtell
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Qiyu Wang
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA.
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7
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Potluri V, Naqvi F, Goldberg DS, Shah M, Loupy A, Abt P, Blumberg E, Trofe-Clark J, Bloom R, Sawinski D, Chattergoon M, Segev DL, Bair-Marcantoni N, Durand CM, Reddy R, Levine M, Brown N, Mapchan S, Aubert O, Desai N, Reese PP. Longer-Term Clinical Outcomes From the THINKER and EXPANDER Trials of Transplantation of HCV-RNA+ Donor Kidneys Into Hepatitis C Virus-Negative Recipients. Kidney Int Rep 2023; 8:1460-1463. [PMID: 37441470 PMCID: PMC10334397 DOI: 10.1016/j.ekir.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/24/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Vishnu Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fizza Naqvi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mital Shah
- Division of Nephrology, Department of Medicine, Robert Wood Johnson University, New Brunswick, New Jersey, USA
| | - Alexandre Loupy
- Université de Paris, INSERM, Paris Translational Research Center for Organ Transplantation, Paris, France
| | - Peter Abt
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Blumberg
- Division of Infectious Disease, Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Trofe-Clark
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roy Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Deirdre Sawinski
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Michael Chattergoon
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, New York University, New York, New York, USA
| | | | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajender Reddy
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Levine
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas Brown
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shristi Mapchan
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olivier Aubert
- Université de Paris, INSERM, Paris Translational Research Center for Organ Transplantation, Paris, France
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Université de Paris, INSERM, Paris Translational Research Center for Organ Transplantation, Paris, France
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sutcliffe S, Ji M, Chang SH, Stewart D, Axelrod DA, Lentine KL, Wellen J, Alrata L, Gupta G, Alhamad T. The association of donor hepatitis C virus infection with 3-year kidney transplant outcomes in the era of direct-acting antiviral medications. Am J Transplant 2023; 23:629-635. [PMID: 37130619 DOI: 10.1016/j.ajt.2022.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 01/14/2023]
Abstract
To determine the effect of donor hepatitis C virus (HCV) infection on kidney transplant (KT) outcomes in the era of direct-acting antiviral (DAA) medications, we examined 68,087 HCV-negative KT recipients from a deceased donor between March 2015 and May 2021. A Cox regression analysis was used to estimate adjusted hazard ratios (aHRs) of KT failure, incorporating inverse probability of treatment weighting to control for patient selection to receive an HCV-positive kidney (either nucleic acid amplification test positive [NAT+, n = 2331] or antibody positive (Ab+)/NAT- [n = 1826]) based on recipient characteristics. Compared with kidney from HCV-negative donors, those from Ab+/NAT- (aHR = 0.91; 95% confidence interval [CI], 0.75-1.10) and HCV NAT+ (aHR = 0.89; 95% CI, 0.73-1.08) donors were not associated with an increased risk of KT failure over 3 years after transplant. Moreover, HCV NAT+ kidneys were associated with a higher 1-year estimated glomerular filtration (63.0 vs 61.0 mL/min/1.73 m2, P = .007) and lower risk of delayed graft function (aOR = 0.76; 95% CI, 0.68-0.84) compared with HCV-negative kidneys. Our findings suggest that donor HCV positivity is not associated with an elevated risk of graft failure. The inclusion of donor HCV status in the Kidney Donor Risk Index may no longer be appropriate in contemporary practice.
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Affiliation(s)
- Siobhan Sutcliffe
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA
| | - Mengmeng Ji
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA; Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA
| | - Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Krista L Lentine
- Division of Nephrology, Saint Louis University, St Louis, Missouri, USA
| | - Jason Wellen
- Division of Transplant Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Louai Alrata
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA.
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9
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Johnson W, Kraft K, Chotai P, Lynch R, Dittus RS, Goldberg D, Ye F, Doby B, Schaubel DE, Shah MB, Karp SJ. Variability in Organ Procurement Organization Performance by Individual Hospital in the United States. JAMA Surg 2023; 158:404-409. [PMID: 36753195 PMCID: PMC9909569 DOI: 10.1001/jamasurg.2022.7853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/23/2022] [Indexed: 02/09/2023]
Abstract
Importance Availability of organs inadequately addresses the need of patients waiting for a transplant. Objective To estimate the true number of donor patients in the United States and identify inefficiencies in the donation process as a way to guide system improvement. Design, Setting, and Participants A retrospective cross-sectional analysis was performed of organ donation across 13 different hospitals in 2 donor service areas covered by 2 organ procurement organizations (OPOs) in 2017 and 2018 to compare donor potential to actual donors. More than 2000 complete medical records for decedents were reviewed as a sample of nearly 9000 deaths. Data were analyzed from January 1, 2017, to December 31, 2018. Exposure Deaths of causes consistent with donation according to medical record review, ventilated patient referrals, center acceptance practices, and actual deceased donors. Main Outcomes and Measures Potential donors by medical record review vs actual donors and OPO performance at specific hospitals. Results Compared with 242 actual donors, 931 potential donors were identified at these hospitals. This suggests a deceased donor potential of 3.85 times (95% CI, 4.23-5.32) the actual number of donors recovered. There was a surprisingly wide variability in conversion of potential donor patients into actual donors among the hospitals studied, from 0% to 51.0%. One OPO recovered 18.8% of the potential donors, whereas the second recovered 48.2%. The performance of the OPOs was moderately related to referrals of ventilated patients and not related to center acceptance practices. Conclusions and Relevance In this cross-sectional study of hospitals served by 2 OPOs, wide variation was found in the performance of the OPOs, especially at individual hospitals. Addressing this opportunity could greatly increase the organ supply, affirming the importance of recent efforts from the federal government to increase OPO accountability and transparency.
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Affiliation(s)
- Wali Johnson
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathryn Kraft
- Division of Abdominal Transplant Surgery, University of Kentucky, Lexington
| | - Pranit Chotai
- Division of Transplantation, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert S. Dittus
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare Center, Nashville
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brianna Doby
- Department of Public Health Sciences, New Mexico State University, College of Health, Education, and Social Transformation, Las Cruces
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Malay B. Shah
- Division of Abdominal Transplant Surgery, University of Kentucky, Lexington
| | - Seth J. Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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Woolley AE, Gandhi AR, Jones ML, Kim JJ, Mallidi HR, Givertz MM, Baden LR, Mehra MR, Neilan AAM. The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients. Transplantation 2023; 107:961-969. [PMID: 36525554 PMCID: PMC10065819 DOI: 10.1097/tp.0000000000004378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/29/2022] [Accepted: 08/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy. METHODS We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY). RESULTS Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs. CONCLUSIONS Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.
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Affiliation(s)
- Ann E Woolley
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aditya R Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Michelle L Jones
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Hari R Mallidi
- Harvard Medical School, Boston, MA
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael M Givertz
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lindsey R Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Mandeep R Mehra
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - And Anne M Neilan
- Harvard Medical School, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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11
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Daloul R, Sureshkumar K, Schnelle K, Von Stein L, Logan A, Pesavento T. Kidney transplant from HCV viremic donors to HCV-negative recipients and risk for de novo donor specific antibodies and acute rejection. Clin Transplant 2023; 37:e14895. [PMID: 36580971 DOI: 10.1111/ctr.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Kidney transplantation from HCV-viremic donors into uninfected recipients is associated with excellent short-term outcomes. However, concerns regarding an increased risk for the development of de novo donor specific antibodies (DSA) and acute rejection have been raised in single center reports. METHODS A retrospective study of HCV-negative kidney-only transplant recipients between 2018 and 2020. Patients were grouped based on the donor HCV status into group 1; HCV-viremic donors, and group 2; HCV-negative donors. Inverse probability of treatment weighting (IPTW), with weights derived from the propensity score, were used to estimate the effect of donors' HCV-viremia on the recipients. The primary objective was to compare the 1-year incidence of de novo DSA. Secondary outcomes included group comparison of the incidence of biopsy proven acute rejection (BPAR), 1-year patient and allograft survival, and 1-year renal allograft function. RESULTS A total of 71 patients were included in the HCV NAT+ group, and 440 in the HCV- negative group. One-year incidence of de novo DSA was higher in the HCV NAT+ group in the IPTW weighted analysis (19% vs. 9%, p = .02). In the unweighted analysis, BPAR occurred in 7% of recipients in the HCV NAT+ group, compared to 3% in the control group (p = .06). However, due to the low event rate in the in the IPTW weighted groups, a statistical significance test could not be performed. Average estimated GFR was higher in the HCV-viremic group at 3 months (61 vs. 53 ml/min/1.73 m2 p = .002), but comparable at 6 (59 vs. 56 ml/min/1.73 m2 , p = .31) and 12 months (60 vs. 55 ml/min/1.73 m2 , p = .07). Patient and allograft survival were comparable between the two groups. CONCLUSION Kidney transplant from HCV-viremic donors was associated with an increased risk for the development of post-transplant de novo DSA in the first year after transplantation, but no difference in patient and graft survival.
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Affiliation(s)
- Reem Daloul
- Division of Nephrology, Department of Internal Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kalathil Sureshkumar
- Division of Nephrology, Department of Internal Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kendra Schnelle
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lauren Von Stein
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - April Logan
- Division of Transplantation, Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Todd Pesavento
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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12
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Kwon JH, Hill MA, Patel R, Tedford RJ, Hashmi ZA, Shorbaji K, Huckaby LV, Welch BA, Kilic A. Outcomes of Over 1000 Heart Transplants Using Hepatitis C-Positive Donors in the Modern Era. Ann Thorac Surg 2023; 115:493-500. [PMID: 36368348 DOI: 10.1016/j.athoracsur.2022.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/10/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Advances in hepatitis C virus (HCV) treatment and the ongoing opioid epidemic have made HCV-positive donors increasingly available for heart transplantation (HT). This analysis reports outcomes of over 1000 HCV-positive HTs in the United States in the modern era. METHODS The United Network of Organ Sharing registry was used to identify HTs between 2015 and 2021. Recipients were grouped by donor HCV status and by nucleic acid amplification test (NAT) positivity. The primary outcome was 1-year mortality, and secondary outcomes included 3-year mortality. A subanalysis compared HCV-positive HT outcomes between NAT-positive and NAT-negative donors. Risk adjustment was performed using Cox regression. Kaplan-Meier analysis was used to estimate survival. RESULTS The frequency of HCV-positive HT increased from 0.12% of HTs in 2015 to 12.9% in 2021 (P < .001). Of 16,648 HTs, 1170 (7.0%) used an organ from an HCV-positive donor. Recipients of HCV-positive organs were more likely to be HCV seropositive, older, and White. Unadjusted 1- and 3-year survival rates were not significantly different between recipients of HCV-negative and HCV-positive organs. After risk adjustment HCV-positive donor status was not associated with an elevated risk for 1-year (hazard ratio, 0.92; 95% CI, 0.71-1.19; P = .518) or 3-year mortality. Among HCV-positive HTs 772 (61.7%) were NAT positive. After risk adjustment NAT positivity did not impact 1-year mortality. CONCLUSIONS The proportion of HCV-positive HTs has increased over 100-fold in recent years. This analysis of the US experience demonstrates that recipients of HCV-positive hearts, including those that are NAT positive, have acceptable outcomes with similar early to midterm survival as recipients of HCV-negative organs.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Morgan A Hill
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Raj Patel
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan J Tedford
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
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13
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Nair SS, Thorp AN, Hanna W, Johnson BK, Smith B, Iyengar S, Howe EA, Mour GK. Effectiveness of education and attitudes toward different types of deceased donor kidneys: Survey analysis of single-center experience. Front Public Health 2023; 11:1116823. [PMID: 37064665 PMCID: PMC10090271 DOI: 10.3389/fpubh.2023.1116823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 04/18/2023] Open
Abstract
Background We lack data on the effectiveness of education and the patient's attitude toward different deceased donor kidney types. A prospective study was performed to evaluate patient attitudes, baseline knowledge, and effectiveness of our kidney transplant education process. We also analyzed the knowledge retention of our waitlist patients. Design We prospectively surveyed a patient cohort using a paired analysis pre and post education with initial evaluation visit. Knowledge retention among waitlist patients was assessed with annual waitlist visit. Results One hundred four patients received paired surveys to assess the baseline knowledge and effectiveness of education. Forty-three patients received a single survey with their annual waitlist evaluation to assess knowledge retention. Paired survey showed mixed results, with no statistically significant improvement in the kidney donor profile index domain. Significant improvement was seen in the hepatitis C virus-positive donor domain and the Public Health Service (PHS) increased-risk donor domain. For the waitlist cohort, overall knowledge retention ranged from excellent to fair, with a decline in knowledge for the PHS increased-risk donor domain. Conclusion Our study suggests that the education intervention regarding different deceased donor kidney types is effective overall and transplant candidates retain the knowledge while waiting for transplant.
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Affiliation(s)
- Sumi S. Nair
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
| | - Andrea N. Thorp
- Department of Nursing, Mayo Clinic, Phoenix, AZ, United States
| | - Wael Hanna
- Dallas Nephrology Associates, Dallas, TX, United States
| | - Bradley K. Johnson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Byron Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Savitha Iyengar
- Manager Transplant Quality and Compliance, Mayo Clinic, Rochester, MN, United States
| | | | - Girish K. Mour
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Girish K. Mour
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14
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Xie MW, Kennan SP, Slaunwhite A, Rose C. Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada. Can J Kidney Health Dis 2023; 10:20543581231156853. [PMID: 37051047 PMCID: PMC10084533 DOI: 10.1177/20543581231156853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/07/2023] [Indexed: 04/07/2023] Open
Abstract
Background: The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years. Objective: This study examines whether graft loss after kidney transplantation differed by donor cause of death. Design: Retrospective cohort. Setting: Provincial transplant program of British Columbia, Canada. Patients: Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012). Measurements: Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other. Methods: Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted. Results: Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all-cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys ( P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015). Limitations: Potential selection bias, potential unmeasured confounding. Conclusions: Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation.
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Affiliation(s)
| | - Sean Patrick Kennan
- British Columbia Transplant, Vancouver, Canada
- The University of British Columbia, Vancouver, Canada
| | - Amanda Slaunwhite
- BC Centre for Disease Control, Vancouver, Canada
- The University of British Columbia, Vancouver, Canada
| | - Caren Rose
- BC Centre for Disease Control, Vancouver, Canada
- The University of British Columbia, Vancouver, Canada
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15
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What's in a name? Higher risks with donation after cardiac death than public health service increased risk livers. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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16
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Deceased donors with multidrug-resistant organisms: implications and future directions. Curr Opin Organ Transplant 2022; 27:250-256. [PMID: 36354250 DOI: 10.1097/mot.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Organ utilization from donors infected or colonized with multidrug-resistant organisms (MDROs) remains inconsistent, and hesitancy to accept organs from these donors may relate to poor outcomes among solid organ transplant recipients with MDRO donor-derived infections (DDIs). An improved understanding of the risk factors for donor MDRO colonization or infection and the risk of MDRO DDI is needed to safely expand the donor pool while minimizing unnecessary organ discard. RECENT FINDINGS Recent studies have begun to delineate risk factors for MDRO acquisition among deceased donors and the epidemiology of MDRO DDIs, but additional efforts are warranted to inform optimal approaches to donor evaluation, risk stratification, management, interfacility and interagency data sharing, and approaches to recipient management. SUMMARY This review summaries recent data regarding risk factors for MDRO colonization and infection in deceased donors, epidemiology of MDRO DDIs, and current approaches to donors harboring MDROs and provides a framework for future research and collaboration.
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17
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Decision-making Among Hepatitis C Virus-negative Transplant Candidates Offered Organs from Donors with HCV Infection. Transplant Direct 2022; 8:e1341. [PMID: 35923812 PMCID: PMC9298473 DOI: 10.1097/txd.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Historically, many organs from deceased donors with hepatitis C virus (HCV) were discarded. The advent of highly curative direct-acting antiviral (DAA) therapies motivated transplant centers to conduct trials of transplanting HCV-viremic organs (nucleic acid amplification test positive) into HCV-negative recipients, followed by DAA treatment. However, the factors that influence candidates' decisions regarding acceptance of transplant with HCV-viremic organs are not well understood. Methods To explore patient-level perceptions, influences, and experiences that inform candidate decision-making regarding transplant with organs from HCV-viremic donors, we conducted a qualitative semistructured interview study embedded within 3 clinical trials investigating the safety and efficacy of transplanting lungs and kidneys from HCV-viremic donors into HCV-negative recipients. The study was conducted from June 2019 to March 2021. Results Among 44 HCV-negative patients listed for organ transplant who were approached for enrollment in the applicable clinical trial, 3 approaches to decision-making emerged: positivist, risk analyses, and instinctual response. Perceptions of risk contributed to conceptualizations of factors influencing decisions. Moreover, most participants relied on multiple decision-making approaches, either simultaneously or sequentially. Conclusions Understanding how different decisional models influence patients' choices regarding transplant with organs from HCV-viremic donors may promote shared decision-making among transplant patients and providers.
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18
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Utilization of HCV Viremic Kidneys with Genotyping/Subtyping-Free Sofosbuvir/Velpatasvir Treatment Strategy: Experience from China. BIOMED RESEARCH INTERNATIONAL 2022; 2022:3758744. [PMID: 35941983 PMCID: PMC9356870 DOI: 10.1155/2022/3758744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/26/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
Background. Owing to the advent of pangenotypic direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) treatment, utilization of HCV-infected deceased donor kidneys with simplified genotyping/subtyping-free sofosbuvir/velpatasvir (SOF/VEL) treatment strategy is now becoming a promising strategy for expanding the organ donor pool. Methods. This retrospective, comparative, single-center study included HCV viremic donor kidneys that were transplanted to 9 HCV-positive (HCV Ab-positive) recipients (D+/R+ group) and 14 HCV-negative recipients (D+/R- group) from May 2018 to January 2021. Both groups received prophylaxis with SOF/VEL treatment within 1-week posttransplant devoid of HCV genotyping/subtyping. The primary outcomes were sustained virologic response 12 weeks after completion of therapy (SVR12) and graft survival at 1-year posttransplant. Results. Baseline characteristics were similar between the HCV D+/R- and D+/R+ groups. The mean age of all recipients was
(SD) years, and 73.9% were male. A total of 92.9% (13 out of 14) recipients had pretreatment HCV viremia in the D+/R- group. The pretreatment HCV viral load in the D+/R+ group (5.98, log 10 IU/mL; IQR, 5.28-6.53) was significantly higher than that in the D+/R- group (3.61, log 10 IU/mL; IQR, 2.57-4.57). After SOF/VEL treatment, SVR12 was achieved in all recipients, with a 100% 1-year patient and graft survival rates. The D+/R+ group had a higher incidence of abnormal liver function (44.4% vs. 7.1%). No significant difference was observed between the two groups in terms of DGF, acute rejection, ALT, serum creatinine, and eGFR within 1-year posttransplant. No severe adverse events associated with either HCV viremia or SOF/VEL were observed. Conclusions. Using a simplified genotyping/subtyping-free SOF/VEL treatment strategy, kidneys from hepatitis C viremic donors for both infected and uninfected recipients presented with safe, excellent, and comparable 1-year outcomes, which can safely expand the donor pool. HCV-positive donor kidneys should be utilized regularly, regardless of the recipient’s HCV status.
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19
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Survival Benefit in Older Patients Transplanted With Viremic Hepatitis C Positive Kidneys When Compared With High KDPI Kidneys. Transplantation 2022; 106:2217-2223. [PMID: 35675439 DOI: 10.1097/tp.0000000000004179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Because of the continued demand in kidney transplantation, organs from donors with risk criteria for blood-borne viruses, high Kidney Donor Profile Index (KDPI) kidneys, and hepatitis C virus (HCV)-positive kidneys are being considered. There continues to be reluctance on the part of the providers and the candidates to accept HCV-positive kidneys. METHODS We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adult (≥18 y old) recipients undergoing kidney transplant from May 10, 2013, to June 30, 2021. We compared patient and graft survival in candidates who received HCV-positive kidneys versus non-hepatitis C (Hep C) high KDPI kidneys by estimated posttransplant survival (EPTS) groups. RESULTS HCV-viremic kidneys were transplanted in 5.6% of patients in the EPTS >61% group compared with 5.1% of patients in the 21%-60% EPTS group and 1.9% of 0%-20% EPTS group (P < 0.001). Of all transplants performed in the EPTS 61%-100% group, 11.9% were KDPI >85% compared with 5.2% in the EPTS 21%-60%, and 0.5% in the EPTS 0%-20%. Patient survival was significantly longer at 1, 3, and 5 y in the EPTS >61% group who received Hep C-viremic or -nonviremic allografts compared with non-Hep C kidneys with KDPI >85%. When it comes to listing, only 25% of candidates in the EPTS >61% group were listed for Hep C nucleic acid testing-positive kidneys in 2021. CONCLUSIONS Our findings could be used for counseling candidates on the types of kidneys they should consider for transplantation. Also, listing practices for viremic Hep C kidneys need continued re-evaluation.
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20
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Patnaik R, Tsai E. Hepatitis C Virus Treatment and Solid Organ Transplantation. Gastroenterol Hepatol (N Y) 2022; 18:85-94. [PMID: 35505819 PMCID: PMC9053510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Hepatitis C virus (HCV) infection is a common indication for liver transplantation. If the patient's HCV is untreated prior to liver transplant, infection of the allograft is nearly universal and can lead to graft failure. The demand for deceased-donor organ transplantation continues to surpass the available supply of donor organs. Waitlist mortality remains an important concern, and several strategies have been enacted to increase organ supply, such as using high-risk donors, including those who are HCV positive. The development of safe and highly effective HCV therapy with direct-acting antiviral agents has revolutionized the management of liver transplant candidates and transplantrecipients. Moreover, thenewer antiviral therapieshave paved the road for use of HCV-viremic organs, effectively expanding the donor pool and changing the landscape of solid organ transplantation. This article reviews the data on HCV treatment prior to and after organ transplantation.
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Affiliation(s)
| | - Eugenia Tsai
- UT Health San Antonio, San Antonio, Texas
- Texas Liver Institute, San Antonio, Texas
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21
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Sise ME, Goldberg DS, Schaubel DE, Fontana RJ, Kort JJ, Alloway RR, Durand CM, Blumberg EA, Woodle ES, Sherman KE, Brown RS, Friedewald JJ, Desai NM, Sultan ST, Levitsky J, Lee MD, Strohbehn IA, Landis JR, Fernando M, Gustafson JL, Chung RT, Reese PP. One-Year Outcomes of the Multi-Center StudY to Transplant Hepatitis C-InfeCted kidneys (MYTHIC) Trial. Kidney Int Rep 2022; 7:241-250. [PMID: 35155863 PMCID: PMC8820987 DOI: 10.1016/j.ekir.2021.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Transplanting kidneys from hepatitis C virus (HCV) viremic donors into HCV-negative patients (HCV D-RNA-positive/R-negative) has evolved from experimental to “standard-of-care” at many centers. Nevertheless, most data derive from single centers and provide only short-term follow-up. Methods The Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC) study was a multicenter (7 sites) trial of HCV D-RNA-positive/R-negative kidney transplantation (KT) followed by 8 weeks of glecaprevir/pibrentasvir (G/P) initiated 2 to 5 days post-KT. Prespecified outcomes included probability of KT (vs. matched waitlist comparators) and 1-year safety outcomes, allograft function, and survival. Results Among 63 enrolled patients, 1-year cumulative incidence of KT was approximately 3.5-fold greater for the MYTHIC cohort versus 2055 matched United Network for Organ Sharing (UNOS) comparators who did not opt-in to receive a kidney from an HCV-viremic donor (68% vs. 19%, P < 0.0001). Of 30 HCV D-RNA-positive/R-negative KT recipients, all achieved HCV cure. None developed clinically significant liver disease or HCV-related kidney injury. Furthermore, 1-year survival was 93% and 1-year graft function was excellent (median creatinine 1.17; interquartile range [IQR]: 1.02–1.38 mg/dl). There were 4 cases of cytomegalovirus (CMV) disease among 10 CMV-negative patients transplanted with a kidney from an HCV-viremic/CMV-positive donor. Conclusion The 1-year findings from this multicenter trial suggest that opting-in for HCV-viremic KT offers can increase probability of KT with excellent 1-year outcomes. Trial Registration: NCT03781726
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22
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Egan TM, Haithcock BE, Lobo J, Mody G, Love RB, Requard JJ, Espey J, Ali MH. Donation after circulatory death donors in lung transplantation. J Thorac Dis 2022; 13:6536-6549. [PMID: 34992833 PMCID: PMC8662509 DOI: 10.21037/jtd-2021-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
Transplantation of any organ into a recipient requires a donor. Lung transplant has a long history of an inadequate number of suitable donors to meet demand, leading to deaths on the waiting list annually since national data was collected, and strict listing criteria. Before the Uniform Determination of Death Act (UDDA), passed in 1980, legally defined brain death in the U.S., all donors for lung transplant came from sudden death victims [uncontrolled Donation after Circulatory Death donors (uDCDs)] in the recipient’s hospital emergency department. After passage of the UDDA, uDCDs were abandoned to Donation after Brain Death donors (DBDs)—perhaps prematurely. Compared to livers and kidneys, many DBDs have lungs that are unsuitable for transplant, due to aspiration pneumonia, neurogenic pulmonary edema, trauma, and the effects of brain death on lung function. Another group of donors has become available—patients with a devastating irrecoverable brain injury that do not meet criteria for brain death. If a decision is made by next-of-kin (NOK) to withdraw life support and allow death to occur by asphyxiation, with NOK consent, these individuals can have organs recovered if death occurs relatively quickly after cessation of mechanical ventilation and maintenance of their airway. These are known as controlled Donation after Circulatory Death donors (cDCDs). For a variety of reasons, in the U.S., lungs are recovered from cDCDs at a much lower rate than kidneys and livers. Ex-vivo lung perfusion (EVLP) in the last decade has had a modest impact on increasing the number of lungs for transplant from DBDs, but may have had a larger impact on lungs from cDCDs, and may be indispensable for safe transplantation of lungs from uDCDs. In the next decade, DCDs may have a substantial impact on the number of lung transplants performed in the U.S. and around the world.
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Affiliation(s)
- Thomas M Egan
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jason Lobo
- Department of Medicine, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Gita Mody
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Robert B Love
- Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA
| | | | - John Espey
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Mir Hasnain Ali
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
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23
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Shepherd HM, Gauthier JM, Puri V, Kreisel D, Nava RG. Advanced considerations in organ donors. J Thorac Dis 2022; 13:6528-6535. [PMID: 34992832 PMCID: PMC8662482 DOI: 10.21037/jtd-2021-08] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 02/02/2021] [Indexed: 12/16/2022]
Abstract
The rising need for lung transplantation over recent years has not paralleled the availability of suitable lung allografts. The number of lung transplantations performed each year in the United States remains limited by an inadequate supply of suitable donors as well as low donor utilization rates. While several methods have been proposed for increasing the donor pool, there is considerable disparity between acceptance and utilization of these practices among transplant centers. In this review article, we explore various approaches for enhancing donor selection and expanding the donor pool. We discuss the use of “extended criteria” donors including high risk groups such as drug overdose donors, and we examine the role of techniques in donor assessment and selection such as the use of computed tomography for accurate size matching. We review topics in donor management such as the establishment of specialized donor care facilities and the implementation of lung-focused resuscitation protocols, and we discuss advancements in donor procurement such as the utilization of local procurement teams. We also review barriers to donation, such as variability in organ procurement organization (OPO) consent practices, as well as patient-specific factors such as religious or cultural beliefs. Addressing these aspects of donor evaluation, management, and accessibility is essential in maximizing the number of lungs available for transplantation within the existing donor pool.
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Affiliation(s)
- Hailey M Shepherd
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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24
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Zaffar D, Muhammad H, Gurakar A. The use of HCV positive donors among non-HCV infected liver transplant recipients. HEPATOLOGY FORUM 2022; 3:1-2. [PMID: 35782374 PMCID: PMC9138910 DOI: 10.14744/hf.2021.2021.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Duha Zaffar
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haris Muhammad
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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An Update on Usage of High-Risk Donors in Liver Transplantation. J Clin Med 2021; 11:jcm11010215. [PMID: 35011956 PMCID: PMC8746244 DOI: 10.3390/jcm11010215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022] Open
Abstract
The ideal management for end stage liver disease, acute liver failure, and hepatocellular carcinoma (HCC), within specific criteria, is liver transplantation (LT). Over the years, there has been a steady increase in the candidates listed for LT, without a corresponding increase in the donor pool. Therefore, due to organ shortage, it has been substantially difficult to reduce waitlist mortality among patients awaiting LT. Thus, marginal donors such as elderly donors, steatotic donors, split liver, and donors after cardiac death (DCD), which were once not commonly used, are now considered. Furthermore, it is encouraging to see the passing of Acts, such as the HIV Organ Policy Equity (HOPE) Act, enabling further research and development in utilizing HIV grafts. Subsequently, the newer antivirals have aided in successful post-transplant period, especially for hepatitis C positive grafts. However, currently, there is no standardization, and protocols are center specific in the usage of marginal donors. Therefore, studies with longer follow ups are required to standardize its use.
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26
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Huckaby LV, Seese LM, Handzel R, Wang Y, Hickey G, Kilic A. Center-level Utilization of Hepatitis C Virus-positive Donors for Orthotopic Heart Transplantation. Transplantation 2021; 105:2639-2645. [PMID: 33988340 PMCID: PMC9015733 DOI: 10.1097/tp.0000000000003674] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of hepatitis C virus-positive (HCV+) donors has expanded the donor pool for orthotopic heart transplantation (OHT). This study evaluated center-level trends and utilization of HCV+ donors for OHT. METHODS Data were extracted from the Scientific Registry of Transplant Recipients on adults (≥18 y) undergoing OHT between January 1, 2016 and December 31, 2019. Centers performing <10 OHTs during the study period were excluded. Donor utilization rates were evaluated at the center level. Center-level characteristics were compared between centers performing HCV+ donor hepatitis C virus-negative (HCV-) recipient OHTs and those not utilizing HCV+ donors for HCV- recipients. RESULTS A total of 10 134 patients underwent OHT, including 613 (6.05%) HCV+ donors transplanted into HCV- recipients. The number of HCV+ OHTs increased from 15 of 2512 (0.60%) in 2016 to 285 of 2490 (11.45%) in 2019 (P < 0.001). In 2016, among 105 centers performing OHTs, 7 (6.67%) utilized HCV+ donors compared to 2019 during which 55 (52.89%) of 104 centers utilized HCV+ donors (P < 0.001). In total, 57 of 107 (53.27%) centers utilized HCV+ donors during the study period. Centers utilizing HCV+ donors had higher overall donor utilization rates (7376/24 378 [30.26%] versus 3463/15 335 [22.58%], P < 0.001) and were higher volume as compared to nonutilizing centers (mean annual OHT volume 30.72 ± 1.21 versus 16.2 ± 1.40, P < 0.001). CONCLUSIONS Although the use of HCV+ donors for OHT is rapidly expanding in the United States, almost half of transplant centers remain nonutilizers. Broader education and implementation of HCV+ donor protocols may be important in expanding OHT to more patients with end-stage heart failure.
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Affiliation(s)
- Lauren V. Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Laura M. Seese
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert Handzel
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gavin Hickey
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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27
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Roth EM, Haque OJ, Yuan Q, Kotton CN, Markmann JF, Eckhoff DE, Elias N. Heterogeneity in transplant center responses to the minimum acceptance criteria across UNOS regions. Clin Transplant 2021; 36:e14551. [PMID: 34843130 DOI: 10.1111/ctr.14551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
Transplantation of organs from increased risk donors for infection transmission (IRDs) is increasing. These organs confer survival benefit to recipients. This study examined transplant center acceptance policies for IRD kidneys across United Network for Organ Sharing (UNOS) regions, based on transplant centers' annual responses to the Minimum Acceptance Criteria (MAC) for acceptance of IRD kidneys, and the association with national and regional IRD kidney utilization. De-identified MAC responses from all transplant centers in the United States from 2007 to 2019 were obtained. Implementation of MAC responses into practice was evaluated based on annual rates of recovery and transplantation of IRD kidneys, by MAC and UNOS region. Nationally, the number of transplant centers willing to accept IRD kidneys across all criteria increased from 22% in 2007 to 64% in 2019. Acceptance rates increased markedly from donors with intravenous drug use and other potential HIV exposures. However, significant heterogeneity exists in transplant center willingness to accept IRD kidneys, both regionally and between criteria. Trends towards increasing acceptance are strongly associated with higher rates of recovery and transplantation of IRD kidneys. Further research on provider- and center-based refusal to consider IRD kidneys for waitlisted patients is needed to improve utilization of this organ pool.
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Affiliation(s)
- Eve M Roth
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Omar J Haque
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Camille N Kotton
- Harvard Medical School, Boston, Massachusetts, USA.,Transplant Infectious Disease and Compromised Host Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James F Markmann
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Devin E Eckhoff
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nahel Elias
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
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28
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The Surge in Deceased Liver Donors Due to the Opioid Epidemic: Is It Time to Split the Difference? Transplantation 2021; 105:2239-2244. [PMID: 33065726 DOI: 10.1097/tp.0000000000003491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study aimed to compare trends in use of drug overdose (DO) donors in adult versus pediatric liver transplants and the utilization of split liver transplantation in this donor population. METHODS The United Network for Organ Sharing database was reviewed for deceased donor liver transplants from March 2002 to December 2017. Recipients were categorized by donor mechanism of death. Donor splitting criteria was defined as age <40 y, single vasopressor or less, transaminases no >3 times the normal limit, and body mass index ≤ 28 kg/m2. RESULTS Adult liver transplants from DO donors increased from 2% in 2002 to 15% in 2017, while pediatric liver transplants from DO donors only increased from <1% to 3% in the same time. While 28% of DO donors met splitting criteria, only 3% of those meeting splitting criteria were used as a split graft. Both pediatric and adult recipients of DO donor livers achieved excellent patient and graft survival. CONCLUSIONS DO donors are underutilized in pediatric liver transplantation. Increased splitting of DO donor livers could significantly decrease, if not eliminate, the pediatric liver waiting list.
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29
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Pretransplant Hepatitis C Virus Treatment Decreases Access to High-quality Livers. Transplant Direct 2021; 7:e684. [PMID: 34549082 PMCID: PMC8440014 DOI: 10.1097/txd.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/27/2022] Open
Abstract
Background Despite the revolutionary role of direct-acting antivirals for hepatitis C virus (HCV), the treatment timing for liver transplant candidates remains controversial. We hypothesize that deferring treatment until after liver transplantation improves access to a larger and higher-quality donor pool without a detrimental impact on post-liver transplantation outcomes. Methods This single-center study includes recipients that underwent deceased-donor liver transplant with HCV as the primary indication January 1, 2014, to December 31, 2018. For recipients that were untreated (n = 87) versus treated (n = 42) pre-LT, we compared post-LT mortality using Cox regression with inverse probability of treatment-weighted data. Results Among pre-LT untreated recipients, 95% were willing to accept an HCV+ donor, and 44.8% received a positive HCV antibody and nucleic acid amplification test (NAT) liver. Among pre-LT treated recipients, 5% were willing to accept an HCV+ donor, and 100% received a negative HCV antibody and NAT liver. The median calculated model for end-stage liver disease at transplant was similar between pre-LT untreated (13, IQR = 9-22) and treated recipients (11, IQR = 8-14) (P = 0.1). Pre-LT treated recipients received livers from older (47 y old versus 37, P < 0.01) and higher body mass index donors (30.2 versus 26.6; P = 0.04) and spent longer on the waiting list (319 d 180, P < 0.001). Unadjusted post-LT mortality at 1 year was higher in the pre-LT treated recipients (14.6% versus 3.5%, P = 0.02). After adjusting for recipient factors, pre-LT treated recipients trended toward a 3.9 times higher risk of mortality compared with the pre-LT untreated recipients (adjusted hazard ratio = 0.973.8615.4) (P = 0.06). Conclusions Deferring HCV treatment improves access to higher-quality donors and may improve post-LT survival.
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30
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Kidney Transplantation From Hepatitis C Viremic Deceased Donors to Aviremic Recipients in a Real-world Setting. Transplant Direct 2021; 7:e761. [PMID: 34514116 PMCID: PMC8425827 DOI: 10.1097/txd.0000000000001217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background. Transplantation of hepatitis C viremic (HCV+) deceased donor kidney transplants (DDKT) into aviremic (HCV–) recipients is a strategy to increase organ utilization. However, there are concerns around inferior recipient outcomes due to delayed initiation of direct-acting antiviral (DAA) therapy and sustained HCV replication when implemented outside of a research setting. Methods. This was a retrospective single-center matched cohort study of DDKT recipients of HCV+ donors (cases) who were matched 1:1 to recipients of HCV– donors (comparators) by age, gender, race, presence of diabetes, kidney donor profile index, and calculated panel-reactive antibody. Data were analyzed using summary statistics, t-tests, and chi-square tests for between-group comparisons, and linear mixed-effects models for longitudinal data. Results. Each group consisted of 50 recipients with no significant differences in baseline characteristics. The 6-mo longitudinal trajectory of serum creatinine and estimated glomerular filtration rate did not differ between groups. All recipients had similar rates of acute rejection and readmissions (all P > 0.05). One case lost the allograft 151 d posttransplant because of acute rejection, and 1 comparator died on postoperative day 7 from cardiac arrest. HCV+ recipients initiated DAA on average 29 ± 11 d posttransplant. Ninety-eight percent achieved sustained virologic response at 4 and 12 wks with the first course of therapy; 1 patient had persistent HCV infection and was cured with a second course of DAA. Conclusions. Aviremic recipients of HCV+ DDKT with delayed DAA initiation posttransplant had similar short-term outcomes compared with matched recipient comparators of HCV– donors.
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31
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Strohbehn IA, Seethapathy R, Lee M, Sise ME. Curative Therapies for Hepatitis C Virus Infection in Patients with Kidney Disease. KIDNEY360 2021; 2:1316-1325. [PMID: 35369667 PMCID: PMC8676392 DOI: 10.34067/kid.0001812021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/21/2021] [Indexed: 02/04/2023]
Abstract
Through the discovery of direct-acting antiviral therapies over the last decade, hepatitis C virus (HCV) has been transformed from a highly morbid and potentially fatal chronic viral infection to a curable illness. HCV is common in patients with kidney disease, is a risk factor for progression of CKD, is associated with higher morbidity and mortality in patients receiving dialysis, and leads to worse allograft and patient outcomes in recipients of kidney transplants. Clinical trial and real-world data of direct-acting antivirals in patients with kidney disease demonstrate extremely high cure rates and favorable adverse event profiles. This review covers the transformative effects of curative HCV therapies on patients with kidney disease, including patients with CKD, ESKD, and those who have received a kidney transplant.
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Affiliation(s)
- Ian A Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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32
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Altshuler PJ, Helmers MR, Schiazza AR, Hu R, Han JJ, Herbst DA, Iyengar A, Atluri P. HCV-Positive Allograft Use in Heart Transplantation Is Associated With Increased Access to Overdose Donors and Reduced Waitlist Mortality Without Compromising Outcomes. J Card Fail 2021; 28:32-41. [PMID: 34314824 DOI: 10.1016/j.cardfail.2021.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Because of ongoing shortages of donors for heart transplantation, the use of donor candidates whose availabilities are the result of drug overdoses (ODs) has become increasingly prevalent, even though these donors carry a high preponderance of the now curable hepatitis C virus (HCV). This study investigated temporal trends and regional variabilities in HVC-positive (HCV+) allograft use in heart transplantation and assessed the relationship between the use of HCV+ graft donors and the use of OD donors as well as assessing waitlist and post-transplant outcomes. METHODS AND RESULTS A retrospective review of the United Network for Organ Sharing database assessed adults listed for heart transplantation. Patients were stratified both temporally into pre-HCV and HCV eras related to HCV+ graft use trends and regionally by degree of HCV+ allograft use. Regions of high HCV+ donor use were associated with an increase in OD donor access by 7.8% across eras compared to 0.4% in low HCV+ donor-use regions. One-year waitlist mortality decreased from 4.7% to 2.5% across eras in high HCV+ donor-use regions (P= 0.001) and remained roughly the same as before in low HCV+ donor-use regions (3.0% vs 2.4%; P= 0.244.). Post-transplant survival at 1 year remained similar across eras. CONCLUSIONS HCV+ donor allograft use can help to optimize donor use, decreasing waitlist mortality without compromising early survival. Ongoing assessment is essential to ensure long-term safety and efficacy of using HCV+ donors.
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Affiliation(s)
- Peter J Altshuler
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexis R Schiazza
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robin Hu
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - D Alan Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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33
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Daloul R, Pesavento T, Goldberg DS, Reese PP. A review of kidney transplantation from HCV-viremic donors into HCV-negative recipients. Kidney Int 2021; 100:1190-1198. [PMID: 34237327 DOI: 10.1016/j.kint.2021.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/29/2022]
Abstract
The safety and efficacy of direct-acting antiviral therapies have allowed the transplantation of organs from hepatitis C virus (HCV)-viremic donors into uninfected recipients. This novel strategy contrasts with the previous standard-of-care practice of limiting the transplantation of HCV infected-donor organs to HCV-infected recipients, or all too often, discarding viable organs. In this review, we summarize the published literature about the safety and feasibility of transplanting organs from HCV-viremic donors, the challenges that hinder wider adoption of this strategy, and future research needs.
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Affiliation(s)
- Reem Daloul
- The Ohio State University Medical Center, Columbus, Ohio, USA.
| | - Todd Pesavento
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - David S Goldberg
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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34
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Rajasekaran A, Franco RA, Overton ET, McGuire BM, Towns GC, Locke JE, Sawinski DL, Bell EK. Updated Pathway to Micro-elimination of Hepatitis C Virus in the Hemodialysis Population. Kidney Int Rep 2021; 6:1788-1798. [PMID: 34307975 PMCID: PMC8258460 DOI: 10.1016/j.ekir.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/25/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic hepatitis C virus (HCV) infection continues to be transmitted to hemodialysis (HD) patients within HD facilities globally. The goal of the World Health Organization to micro-eliminate HCV infection from the HD population by the year 2030 is not on target to be achieved. Obstacles to eliminate HCV in HD settings remain daunting due to a complex system created by a confluence of guidelines, legislation, regulation, and economics. HCV prevalence remains high and seroconversion continues among the HD patient population globally as a result of the HD procedure. Preventive strategies that effectively prevent HCV transmission, treatment-as-prevention, and rapid referral to treatment balanced with kidney transplant candidacy should be added to the current universal precautions approach. A safer system must be designed before HCV transmission can be halted and eliminated from the HD population.
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Affiliation(s)
- Arun Rajasekaran
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ricardo A. Franco
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Edgar T. Overton
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brendan M. McGuire
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Graham C. Towns
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme E. Locke
- Comprehensive Transplant Institute, Department of Medicine and Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deirdre L. Sawinski
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emmy K. Bell
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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35
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Keenan S, Kramer A, Healey A, Weiss MJ, Dhanani S, Beed S, Djogovic D, Sullivan K, Shemie SD. The variable impact of the overdose crisis on organ donation among five Canadian provinces: a retrospective study. Can J Anaesth 2021; 68:846-854. [PMID: 33564994 DOI: 10.1007/s12630-021-01945-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND While most overdose deaths in Canada occur in the community, some patients are resuscitated, admitted to intensive care units having sustained severe anoxic brain injury, and have the potential to be organ donors. The purpose of this study was to determine the impact of the overdose crisis on organ donation in selected Canadian provinces. METHODS We obtained data on the total number of organ donors and those dying because of overdose in five Canadian provinces from 2014 to 2018. We also obtained data for January-June 2019 for four of five provinces (Quebec excepted). We accessed federal and provincial data on the number of overdose deaths and compared the proportion of organ donors who died of an overdose both over time and between provinces. The number of organ transplants resulting from donors dying of an overdose from three provinces was also determined. RESULTS From 2014 to 2017, there was a 35% increase (554 to 747) in total deceased organ donors but a 294% increase (31 to 122) in organ donors dying of an overdose. While the proportion of organ donors dying from an overdose increased overall, this varied from 35% (42 of 121) in British Columbia to < 5% in both Quebec (9 of 182) and Nova Scotia (< 2 of 16). There were 1,043 organ transplants resulting from organ donors dying of overdose in BC, Ontario and Alberta although only 2.5-3.5% (297 of 10,858) of those dying of an overdose became organ donors. CONCLUSIONS There has been an increase in organ donors dying from drug overdose in Canada. Regional variation mirrors differences in total opiate-related death.
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Affiliation(s)
- Sean Keenan
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Donation Services, BC Transplant, Vancouver, BC, Canada.
| | - Andreas Kramer
- Department of Critical Care Medicine & Clinical Neurosciences, University of Calgary, Southern Alberta Organ and Tissue Donation Program, Calgary, AB, Canada
| | - Andrew Healey
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Trillium Gift of Life Network, Toronto, ON, Canada
| | - Matthew J Weiss
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
| | - Sonny Dhanani
- Division of Critical Care, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stephen Beed
- Department of Anesthesia and Critical Care (adult), Dalhousie University, Nova Scotia Organ and Tissue Donation Program, Halifax, NS, Canada
| | - Dennis Djogovic
- Department of Critical Care Medicine, University of Alberta, Human Organ Procurement and Exchange (HOPE), Edmonton, AB, Canada
| | - Kathleen Sullivan
- Information Management, Organ & Tissue Donation & Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, MUHC Research Institute, McGill University, Deceased Organ Donation, Canadian Blood Services, Montreal, QC, Canada
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36
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Agbim U, Cseprekal O, Yazawa M, Talwar M, Balaraman V, Bhalla A, Podila PSB, Maliakkal B, Nair S, Eason JD, Molnar MZ. Factors associated with hepatitis C antibody seroconversion after transplantation of kidneys from hepatitis C infected donors to hepatitis C naïve recipients. Ren Fail 2021; 42:767-775. [PMID: 32729359 PMCID: PMC7472509 DOI: 10.1080/0886022x.2020.1798784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background We aimed to assess the probability and factors associated with the presence of hepatitis C virus (HCV) antibody among HCV seronegative kidney transplant recipients receiving HCV-infected (nucleic acid testing positive) donor kidneys. Methods This is a retrospective review examining HCV antibody seroconversion of all kidney transplant recipients receiving an organ from an HCV-infected donor between 1 March 2018 and 2 December 2019 at a high-volume kidney transplant center in the southeast United States. Results Of 97 patients receiving HCV-infected kidneys, the final cohort consisted of 85 recipients with 5 (5.9%) recipients noted to have HCV antibody seroconversion in the setting of HCV viremia. The HCV RNA level at closest time of antibody measurement was higher in the seroconverted patients versus the ones who never converted [median and (interquartile range): 1,091,500 (345,000–8,360,000) vs 71,500 (73–313,000), p = 0.02]. No other significant differences including type of immunosuppression were noted between the HCV antibody positive group and HCV antibody negative group. Donor donation after cardiac death status [Odds Ratio (OR) and 95% Confidence Interval (CI) was: 8.22 (1.14–59.14)], donor age [OR (95% CI) (+5 years) was: 3.19 (1.39–7.29)] and Kidney Donor Profile Index [OR (95% CI) (+1) was:1.07 (1.01–1.15)] showed a statistically significant association with HCV seroconversion. Conclusions HCV antibody should not be considered routine screening for presence of infection in previously HCV naïve kidney transplant recipients receiving kidneys from HCV-infected donors, as only a modest percentage have antibody despite active viremia. The assessment of HCV viral load should be routine in all transplant recipients receiving organs from public health service increased risk donors.
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Affiliation(s)
- Uchenna Agbim
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
| | - Orsolya Cseprekal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Masahiko Yazawa
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Tokyo, Japan
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pradeep S B Podila
- Faith and Health Division, Methodist Le Bonheur Healthcare, Memphis, TN, USA.,Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, USA
| | - Benedict Maliakkal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satheesh Nair
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Designing a Liver Transplant Patient and Family Decision Support Tool for Organ Offer Decisions. Transplant Direct 2021; 7:e695. [PMID: 33937520 PMCID: PMC8081471 DOI: 10.1097/txd.0000000000001140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/21/2021] [Accepted: 01/31/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality. METHODS In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups. RESULTS We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer. CONCLUSIONS Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.
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Hepatitis C-Positive Donors in Cardiac Transplantation: Problems and Opportunities. Curr Heart Fail Rep 2021; 17:106-115. [PMID: 32474734 DOI: 10.1007/s11897-020-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C-infected donors as well as the recent advancements that are making the use of these organs possible. RECENT FINDINGS With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.
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Weinfurtner K, Reddy KR. Hepatitis C viraemic organs in solid organ transplantation. J Hepatol 2021; 74:716-733. [PMID: 33212088 DOI: 10.1016/j.jhep.2020.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
Although rates of organ donation and solid organ transplantation have been increasing over the last few decades, demand for organs still greatly exceeds supply. Several strategies have been utilised to increase organ supply, including utilisation of high-risk (e.g. HCV antibody-positive) donors. In this context, organs from HCV antibody-positive donors have been used in recipients with chronic HCV since the early 1990s. Recently, transplantation of HCV-viraemic organs into HCV-naïve recipients has garnered significant interest, owing to the development of safe and highly effective direct-acting antivirals and increased experience of treating HCV in the post-transplant setting. Preliminary studies based largely in the US have shown excellent outcomes in kidney, liver, heart, and lung transplantation. This practice has the potential to significantly increase transplantation rates and decrease waitlist mortality; however, intentionally transmitting an infectious disease to recipients has important practical and ethical implications. Further, the generalisability of the US experience to other countries is limited by significant differences in HCV-viraemic donor populations. This review summarises the current data on this practice, discusses barriers to implementation, and highlights areas that warrant further study.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania.
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40
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Anderson B, Jezewski E, Sela N, Westphal S, Hoffman A. Public health service increased risk donor kidney grafts for transplant into children, a survey of pediatric nephrologists. Pediatr Transplant 2021; 25:e13863. [PMID: 33027552 DOI: 10.1111/petr.13863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Kidney transplant is the best treatment for end-stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS-IRD) represent a significant portion of available organs which are discarded at disproportional rates. METHODS Pediatric nephrologists were surveyed regarding PHS-IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS-IRD acceptance. RESULTS Twenty-two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS-IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS-IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS-IRD as the same, and 90% supported stratifying PHS-IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%). CONCLUSIONS With improved utilization, PHS-IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS-IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.
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Affiliation(s)
- Blaire Anderson
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Emily Jezewski
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nathalie Sela
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott Westphal
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Arika Hoffman
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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41
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Paradigm Shift in Utilization of Livers from Hepatitis C-Viremic Donors into Hepatitis C Virus-Negative Patients. Clin Liver Dis 2021; 25:195-207. [PMID: 33978579 DOI: 10.1016/j.cld.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite record-breaking numbers of liver transplants (LTs) performed in the United States in each of the last 7 years, many patients remain on the wait list as the demand for LT continues to exceed the supply of available donors. The emergence of highly effective and well-tolerated direct-acting antiviral therapy has transformed the clinical course and management of hepatitis C virus (HCV) in both the pretransplant and posttransplant setting. Historically, donor livers infected with HCV were either transplanted into patients already infected with HCV or discarded.
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42
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Schlendorf KH, Zalawadiya S, Shah AS, Perri R, Wigger M, Brinkley DM, Danter MR, Menachem JN, Punnoose LR, Balsara K, Sacks SB, Ooi H, Awad JA, Sandhaus E, Schwartz C, O'Dell H, Carver AB, Edmonds CL, Ruzevich-Scholl S, Lindenfeld J. Expanding Heart Transplant in the Era of Direct-Acting Antiviral Therapy for Hepatitis C. JAMA Cardiol 2021; 5:167-174. [PMID: 31851352 DOI: 10.1001/jamacardio.2019.4748] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance For patients awaiting heart transplant, hepatitis C-positive donors offer an opportunity to expand the donor pool, shorten wait times, and decrease wait-list mortality. While early reported outcomes among few heart transplant recipients have been promising, knowledge of 1-year outcomes in larger cohorts of patients is critical to shared decision-making with patients about this option. Objective To better define the association of hepatitis C-positive donors with heart transplant volumes, wait-list duration, the transmission and cure of donor-derived hepatitis C, and morbidity and mortality at 1 year. Design, Setting, and Participants This was a prospective, single-center observational study of 80 adult (age 18 years or older) patients who underwent heart transplant using hearts from hepatitis C-positive donors between September 2016 and April 2019 at a large academic medical center. Among donors, who were considered hepatitis C-positive if results from hepatitis C antibody and/or nucleic acid testing were positive, 70 had viremia and 10 were seropositive but did not have viremia. Follow-up was available through May 15, 2019. Comparisons were drawn with patients who underwent transplant with hearts from hepatitis C-negative donors during the same period. Exposures In addition to standard posttransplant management, transplant recipients who developed donor-derived hepatitis C infection were treated with direct-acting antivirals. Main Outcomes and Measures The main outcomes included wait-list duration and 1-year survival in all patients, and for those who developed donor-derived hepatitis C, the response to direct-acting antiviral treatment. Results Of 80 patients, 57 (71.3%) were men, 55 (68.7%) were white, and 17 (26.3%) were black; the median age at transplant was 54.5 years (interquartile range, 46-62 years). Following consent to accept hearts from hepatitis C-exposed donors, the median days to heart transplant was 4 (interquartile range, 1-18). No recipients of donors with negative nucleic acid testing results (10 [12.5%]) developed donor-derived hepatitis C. Of 70 patients who were recipients of donors with positive nucleic acid testing results, 67 (95.7%) developed donor-derived hepatitis C over a median follow-up of 301 days (interquartile range, 142-617). Treatment with direct-acting antivirals was well tolerated and yielded sustained virologic responses in all treated patients. Within the cohort with infection, 1-year patient survival was 90.4%, which was not significantly different compared with the cohort without infection or with patients who received transplants from hepatitis C-negative donors during the same period. Conclusions and Relevance In the era of direct-acting antivirals, hepatitis C-positive donors are a viable option to expand the donor pool, potentially reducing wait-list duration and mortality. In heart transplant recipients with donor-derived hepatitis C, infection is well-tolerated and curable, and 1-year survival is equivalent to that in recipients of hepatitis C-negative donors.
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Affiliation(s)
| | | | - Ashish S Shah
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roman Perri
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | - Keki Balsara
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Henry Ooi
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph A Awad
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily Sandhaus
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Heather O'Dell
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Cori L Edmonds
- Vanderbilt University Medical Center, Nashville, Tennessee
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Grubb CJ, Bergeria CL, Huhn AS, Dunn KE. Attitudes Toward Organ Donation for Persons Who Have a Substance Use Disorder Relative to Other Health Conditions. Front Psychiatry 2021; 12:698645. [PMID: 34867506 PMCID: PMC8633394 DOI: 10.3389/fpsyt.2021.698645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Increases in opioid-related overdose and death have led to increases in the number of organs available for donation and transplant, however persons who have a substance use disorder (SUD) may be disadvantaged relative to other health conditions with regard to receiving an organ for transplant. Objective: This study aimed to evaluate perceptions regarding acceptability and priority for organ donation vs. a control condition (resuscitation) for hypothetical persons with nine target health conditions including a substance use disorder, among persons recruited as part of an online survey. Methods: Respondents (N = 285; male = 172, female = 113) recruited from Amazon Mechanical Turk rated acceptability and priority that hypothetical persons representing nine target health conditions expected to influence transplant success (including a SUD) receive an organ transplant and resuscitation via a survey hosted by Qualtrics. Primary outcomes of stigma ratings and priority ranking of persons as a function of the hypothetical target health condition were analyzed using Repeated Measures Analyses of Variance and Bonferroni-corrected t-tests. Demographic information was presented descriptively for all respondents. Results: Ratings for acceptability and priority for persons who had a SUD were generally lower than ratings for other conditions for both organ for transplant and resuscitation, though respondents reported less stigma toward resuscitation, F (8) = 22.35, p <0.001 overall. Respondents were least supportive of persons who smoked cigarettes receiving an organ, p's < 0.001. Priority rankings favored persons who were young or had a history of heart disease. Multivariable models determined that target health condition, F (8) = 33.64, p < 0.001, was a better and more consistent predictor of response than demographic variables that were examined. Conclusions: Data suggest that general perception of acceptability and priority ranking for receipt of life-saving interventions was lower for persons who have a SUD relative to other clinically-relevant health conditions. Research to examine this effect among persons working in the donation system are warranted and efforts to reduce stigma toward persons who have a SUD should be continued.
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Affiliation(s)
- Caitlyn J Grubb
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cecilia L Bergeria
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Andrew S Huhn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly E Dunn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Frye CC, Gauthier JM, Bery A, Gerull WD, Morkan DB, Liu J, Shea Harrison M, Terada Y, Van Zanden JE, Marklin GF, Pasque MK, Nava RG, Meyers BF, Patterson AG, Kozower BD, Hachem R, Byers D, Witt C, Kulkarni H, Kreisel D, Puri V. Donor management using a specialized donor care facility is associated with higher organ utilization from drug overdose donors. Clin Transplant 2020; 35:e14178. [PMID: 33274521 DOI: 10.1111/ctr.14178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/27/2022]
Abstract
Drug overdoses have tripled in the United States over the last two decades. With the increasing demand for donor organs, one potential consequence of the opioid epidemic may be an increase in suitable donor organs. Unfortunately, organs from donors dying of drug overdose have poorer utilization rates than other groups of brain-dead donors, largely due to physician and recipient concerns about viral disease transmission. During the study period of 2011 to 2016, drug overdose donors (DODs) account for an increasingly greater proportion of the national donor pool. We show that a novel model of donor care, known as specialized donor care facility (SDCF), is associated with an increase in organ utilization from DODs compared to the conventional model of hospital-based donor care. This is likely related to the close relationship of the SDCF with the transplant centers, leading to improved communication and highly efficient donor care.
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Affiliation(s)
- Christian Corbin Frye
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Deniz B Morkan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - M Shea Harrison
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Judith E Van Zanden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Gary F Marklin
- Mid-America Transplant, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Alexander G Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey Hachem
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Derek Byers
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Chad Witt
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hrishikesh Kulkarni
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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45
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Da BL, Ezaz G, Kushner T, Crismale J, Kakked G, Gurakar A, Dieterich D, Schiano TD, Saberi B. Donor Characteristics and Regional Differences in the Utilization of HCV-Positive Donors in Liver Transplantation. JAMA Netw Open 2020; 3:e2027551. [PMID: 33275155 PMCID: PMC7718602 DOI: 10.1001/jamanetworkopen.2020.27551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Increased utilization of hepatitis C virus (HCV)-positive liver allografts for liver transplant (LT) has been endorsed as one of several ways to combat national organ shortages. However, HCV-positive donors remain poorly characterized, and Organ Procurement and Transplantation Network regional differences in the utilization of HCV-positive liver allografts are unclear. OBJECTIVE To characterize HCV-positive donors and the allografts that come from them. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, the Scientific Registry of Transplant Recipients database was queried for all donors who underwent HCV testing from June 2015 to December 2018. Clinical and allograft characteristics were evaluated, and utilization across the United States was studied. Patients with positive or negative results for HCV antibody (Ab) and HCV nucleic acid amplification testing (NAT) were included in this study. Donors utilized for living donor transplant and pediatric (age <18 years) recipients were excluded. MAIN OUTCOMES AND MEASURES The primary comparison was between donors who were HCV Ab positive and those who were HCV Ab negative. Regional variations in the utilization of HCV-positive and HCV-negative donors were analyzed. RESULTS Of 24 500 donors utilized for LT, 1887 (7.7%) were HCV Ab positive; 64.4% of HCV Ab-positive donors were HCV NAT positive. HCV Ab-positive donors were younger (median [interquartile range] age, 35 [29-46] years vs 40 [27-54] years) and had fewer comorbidities, such as diabetes (8.3% vs 12.0%) and hypertension (25.9% vs 35.2%), compared with HCV Ab-negative donors. These findings were even more pronounced in HCV Ab-positive /NAT-positive compared with HCV Ab-positive/NAT-negative donors. Organ Procurement and Transplantation Network regions 2, 3, 10, and 11 had the highest absolute utilization of HCV Ab-positive donors, accounting for 64.4% of all HCV Ab-positive donors used in the United States. Region 1 had the highest relative utilization of HCV Ab-positive donors (18.7%). The use of HCV Ab-positive donors in some regions was associated with the rate of drug overdose, but this was not always the case. Similar utilization results were found with HCV NAT-positive donors. CONCLUSIONS AND RELEVANCE In this cross-sectional study, HCV-positive donors were younger and healthier than utilized HCV-negative donors. Significant differences exist in the utilization of HCV-positive donors across the 11 Organ Procurement and Transplantation Network regions, which is not entirely explained by organ demand or by higher availability of HCV-positive livers as per the distribution of the opioid epidemic. Initiatives to increase the use of HCV-positive donors, particularly in regions of high organ demand, should be implemented.
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Affiliation(s)
- Ben L. Da
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
- Sandra Atlas Bass Center for Liver Diseases & Transplantation, Division of Hepatology, Department of Internal Medicine, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York
| | - Ghideon Ezaz
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gaurav Kakked
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas D. Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Behnam Saberi
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Impact of Donor Hepatitis C Virus on Kidney Transplant Outcomes for Hepatitis C-positive Recipients in the Direct-acting Antiviral Era: Time to Revise the Kidney Donor Risk Index? Transplantation 2020; 104:1215-1228. [PMID: 31517783 DOI: 10.1097/tp.0000000000002949] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Kidneys from donors with hepatitis C virus (HCV) infection are traditionally considered to be at risk for poorer survival outcomes, as reflected in the kidney donor profile index (KDPI). Modern direct-acting antivirals may modify this risk. METHODS Using United Network for Organ Sharing data, HCV-infected adult first-time kidney transplant recipients from 2014 to 2017 were examined. Graft and patient survival were compared in a propensity-matched cohort of recipients of HCV antibody (Ab)(+) kidneys versus Ab(-) kidneys. Subsequent analysis was performed in a propensity-matched cohort of recipients of HCV-viremic (RNA positive) versus HCV-naïve kidneys. RESULTS There were 379 recipients each in the matched cohort of recipients of HCV Ab(+) versus HCV Ab(-) kidneys. Despite a higher KDPI (58.2% for HCV Ab[+] versus 38.8% for HCV Ab[-]), 1-year patient and graft survival were similar in the HCV(+) and HCV(-) groups (95.4% and 94.9% versus 97.9% and 96.0%, P = 0.543 and P = 0.834, respectively). There were 200 recipients each in the cohort of recipients of HCV-viremic versus HCV-naïve kidneys, with the KDPI again higher in the HCV-viremic group (56.8% versus 35.2%). Baseline hazard ratios (HRs) for graft failure (HR, 4.69; P = 0.009) and death (HR, 7.60; P = 0.003) were significantly elevated in the viremic group, but crossed 1 at 21 and 24 months, respectively. CONCLUSIONS In the modern direct-acting antiviral era, calculated likely KDPI overestimates risk kidneys from HCV (+) donors. Donor viremia conveys an early risk which appears to subside over time. These results suggest that it may be time to revise the kidney donor risk index.
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Sise ME, Goldberg DS, Kort JJ, Schaubel DE, Alloway RR, Durand CM, Fontana RJ, Brown RS, Friedewald JJ, Prenner S, Landis JR, Fernando M, Phillips CC, Woodle ES, Rike-Shields A, Sherman KE, Elias N, Williams WW, Gustafson JL, Desai NM, Barnaba B, Norman SP, Doshi M, Sultan ST, Aull MJ, Levitsky J, Belshe DS, Chung RT, Reese PP. Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC): An Open-Label Study of Combined Glecaprevir and Pibrentasvir to Treat Recipients of Transplanted Kidneys from Deceased Donors with Hepatitis C Virus Infection. J Am Soc Nephrol 2020; 31:2678-2687. [PMID: 32843477 DOI: 10.1681/asn.2020050686] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/06/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Single-center trials and retrospective case series have reported promising outcomes using kidneys from donors with hepatitis C virus (HCV) infection. However, multicenter trials are needed to determine if those findings are generalizable. METHODS We conducted a prospective trial at seven centers to transplant 30 kidneys from deceased donors with HCV viremia into HCV-uninfected recipients, followed by 8 weeks of once-daily coformulated glecaprevir and pibrentasvir, targeted to start 3 days posttransplant. Key outcomes included sustained virologic response (undetectable HCV RNA 12 weeks after completing treatment with glecaprevir and pibrentasvir), adverse events, and allograft function. RESULTS We screened 76 patients and enrolled 63 patients, of whom 30 underwent kidney transplantation from an HCV-viremic deceased donor (median kidney donor profile index, 53%) in May 2019 through October 2019. The median time between consent and transplantation of a kidney from an HCV-viremic donor was 6.3 weeks. All 30 recipients achieved a sustained virologic response. One recipient died of complications of sepsis 4 months after achieving a sustained virologic response. No severe adverse events in any patient were deemed likely related to HCV infection or treatment with glecaprevir and pibrentasvir. Three recipients developed acute cellular rejection, which was borderline in one case. Three recipients developed polyomavirus (BK) viremia near or >10,000 copies/ml that resolved after reduction of immunosuppression. All recipients had good allograft function, with a median creatinine of 1.2 mg/dl and median eGFR of 57 ml/min per 1.73 m2 at 6 months. CONCLUSIONS Our multicenter trial demonstrated safety and efficacy of transplantation of 30 HCV-viremic kidneys into HCV-negative recipients, followed by early initiation of an 8-week regimen of glecaprevir and pibrentasvir.
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Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Jens J Kort
- Global Medical Affairs Research and Development, AbbVie Inc., North Chicago, Illinois
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa Fernando
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin C Phillips
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adele Rike-Shields
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.,The Christ Hospital, Cincinnati, Ohio
| | - Kenneth E Sherman
- Division of Digestive Disease, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nahel Elias
- Transplant Center and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jenna L Gustafson
- Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Silas P Norman
- Division of Nephrology, Michigan Medicine, Ann Arbor, Michigan
| | - Mona Doshi
- Division of Nephrology, Michigan Medicine, Ann Arbor, Michigan
| | - Samuel T Sultan
- Division of Transplant Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Meredith J Aull
- Division of Transplant Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dianne S Belshe
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond T Chung
- Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter P Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Short-Term Graft Failure of Organs Procured from Drug-Related Deaths Compared with Other Causes of Death. J Med Toxicol 2020; 17:37-41. [PMID: 32789584 DOI: 10.1007/s13181-020-00801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND A gap exists between the number of patients on the national organ transplant waiting list and the number of transplants performed. Victims of drug and overdose-related death are increasingly utilized as organ donors. We sought to evaluate the suitability of organs from drug and overdose-related death for organ transplantation. This study compares the proportion of short-term allograft failure of organs procured from patients with drug-related deaths with those without drug-related deaths. METHODS Organ donations after drug-related deaths (DDD) were compared with organ donations from non-drug-related donations after brain deaths (DBD) and donations after circulatory deaths (DCD) utilizing the Gift of Hope Organ & Tissue Donor Network for a total of 15 months. RESULTS Eighty-one donors were identified from each of the DDD, DBD, and DCD groups with 264, 234, and 181 organs transplanted, respectively. The proportions of short-term graft failures were 1.15% in the DDD group compared with 2.14% in the DBD group (p = NS) and 5.52% in the DCD group (p = 0.01). The US Public Health Service increased-risk features for transmission of infectious diseases were present in 70.3% of the DDD cases. Donors from the DDD group were younger on average than those in other groups (33 to 42 years). CONCLUSIONS The proportion of graft failures in the drug-related deaths (DDD) group was equal to or less than those from other causes of death on short-term follow-up. Drug-related death does not appear to be a contraindication for organ procurement despite increased risk features for infectious disease transmission.
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Pasrija C, Parchment N, Tran D, Mackowick K, Boulos F, Iacono A, Kim J, Griffith BP, Sanchez PG, Pham SM, Kon ZN. Strategic application of modular risk components to safely increase lung transplantation volume. J Card Surg 2020; 35:2177-2184. [PMID: 33448475 DOI: 10.1111/jocs.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Considerable growth of individual lung transplant programs remains challenging. We hypothesized that the systematic implementation of modular risk components to a lung transplantation program would allow for expeditious growth without increasing mortality. METHODS All consecutive patients placed on the lung transplantation waitlist were reviewed. Patients were stratified by an 18-month period surrounding the systematic implementation of the modular risk components Era 1 (1/2014-6/2015) and Era 2 (7/2015-12/2016). Modular risk components were separately evaluated for donors, recipients, and perioperative features. RESULTS One hundred and thirty-two waitlist patients (Era 1: 48 and Era 2: 84) and 100 transplants (Era 1: 32 and Era 2: 68) were identified. There was a trend toward decreased waitlist mortality (P = .07). In Era 2, the use of ex vivo lung perfusion (P = .05) and donor-recipient over-sizing (P = .005) significantly increased. Moreover, transplantation with a lung allocation score greater than 70 (P = .05), extracorporeal support (P = .06), and desensitization (P = .008) were more common. Transplant rate significantly improved from Era 1 to Era 2 (325 vs 535 transplants per 100 patient years, P = .02). While primary graft dysfunction (PGD) grade 3 at 72 hours (P = .05) was significantly higher in Era 2, 1-year freedom from rejection was similar (86% vs 90%, P = .69) and survival (81% vs 95%, P = .02) was significantly greater in Era 2. CONCLUSIONS The systematic implementation of a modular risk components to a lung transplantation program can result in a significant increase in center volume. However, measures to mitigate an expected increase in the incidence of PGD must be undertaken to maintain excellent short and midterm outcomes.
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Affiliation(s)
- Chetan Pasrija
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathaniel Parchment
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Douglas Tran
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristen Mackowick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Francesca Boulos
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aldo Iacono
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - June Kim
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Bartley P Griffith
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
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50
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Kapila N, Menon KVN, Al-Khalloufi K, Vanatta JM, Murgas C, Reino D, Ebaid S, Shaw JJ, Agrawal N, Rhazouani S, Navas V, Sheffield C, Rahman AU, Castillo M, Lindenmeyer CC, Miller C, Quintini C, Zervos XB. Hepatitis C Virus NAT-Positive Solid Organ Allografts Transplanted Into Hepatitis C Virus-Negative Recipients: A Real-World Experience. Hepatology 2020; 72:32-41. [PMID: 31659775 DOI: 10.1002/hep.31011] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/22/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Hepatitis C virus (HCV)-viremic organs are underutilized, and there is limited real-world experience on the transplantation of HCV-viremic solid organs into recipients who are HCV negative. APPROACH AND RESULTS Patients listed or being evaluated for solid organ transplant after January 26, 2018, were educated and consented by protocol on the transplantation of HCV-viremic organs. All recipients were HCV nucleic acid test and anti-HCV antibody negative at the time of transplant and received an HCV-viremic organ. The primary outcome was sustained virological response (SVR) at 12 weeks after completion of direct-acting antiviral (DAA) therapy (SVR12 ). Seventy-seven patients who were HCV negative underwent solid organ transplantation from a donor who was HCV viremic. No patients had evidence of advanced hepatic fibrosis. Treatment regimen and duration were at the discretion of the hepatologist. Sixty-four patients underwent kidney transplant (KT), and 58 KT recipients had either started or completed DAA therapy. Forty-one achieved SVR12 , 10 had undetectable viral loads but are not eligible for SVR12 , and 7 remain on treatment. One KT recipient was a nonresponder because of nonstructural protein 5A resistance. Four patients underwent liver transplant and 2 underwent liver-kidney transplant. Three patients achieved SVR12 , 1 has completed DAA therapy, and 2 remain on treatment. Six patients underwent heart transplant and 1 underwent heart-kidney transplant. Six patients achieved SVR12 and 1 patient remains on treatment. CONCLUSIONS Limited data exist on the transplantation of HCV-viremic organs into recipients who are HCV negative. Our study is the largest to describe a real-world experience of the transplantation of HCV-viremic organs into recipients who are aviremic. In carefully selected patients, the use of HCV-viremic grafts in the DAA era appears to be efficacious and well tolerated.
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Affiliation(s)
- Nikhil Kapila
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL.,Department of Gastroenterology and Hepatology, Duke University, Durham, NC
| | | | | | - Jason M Vanatta
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Carla Murgas
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Diego Reino
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Samer Ebaid
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Joshua J Shaw
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Neerja Agrawal
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Salwa Rhazouani
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | - Viviana Navas
- Department of Transplant, Cleveland Clinic Florida, Weston, FL
| | | | - Asad Ur Rahman
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL
| | | | | | - Charles Miller
- Department of Transplant, Cleveland Clinic, Cleveland, OH
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