The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study

Management of hypertension in heart transplant recipients: an ongoing conundrum

PURPOSE OF REVIEW

Hypertension remains one of the most common clinical problems leading to significant posttransplant complications. This study reviews the pathophysiology of hypertension in the postcardiac transplant phase and provides an update on currently available antihypertensive therapies for heart transplant patients.

RECENT FINDINGS

The true prevalence of hypertension in the heart transplant population remains unknown. Effective blood pressure (BP) control is key to prevent left ventricular remodeling, diastolic dysfunction and stroke. Calcium channel blockers (CCBs) are the most commonly and preferred agents in the early posttransplant phase and may have renal protective effects. Angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) can all be used as second line antihypertensive agents and may have a role in preventing other long-term complications such as calcineurin-inhibitor induced nephropathy. Although more data are needed, sodium-glucose co-transporter 2 inhibitors (SGLT2i) appeared to be well tolerated and could be considered especially in the presence of type diabetes and chronic kidney disease. Conversely, angiotensin receptor-neprilysin inhibition (ARNI) have not been studied in the heart transplant population therefore cannot be recommended at this time.

SUMMARY

Hypertension is very common after heart transplant. Early steroid wean and traditional risk factor modification play an important part in the management of post-heart transplant hypertension. CCB, ACEI, ARB are the preferred antihypertensive agents to improve postcardiac transplant complications. Novel therapies such as SGLT2i appear well tolerated and may have benefits in both BP and glycemic control in heart transplant; however, larger trials are needed.

To decline or not to decline: Consequences of decision-making regarding lung offers from donors with hepatitis C

OBJECTIVE

Lung transplants from donors with hepatitis C (HCV D+) have excellent outcomes, but these organs continue to be declined. We evaluated whether (1) being listed to consider and (2) accepting versus declining HCV D+ offers provided a survival benefit to lung transplant candidates.

METHODS

Using the Scientific Registry of Transplant Recipients, we identified all adult (≥18 years) lung transplant candidates 2016-2021 and compared waitlist mortality between those willing versus not willing to consider HCV D+ offers using competing risk regression. We identified all candidates offered an HCV D+ lung that was later accepted and followed them from offer decision until death or end-of-study. We estimated adjusted mortality risk of accepting versus declining an HCV D+ lung offer using propensity-weighted Cox regression.

RESULTS

From 2016 to 2021, we identified 21,007 lung transplant candidates, 33.8% of whom were willing to consider HCV D+ offers. Candidates willing to consider HCV D+ offers had a 17% lower risk of waitlist mortality (subhazard ratio, 0.83; 95% confidence interval, 0.75-0.91, P < .001). Over the same period, 665 HCV D+ lung offers were accepted after being declined a total of 2562 times. HCV D+ offer acceptance versus decline was associated with a 20% lower risk of mortality (adjusted hazard ratio, 0.80; 95% confidence interval, 0.66-0.96, P = .02).

CONCLUSIONS

Considering HCV D+ lung offers was associated with a 17% lower risk of waitlist mortality, whereas accepting versus declining an HCV D+ lung offer was associated with a 20% lower risk of mortality. Centers and candidates should consider accepting suitable HCV D+ lung offers to optimize outcomes.

Organ Nonutilization Following Revision to the Public Health Service Donor Risk Criteria for HIV, HCV, or HBV Transmission

BACKGROUND

Organs from Public Health Service criteria (PHSC) donors, previously referred to as PHS infectious-risk donors, have historically been recovered but not used, traditionally referred to as "discard," at higher rates despite negligible risk to recipients. On March 1, 2021, the definition of PHSC donors narrowed to include only the subset of donors deemed to have meaningfully elevated risk in the current era of improved infectious disease testing.

METHODS

Using Scientific Registry of Transplant Recipients data from May 1, 2019, to December 31, 2022, we compared rates of PHSC classification and nonutilization of PHSC organs before versus after the March 1, 2021, policy change among recovered decedents using the χ 2 tests. We performed an adjusted interrupted time series analysis to examine kidney and liver recovery/nonuse (traditionally termed "discard") and kidney, liver, lung, and heart nonutilization (nonrecovery or recovery/nonuse) prepolicy versus postpolicy.

RESULTS

PHSC classification dropped sharply from 24.5% prepolicy to 15.4% postpolicy ( P  < 0.001). Before the policy change, PHSC kidney recovery/nonuse, liver nonuse, lung nonuse, and heart nonuse were comparable to non-PHSC estimates (adjusted odds ratio: kidney =  0.98 1.06 1.14 , P  = 0.14; liver =  0.85 0.92 1.01 , P  = 0.07; lung =  0.91 0.99 1.08 , P  = 0.83; heart =  0.89 0.97 1.05 , P  = 0.47); following the policy change, PHSC kidney recovery/nonuse, liver nonuse, lung nonuse, and heart nonuse were lower than non-PHSC estimates (adjusted odds ratio: kidney =  0.77 0.84 0.91 , P  < 0.001; liver =  0.77 0.84 0.92 , P  < 0.001; lung =  0.74 0.81 0.90 , P  < 0.001; heart =  0.61 0.67 0.73 , P  < 0.001).

CONCLUSIONS

Even though PHSC donors under the new definition are a narrower and theoretically riskier subpopulation than under the previous classification, PHSC status appears to be associated with a reduced risk of kidney and liver recovery/nonuse and nonutilization of all organs. Although historically PHSC organs have been underused, our findings demonstrate a notable shift toward increased PHSC organ utilization.

A Contemporary Analysis of Mental Well-being Among Living Donor Kidney Applicants

Background

Living donation is paramount for expanding the donor pool. The aim of this study was to assess changes over time in self-reported mental health of living donor kidney applicants in efforts to inform patient-centered discussions with potential donors.

Methods

Kidney donor applications from 2017 through 2021 were compiled. Data included age, gender, race, ethnicity, applicant-recipient relationship, medical history, and medications. Trends over time were analyzed and post hoc analyses were performed.

Results

During the study period, 2479 applicants to the living donor kidney program were evaluated; 73% of applicants were female individuals. More than half of applicants were not related to their intended recipient; this fraction increased from 46% in 2017 to 58% in 2021 (P < 0.01). A similar decline in family relations was not present among Black and Latino applicants. Of all applicants, 18% reported depression and 18% reported anxiety; 20% reported taking antidepressants or anxiolytics. Depression and anxiety increased 170% (P < 0.001) and 136% (P < 0.001) from 2018 to 2019, respectively; antidepressant and anxiolytic use rose 138% (P < 0.001) between 2018 and 2020.

Conclusions

The profile of living donor applicants has changed in recent years, with approximately 1 in 5 requiring antidepressants or anxiolytics. Predonation counseling and postdonation monitoring are imperative to decrease adverse psychological outcomes for living donors.

Utilising organs from hepatitis C virus PCR-positive donors in Western Australia

We transplanted six solid organs from three hepatitis C virus (HCV) polymerase chain reaction (PCR)-positive donors during 2018-2023. Recipients were treated with glecaprevir/pibrentasvir or sofosbuvir/velpatasvir for 4-12 weeks, with all six achieving sustained virological response without significant adverse events. As occurs in other jurisdictions, solid organ transplants from HCR PCR-positive donors can be safely utilised in Australia.

Rate of Deceased Kidney Donation From Potential In-Hospital Deaths in the US, 2003-2021

This cross-sectional study calculates deceased kidney donation rates in the US using deaths compatible with donation as the metric’s denominator.

Later Brain Death Declaration Correlates to Favorable Donor Characteristics but Decreased Heart Acceptance

BACKGROUND

With rates of potential donor heart discard as high as 66% nationally, quality improvement efforts must seek to optimize donor utilization. Whether the timing of donor brain death declaration (BDD) influences organ acceptance is understudied. The authors sought to characterize the impacts of time between donor hospital admission and BDD on heart utilization and posttransplant outcomes.

METHODS

All potential heart donors and recipients in the United Network for Organ Sharing database were identified (2006-2021). Admission-to-BDD cohorts were: 1 to 2 d (n = 52 469), 3 to 4 d (n = 44 033), 5 to 7 d (n = 24 509), and 8 to 10 d (n = 8576). Donor clinical characteristics were compared between cohorts, and donor acceptance was assessed using multivariable binary logistic regression. Recipient posttransplant survival was assessed with the Kaplan-Meier method.

RESULTS

Donor demographics and comorbidity profiles (diabetes and hypertension) were comparable across cohorts. Anoxia/overdose deaths were more common (10% > 21% > 24% > 18%, respectively) and cardiopulmonary resuscitation requirements were higher (37% > 52% > 58% > 47%) when BDD occurred longer after admission. Renal dysfunction (44% > 44% > 35% > 29%) and inotrope requirements (52% > 25% > 36% > 29%) were lower in the later BDD cohorts. Proportions of hepatic dysfunction (18%-21%) and left ventricular ejection fraction <50% (13%-16%) were clinically equivalent. Donor acceptance differed by admission-to-BDD cohort (36% [1-2 d], 34% [3-4 d], 30% [5-7 d], and 28% [8-10 d]). Admission-to-BDD >4 d was independently associated with lower odds of acceptance on multivariable analysis (odds ratio 0.79, P  < 0.001). Recipients experienced equivalent posttransplant survival for all donor admission-to-BDD cohorts ( P  = 0.999 adults and P  = 0.260 pediatrics).

CONCLUSIONS

Heart donors with later BDD were disproportionately discarded despite similar-to-favorable overall clinical profiles, resulting in nearly 3000 fewer transplants during the study. Increased utilization of donors with later BDD and "high-risk" characteristics (eg, anoxia/overdose, cardiopulmonary resuscitation requirement) can improve rates of transplantation without compromising outcomes.

Patient Perspectives on Solid Organ Transplantation From Donors With Hepatitis C Viremia to Recipients Without Hepatitis C Viremia

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.

Implications of drug intoxication on donor utilization and outcomes in liver transplantation

INTRODUCTION

This study evaluates the implications of drug intoxication (DI) on donor utilization and outcomes in liver transplantation (LT).

METHODS

The UNOS STAR database was evaluated for all potential donors and adult, first-time, whole LT between 2005 and 2019. Logistic regression analyses evaluated liver utilization; proportional hazards modeling assessed risk of 1-year graft loss.

RESULTS

A total of 132 783 potential donors (10 205, 7.7% from DI), and 90 612 adult LT were identified (7490, 8.3% from DI). DI donors had median age 32 years (IQR 26-40 years, p < .001), were 42.6% female (n = 4346), and 15.5% were DCD donors (n = 1583). Utilization of DI donors changed over time, such that by 2015-2019 they were the most likely donor cause of death (COD) to be utilized. Among LT recipients, there were insignificant differences (<2% variance) in age, gender, ethnicity, and etiology of liver disease according to donor COD. Recipients with MELD scores >30 more frequently received grafts from donors with trauma (23.8%) and DI (21.8%) versus cardiovascular (20.0%) and CVA/stroke (19.9%, p < .001). Among DBD donors, DI-COD was associated with superior 1-year graft survival compared to donors from trauma (HR 1.172, 95% CI 1.057-1.300) and CVA/stroke (HR 1.404, 95% CI 1.264-1.561, p < .001). Donor COD was not significantly associated with 1-year graft loss among DCD donors.

CONCLUSIONS

There is an increased likelihood of donor utilization when COD is drug overdose and an increased likelihood of 1-year graft survival compared to donors from trauma, CVA/stroke, and other COD.

Impact of the coronavirus disease 2019 pandemic on drug overdoses in the United States and the effect on cardiac transplant volume and survival

BACKGROUND

Drug overdose (DO) deaths rose to unprecedented levels during the coronavirus disease 2019 (COVID-19) pandemic. This study examines the impact of COVID-19 on the availability of cardiac allografts from DO donors and the implications of DO donor use on recipient survival.

METHODS

Heart transplants reported to the United Network for Organ Sharing from January 2017 to November 2019 ("pre-COVID") and from March 2020 to June 2021 ("COVID pandemic") were analyzed with respect to DO donor status. Outcomes were analyzed using Kaplan-Meier survival and Cox regression to identify predictors of survival. Characteristics of discarded cardiac allografts were also compared by DO donor status.

RESULTS

During the COVID-19 pandemic, 27.2% of cardiac allografts were from DO donors vs 20.5% pre-COVID, a 32.7% increase (p < 0.001). During the pandemic, DO donors were younger (84.7% vs 76.3% <40 years, p < 0.001), had higher cigarette use (16.1% vs 10.8%, p < 0.001), higher cocaine use (47.4% vs 19.7%, p < 0.001), and higher incidence of hepatitis C antibodies (26.8% vs 6.1%, p < 0.001) and RNA positivity (16.2% vs 4.2%, p < 0.001). While DO donors were less likely to require inotropic support (30.8% vs 35.4%, p = 0.008), they were more likely to have received cardiopulmonary resuscitation (95.3% vs 43.2%, p < 0.001). Recipient survival was equivalent using Kaplan-Meier analysis (log-rank, p = 0.33) and survival probability at 36 months was 85.6% (n at risk = 398) for DO donors vs 83.5% (n at risk = 1,633) for all other donors. Cox regression demonstrated that DO donor status did not predict mortality (hazard ratio 1.05; 95% confidence interval 0.90-1.23, p = 0.53).

CONCLUSIONS

During the COVID-19 pandemic, there was a 32.7% increase in heart transplants utilizing DO donor hearts, and DO became the most common mechanism of death for donors. The use of DO donor hearts did not have an impact on short-term recipient survival.

Racial disparities across multiple stages of the deceased organ donation process

Pervasive structural violence causes higher organ failure rates among Black Americans and an excess of Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 organ procurement organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval) of non-Black versus Black patients transitioning from OPO referral to approach of 1.39 (1.35, 1.44), approach to authorization: 1.64 (1.56, 1.72), authorization to procurement: 1.10 (1.04, 1.16), and procurement to transplant: 1.00 (0.95, 1.06). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.89%, 8.18%, 6.79%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had odds ratios of organ utilization of 1.81 (1.61, 2.03), 3.19 (2.91, 3.50), and 1.24 (1.05, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1700 donors-two-thirds of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.

Heart transplantation: advances in expanding the donor pool and xenotransplantation

Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.

Sexual and gender minority relevant policies in Canadian and United States organ and tissue donation and transplantation systems: An opportunity to improve equity and safety

Current policies in organ and tissue donation and transplantation (OTDT) systems in Canada and the United States unnecessarily restrict access to donation for sexual and gender minorities (SGMs) and pose safety risks to transplant recipients. We compare SGM-relevant policies between the Canadian and United States systems. Policy domains include the risk assessment of living and deceased organ and tissue donors, physical examination considerations, viral testing recommendations, and informed consent and communication. Identified gaps between current evidence and existing OTDT policies along with differences in SGM-relevant policies between systems, represent an opportunity for improvement. Specific recommendations for OTDT system policy revisions to achieve these goals include the development of behavior-based, gender-neutral risk assessment criteria, a reduction in current SGM no-sexual contact period requirements pending development of inclusive criteria, and destigmatization of sexual contact with people living with human immunodeficiency virus. OTDT systems should avoid rectal examinations to screen for evidence of receptive anal sex without consent and mandate routine nucleic acid amplification test screening for all donors. Transplant recipients must receive enhanced risk-to-benefit discussions regarding decisions to accept or decline an offer of an organ classified as increased risk. These recommendations will expand the donor pool, enhance equity for SGM people, and improve safety and outcomes for transplant recipients.

The changing epidemiology of adult liver transplantation in the United States in 2013-2022: The dominance of metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease

BACKGROUND

The high prevalence of obesity in the United States drives the burden of NASH, recently renamed as metabolic dysfunction-associated steatohepatitis (MASH). We assessed the most recent trends in liver transplantation in the United States.

METHODS

The Scientific Registry of Transplant Recipients (SRTR 2013-2022) was used to select adult (18 years or above) candidates who underwent liver transplant.

RESULTS

There were 116,292 candidates who underwent liver transplant with known etiology of chronic liver disease. In candidates without HCC, the most common etiology was alcohol-associated liver disease (ALD), increasing from 23% (2013) to 48% (2022), followed by NASH/MASH, which increased from 19% to 27%; the rates of viral hepatitis decreased (chronic hepatitis C: 28%-4%; chronic hepatitis B: 1.8%-1.1%) (all trend p<0.01). The proportion of HCC decreased from 25% (2013-2016) to 17% (2021-2022). Among HCC cohort, the proportion of chronic hepatitis C decreased from 60% (2013) to 27% (2022), NASH/MASH increased from 10% to 31%, alcohol-associated liver disease increased from 9% to 24% (trend p<0.0001), and chronic hepatitis B remained stable between 5% and 7% (trend p=0.62). The rapid increase in the proportion of NASH/MASH in HCC continued during the most recent study years [20% (2018), 28% (2020), 31% (2022)]; the trend remained significant after adjustment for age, sex, ethnicity, obesity, and type 2 diabetes.

CONCLUSIONS

Liver transplant etiologies in the United States have changed over the last decade. Alcohol-associated liver disease and NASH/MASH remain the 2 most common indications for transplantation among those without HCC, and NASH/MASH is the most common in patients with HCC.

Cost minimization analysis of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants

BACKGROUND

Trials describing 4-12 week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R-transplants), may be limited in application by costs and delayed access to expensive DAAs. A short prophylactic strategy may be safer and cost-effective. Here, we report a cost minimization analysis using the health system perspective to determine the least expensive DAA regimen, using available published strategies.

OBJECTIVES

To conduct cost-minimization analyses (CMAs) from the health system perspective of four DAA regimens to prevent and/or treat HCV transmission from D+/R-kidney transplants.

METHODS

CMAs comparing 4 strategies: 1) 7-day prophylaxis with generic sofosbuvir/velpatasvir (SOF/VEL), with 12-week branded glecaprevir/pibrentasvir (G/P) for those with transmission; 2) 8-day branded G/P prophylaxis, with 12-week branded SOF/VEL/voxilaprevir for those with transmission; 3) 4-week perioperative generic SOF/VEL prophylaxis, with 12-week branded G/P for those with transmission; and 4) 8-week branded G/P "transmit-and-treat." We included data from published literature to estimate the probability of viral transmission in patients who received DAA prophylaxis, and assumed a 100% transmission rate for those who received the "transmit-and-treat" approach.

RESULTS

In base-case analyses, strategies 1 (expected cost [EC]: $2326) and 2 (expected cost: $2646) were less expensive than strategies 3 (EC: $4859) and 4 (EC: $18,525). Threshold analyses for 7-day SOF/VEL versus 8-day G/P suggested that there were reasonable input levels at which the 8-day strategy may be least costly. The threshold values for the SOF/VEL prophylaxis strategies (7-day vs. 4- week) indicated that the 4-week strategy is unlikely to be less costly under any reasonable value of the input variables.

CONCLUSIONS

Short duration DAA prophylaxis using 7 days of SOF/VEL or 8 days of G/P has the potential to yield significant cost savings for D+/R- kidney transplants.

Management of Hepatitis C Virus and Hepatitis B Virus Infection in the Setting of Kidney Disease

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.

Preemptive antiviral therapy in lung transplantation from hepatitis C donors results in a rapid and sustained virologic response

Objective

The study objective was to assess the safety and efficacy of a preemptive direct-acting antiviral therapy in lung transplants from hepatitis C virus donors to uninfected recipients.

Methods

This study is a prospective, open-label, nonrandomized, pilot trial. Recipients of hepatitis C virus nucleic acid test positive donor lungs underwent preemptive direct-acting antiviral therapy with glecaprevir 300 mg/pibrentasvir 120 mg for 8 weeks from January 1, 2019, to December 31, 2020. Recipients of nucleic acid test positive lungs were compared with recipients of lungs from nucleic acid test negative donors. Primary end points were Kaplan-Meier survival and sustained virologic response. Secondary outcomes included primary graft dysfunction, rejection, and infection.

Results

Fifty-nine lung transplantations were included: 16 nucleic acid test positive and 43 nucleic acid test negative. Twelve nucleic acid test positive recipients (75%) developed hepatitis C virus viremia. Median time to clearance was 7 days. All nucleic acid test positive patients had undetectable hepatitis C virus RNA by week 3, and all alive patients (n = 15) remained negative during follow-up with 100% sustained virologic response at 12 months. One nucleic acid test positive patient died of primary graft dysfunction and multiorgan failure. Three of 43 nucleic acid test negative patients (7%) had hepatitis C virus antibody positive donors. None of them developed hepatitis C virus viremia. One-year survival was 94% for nucleic acid test positive recipients and 91% for nucleic acid test negative recipients. There was no difference in primary graft dysfunction, rejection, or infection. One-year survival for nucleic acid test positive recipients was similar to a historical cohort of the Scientific Registry of Transplant Recipients (89%).

Conclusions

Recipients of hepatitis C virus nucleic acid test positive lungs have similar survival as recipients of nucleic acid test negative lungs. Preemptive direct-acting antiviral therapy results in rapid viral clearance and sustained virologic response at 12 months. Preemptive direct-acting antiviral may partially prevent hepatitis C virus transmission.

Organ Donors with Human Immunodeficiency Virus and Hepatitis C Virus: Expanding the Donor Pool

Using organs from donors with treatable infections is a strategy to increase the quality and number of organs for transplantation. For HIV, pilot studies of kidney and liver transplantation from donors with HIV to recipients with HIV demonstrate excellent early outcomes. However, the number of donors and transplants per year remains lower than projected due to several barriers. For HCV, the use of organs from donors with HCV has expanded to recipients without HCV due to safe, effective direct-acting antivirals for HCV, which are well-tolerated in transplant recipients. Studies across organ types demonstrate good outcomes and shorter wait times.

Trends in use and three-year outcomes of hepatitis C virus-viremic donor lung transplants for hepatitis C virus-seronegative recipients

OBJECTIVE

The feasibility and 6-month outcome safety of lung transplants (LTs) from hepatitis C virus (HCV)-viremic donors for HCV-seronegative recipients (R-) were established in 2019, but longer-term safety and uptake of this practice nationally remain unknown.

METHODS

We identified HCV-seronegative LT recipients (R-) 2015-2020 using the Scientific Registry of Transplant Recipients. We classified donors as seronegative (D-) or viremic (D+). We used χ2 testing, rank-sum testing, and Cox regression to compare posttransplant outcomes between HCV D+/R- and D-/R- LT recipients.

RESULTS

HCV D+/R- LT increased from 2 to 97/year; centers performing HCV D+/R- LT increased from 1 to 25. HCV D+/R- versus HCV D-/R- LT recipients had more obstructive disease (35.7% vs 23.3%, P < .001), lower lung allocation score (36.5 vs 41.1, P < .001), and longer waitlist time (P = .002). HCV D+/R- LT had similar risk of acute rejection (adjusted odds ratio [aOR], 0.87; P = .58), extracorporeal membranous oxygenation (aOR, 1.94; P = .10), and tracheostomy (aOR, 0.42; P = .16); similar median hospital stay (P = .07); and lower risk of ventilator > 48 hours (aOR, 0.68; P = .006). Adjusting for donor, recipient, and transplant characteristics, risk of all-cause graft failure and mortality were similar at 30 days, 1 year, and 3 years for HCV D+/R- versus HCV D-/R- LT (all P > .1), as well as for high- (≥20/year) versus low-volume LT centers and high- (≥5/year) versus low-volume HCV D+/R- LT centers (all P > .5).

CONCLUSIONS

HCV D+/R- and HCV D-/R- LT have similar outcomes at 3 years posttransplant. These results underscore the safety of HCV D+/R- LT and the potential benefit of expanding this practice further.

Outcome of Kidney Transplants from Viremic and Non-Viremic Hepatitis C Virus Positive Donors into Negative Recipients: Results of the Spanish Registry

Historically, donor infection with hepatitis-C virus (HCV) has been a barrier to kidney transplantation. However, in recent years, it has been reported that HCV positive kidney donors transplanted into HCV negative recipients offer acceptable mid-term results. However, acceptance of HCV donors, especially viremic, has not broadened in the clinical practice. This is an observational, multicenter, retrospective study including kidney transplants from HCV positive donors into negative recipients reported to the Spanish group from 2013 to 2021. Recipients from viremic donors received peri-transplant treatment with direct antiviral agents (DAA) for 8-12 weeks. We included 75 recipients from 44 HCV non-viremic donors and 41 from 25 HCV viremic donors. Primary non function, delayed graft function, acute rejection rate, renal function at the end of follow up, and patient and graft survival were not different between groups. Viral replication was not detected in recipients from non-viremic donors. Recipient treatment with DAA started pre-transplant avoids (n = 21) or attenuates (n = 5) viral replication but leads to non-different outcomes to post-transplant treatment with DAA (n = 15). HCV seroconversion was more frequent in recipients from viremic donors (73% vs. 16%, p < 0.001). One recipient of a viremic donor died due to hepatocellular carcinoma at 38 months. Donor HCV viremia seems not to be a risk factor for kidney transplant recipients receiving peri-transplant DAA, but continuous surveillance should be advised.

Analysis of the effects of donor and recipient hepatitis C infection on kidney transplant outcomes in the United States

BACKGROUND

As Hepatitis C virus infection (HCV+) rates in kidney donors and transplant recipients rise, direct-acting antivirals (DAA) may affect outcomes.

AIM

To analyze the effects of HCV+ in donors, recipients, or both, on deceased-donor (DD) kidney transplantation (KT) outcomes, and the impact of DAAs on those effects.

METHODS

The Organ Procurement and Transplantation Network data of adult first solitary DD-KT recipients 1994-2019 were allocated into four groups by donor and recipient HCV+ status. We performed patient survival (PS) and death-censored graft survival (DCGS) pairwise comparisons after propensity score matching to assess the effects of HCV+ in donors and/or recipients, stratifying our study by DAA era to evaluate potential effect modification.

RESULTS

Pre-DAA, for HCV+ recipients, receiving an HCV+ kidney was associated with 1.28-fold higher mortality (HR _1.151.28_1.42) and 1.22-fold higher death-censored graft failure (HR _1.081.22_1.39) compared to receiving an HCV- kidney and the absolute risk difference was 3.3% (95%CI: 1.8%-4.7%) for PS and 3.1% (95%CI: 1.2%-5%) for DCGS at 3 years. The HCV dual-infection (donor plus recipient) group had worse PS (0.56-fold) and DCGS (0.71-fold) than the dual-uninfected. Donor HCV+ derived worse post-transplant outcomes than recipient HCV+ (PS 0.36-fold, DCGS 0.34-fold). In the DAA era, the risk associated with HCV+ in donors and/or recipients was no longer statistically significant, except for impaired PS in the dual-infected vs dual-uninfected (0.43-fold).

CONCLUSION

Prior to DAA introduction, donor HCV+ negatively influenced kidney transplant outcomes in all recipients, while recipient infection only relatively impaired outcomes for uninfected donors. These adverse effects disappeared with the introduction of DAA.

Outcomes of Over 1000 Heart Transplants Using Hepatitis C-Positive Donors in the Modern Era

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.

Donor substance abuse and heart transplantation outcomes

Heart failure continues to account for millions of cases and deaths worldwide. Heart transplant is the gold standard for treatment of advanced heart failure. Unfortunately, the supply of donor hearts continues to be limited with the increase in demand for heart transplantation. In this review, we aim to explore the safety and efficacy of using hearts from donors with history of substance use. Despite the theoretical effect of cocaine and alcohol on the cardiovascular system, several studies demonstrate no difference in outcomes (overall survival, graft rejection, graft vasculopathy) when using hearts from patients with history of cocaine and alcohol use. The opioid epidemic has expanded the potential donor pool where the current studies have not shown any adverse outcomes when considering donors with history of opioid use. The currently available evidence would support the use of donor hearts from patients with history of alcohol, cocaine, opioids, and marijuana use. Further studies are needed to evaluate the safety of using donor hearts from patients with history of nicotine use.

Effectiveness of education and attitudes toward different types of deceased donor kidneys: Survey analysis of single-center experience

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.

Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada

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.

A systematic review of direct acting antiviral therapies in hepatitis C virus-negative liver transplant recipients of hepatitis C-viremic donors

The introduction of safe and highly effective direct acting antivirals (DAAs) has significantly improved hepatitis C virus (HCV) treatment outcomes after transplant. The solid organ transplant community has sought to identify strategies aimed at increasing the donor pool including the utilization of HCV-viremic organs in HCV-negative recipients. We will review the existing literature to evaluate DAA use for the treatment of HCV viremia post-liver transplant in patients who receive HCV-viremic allografts. A PubMed search was conducted and references for each study were also reviewed to identify additional articles. Randomized controlled trials, cohort studies, case series, and case reports were included if: published in English language, evaluated DAA treatment outcomes after liver only or simultaneous liver-kidney transplantation with HCV-viremic allografts in HCV-negative recipients, and had full-text article availability. Our review included 16 studies and 2 case reports. The majority of liver transplant recipients were treated with a pangenotypic DAA for 12 weeks with a heterogeneous median time to initiation (range 1.7-118 days). Sustained virologic response was assessed in 253 liver transplant patients with 99.6% achieving cure with minimal DAA-attributed adverse drug events. There were 23 reported episodes of rejection, 12 deaths, and 1 graft loss among all studies. Treatment with DAA after transplantation of HCV-viremic livers into HCV-negative recipients appears to be safe and effective; however, long-term outcomes remain unknown. Transplant pharmacists play a key role in the development of center-specific protocols to optimize post-transplant outcomes in this unique patient population.

Trends and three-year outcomes of hepatitis C virus-viremic donor heart transplant for hepatitis C virus-seronegative recipients

Objective

Heart transplants (HTs) from hepatitis C virus (HCV)-viremic donors to HCV-seronegative recipients (HCV D+/R-) have good 6-month outcomes, but practice uptake and long-term outcomes overall and among candidates on mechanical circulatory support (MCS) have yet to be established.

Methods

Using the Scientific Registry of Transplant Recipients, we identified US adult HCV-seronegative HT recipients (R-) from 2015 to 2021. We classified donors as HCV-seronegative (D-) or HCV-viremic (D+). We used multivariable regression to compare post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, acute rejection, and risk of post-HT mortality between HCV D+/R- and HCV D-/R-. Models were adjusted for donor, recipient, and transplant characteristics and center HT volume. We performed subgroup analyses of recipients bridged with MCS.

Results

From 2015 to 2021, the number of HCV D+/R- HT increased from 1 to 181 and the number of centers performing HCV D+/R- HT increased from 1 to 60. Compared with HCV D-/R- recipients, HCV D+/R- versus D-/R- recipients overall and among patients bridged with MCS had similar odds of post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, and acute rejection; and mortality risk at 30 days, 1 year, and 3 years (all P > .05). High center HT volume but not HCV D+/R- volume (<5 vs >5 in any year) was associated with lower mortality for HCV D+/R- HT.

Conclusions

HCV D+/R- and D-/R- HT have similar outcomes at 3 years' posttransplant. These results underscore the opportunity provided by HCV D+/R- HT, including among the growing population bridged with MCS, and the potential benefit of further expanding use of HCV+ allografts.

Deceased Donor Characteristics and Kidney Transplant Outcomes

Kidney transplantation is the therapy of choice for people living with kidney failure who are suitable for surgery. However, the disparity between supply versus demand for organs means many either die or are removed from the waiting-list before receiving a kidney allograft. Reducing unnecessary discard of deceased donor kidneys is important to maximize utilization of a scarce and valuable resource but requires nuanced decision-making. Accepting kidneys from deceased donors with heterogenous characteristics for waitlisted kidney transplant candidates, often in the context of time-pressured decision-making, requires an understanding of the association between donor characteristics and kidney transplant outcomes. Deceased donor clinical factors can impact patient and/or kidney allograft survival but risk-versus-benefit deliberation must be balanced against the morbidity and mortality associated with remaining on the waiting-list. In this article, the association between deceased kidney donor characteristics and post kidney transplant outcomes for the recipient are reviewed. While translating this evidence to individual kidney transplant candidates is a challenge, emerging strategies to improve this process will be discussed. Fundamentally, tools and guidelines to inform decision-making when considering deceased donor kidney offers will be valuable to both professionals and patients.

Donors with human immunodeficiency virus and hepatitis C virus for solid organ transplantation: what's new

PURPOSE OF THE REVIEW

Passage of the HOPE Act and the advent of direct-acting antiviral (DAA) therapies have allowed for expansion of the donor organ pool to include donors with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), thus providing new opportunities for waitlist candidates. This article provides updates on recent studies in solid organ transplantation (SOT) utilizing donors with HIV and HCV.

RECENT FINDINGS

The first pilot studies of kidney and liver transplantation from donors-with-HIV to recipients-with-HIV (HIV D+/R+) show robust patient survival, comparable graft survival to transplantation from donors without HIV (HIV D-/R+) and no increased rates of HIV breakthrough. The number of HIV D+ organs utilized has been lower than initial estimates due to several potential factors. With high numbers of overdose deaths from the opioid epidemic, there have been more HCV D+ organs available, leading to transplantation in recipients without HCV (HCV D+/R-) in combination with DAAs. Outcomes in both abdominal and thoracic HCV D+/R transplantation are excellent.

SUMMARY

With recent findings of good outcomes in both HIV D+/R+ and HCV D+/R- SOT, we feel the evidence supports both practices as standard clinical care options to mitigate organ shortage and reduce waitlist mortality.

Decision-making Among Hepatitis C Virus-negative Transplant Candidates Offered Organs from Donors with HCV Infection

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.

Efficacy and Safety of Direct-Acting Antivirals in Kidney Transplantation From HCV-Viremic Donors to Negative Recipients: A Meta-Analysis

Background:

With the development of direct-acting antiviral agents (DAAs), the research on kidney transplantation from Hepatitis C virus (HCV)-viremic donors to HCV-negative recipients has grown. The objective of this comprehensive analysis was to evaluate the efficacy and safety of DAAs in kidney transplantation from HCV-viremic donors to negative recipients.

Methods

Multiple databases were searched for a systematic and comprehensive up to March 2022. The primary outcomes included the percentage of sustained virological response at week 12 after the end of treatment (SVR12), adverse events (AEs; any grade), and severe adverse events (SAEs) as the endpoints. Publication bias was examined by using the funnel plots and Egger's test.

Results

In total, 16 studies with 454 subjects were included in the study and the pooled estimate of SVR12, AEs, and SAEs rates were 100.0% (95% CI: 99.2-100.0), 1.9%(95%CI: 0.0-4.9), and 0.0% (95%CI: 0.0-1.5). Subgroup analysis showed that pooled SVR12 rates were 100.0% (95%CI: 99.6-100.0) for genotype (GT)1a and 96.3% (95%CI: 83.3-100.0) for GT2; 100.0% (95%CI: 98.9-100.0) for DAAs treatments; and 100.0% (95%CI: 98.2-100.0) for prophylaxis subgroup. Egger's tests showed that no publication bias was found in this study.

Conclusion

This comprehensive analysis showed the high efficacy and safety of DAAs in kidney transplantation from HCV-viremic donors to HCV-negative recipients.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=246541.

Liver Outcome in Renal Transplant Recipients Who Acquired Hepatitis C Infection From an Infected Graft: Study Based on Liver Biopsy Findings

Long-term liver outcome in hepatitis C virus (HCV)-negative kidney recipients who acquired HCV infection from viremic donors is of intense interest in the transplant community. We evaluated the incidence of fibrosis in liver biopsy specimens of recipients who were transplanted with HCV-infected grafts.

The Use of Hepatitis C Virus-Positive Organs in Hepatitis C Virus-Negative Recipients

The use of hepatitis C virus (HCV) -positive organs in HCV-negative recipients with posttransplant antiviral treatment has increasingly been studied since the introduction of new direct-acting antivirals. This article reviews existing experience in liver and kidney transplant. Fifteen studies with 218 HCV D+/R- liver transplants, with 182 from viremic donors, show a sustained viral response for 12 weeks (SVR12) rate of 99.5%. Nine studies involving 204 HCV donor-positive recipient-negative kidney transplant recipients had an SVR12 rate of 99.5%. Complications are infrequent. Preemptive treatment in kidney transplant of for only 4 weeks or even 4 days showed surprising success rates.

Viral hepatitis: Past, present, and future

Each hepatitis virus-Hepatitis A, B, C, D, E, and G-poses a distinct scenario to the patient and clinician alike. Since the discovery of each virus, extensive knowledge regarding epidemiology, virologic properties, and the natural clinical and immunologic history of acute and chronic infections has been generated. Basic discoveries about host immunologic responses to acute and chronic viral infections, combined with virologic data, has led to vaccines to prevent Hepatitis A, B, and E and highly efficacious antivirals for Hepatitis B and C. These therapeutic breakthroughs are transforming the fields of hepatology, transplant medicine in general, and public and global health. Most notably, there is even an ambitious global effort to eliminate chronic viral hepatitis within the next decade. While attainable, there are many barriers to this goal that are being actively investigated in basic and clinical labs on the local, national, and international scales. Herein, we discuss pertinent clinical information and recent organizational guidelines for each of the individual hepatitis viruses while also synthesizing this information with the latest research to focus on exciting future directions for each virus.

Temporal Trends in Utilization and Outcomes of DCD Livers in the United States

BACKGROUND

Historically, donation after circulatory death (DCD) livers were frequently discarded because of higher mortality and graft loss after liver transplantation (LT). However, the demand for LT continues to outstrip the supply of "acceptable" organs. Additionally, changes in the donor pool, organ allocation, and clinical management of donors and recipients, and improved clinical protocols might have altered post-DCD-LT outcomes.

METHODS

We studied 5975 recovered DCD livers using US Scientific Registry of Transplant Recipients data from 2005 to 2017, with a comparison group of 78 235 adult donation after brain death (DBD) livers recovered during the same time period. We quantified temporal trends in discard using adjusted multilevel logistic regression and temporal trends in post-LT mortality and graft loss for DCD LT recipients using adjusted Cox regression.

RESULTS

DCD livers were more likely to be discarded than DBD livers across the entire study period, and the relative likelihood of discard increased over time (adjusted odds ratio [aOR] of discard DCD versus DBD 3.854.455.14 2005-2007, 5.225.876.59 2015-2017) despite improving outcomes after DCD LT. Mortality risk for DCD LTs decreased in each time period (compared with 2005-2007, aHR 2008-2011 0.720.840.97, aHR 2012-2014 0.480.580.70, aHR 2015-2017 0.340.430.55), as did risk of graft loss (compared with 2005-2007, aHR 2008-2011 0.690.810.94, aHR 2012-2014 0.450.550.67, aHR 2015-2017 0.360.450.56).

CONCLUSIONS

Despite dramatic improvements in outcomes of DCD LT recipients, DCD livers remain substantially more likely to be discarded than DBD livers, and this discrepancy has actually increased over time. DCD livers are underutilized and have the potential to expand the donor pool.

Hepatitis C positive organ transplantation to negative recipients at a multiorgan Canadian transplant centre: ready for prime time

BACKGROUND

Transplantation offers the best survival for patients with end stage organ disease. Transplant of hepatitis C virus (HCV) nucleic acid test (NAT) positive organs into negative recipients is a novel strategy that can expand the donor pool. We aim to evaluate our centre's experience.

METHODS

We preformed a retrospective review of anti-HCV NAT positive and negative organs into negative recipients transplanted over 27 months. Primary outcome was the success rate of eradication of HCV post-transplant. Secondary outcomes were rate of transmission of HCV, treatment adverse events, and graft failure.

RESULTS

33 anti-HCV positive organs were transplanted into negative recipients. 22 (66.7%) were NAT positive. Median recipients age was 49 years (interquartile range [IQR] 44.5-62.0) with the majority being males (57.6%). NAT positive organ transplantations included 16 kidneys, 3 livers, 1 kidney-pancreas, 1 liver-kidney, and 1 heart. The most common HCV genotype was 1a (59.1%). The median time to initiating therapy was 41.5 days. SVR12 was 100% in patients who finished therapy. There were no adverse events with therapy and no graft failure.

CONCLUSIONS

Anti-HCV NAT positive organ transplantation into negative recipients is safe with excellent eradication rates and no significant adverse events or graft failure. This would expand donor pool to close the gap between supply and demand.

Advanced considerations in organ donors

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.

The benefit to waitlist patients in a national paired kidney exchange program: Exploring characteristics of chain end living donor transplants

Nondirected kidney donors can initiate living donor chains that end to patients on the waitlist. We compared 749 National Kidney Registry (NKR) waitlist chain end transplants to other transplants from the NKR and the Scientific Registry of Transplant Recipients between February 2008 and September 2020. Compared to other NKR recipients, chain end recipients were more often older (53 vs. 52 years), black (32% vs. 15%), publicly insured (71% vs. 46%), and spent longer on dialysis (3.0 vs. 1.0 years). Similar differences were noted between chain end recipients and non-NKR living donor recipients. Black patients received chain end kidneys at a rate approaching that of deceased donor kidneys (32% vs. 34%). Chain end donors were older (52 vs. 44 years) with slightly lower glomerular filtration rates (93 vs. 98 ml/min/1.73 m² ) than other NKR donors. Chain end recipients had elevated risk of graft failure and mortality compared to control living donor recipients (both p < .01) but lower graft failure (p = .03) and mortality (p < .001) compared to deceased donor recipients. Sharing nondirected donors among a multicenter network may improve the diversity of waitlist patients who benefit from living donation.

Development of the Eurotransplant Discard Risk Index to Predict Acceptance of Livers for Transplantation: A Retrospective Database Analysis

OBJECTIVES

The utilization of liver allografts could be optimized if nonacceptance is predicted. This study aimed to evaluate the prognostic ability of an updated Discard Risk Index in Eurotransplant.

MATERIALS AND METHODS

Potential deceased donors from January 2010 to December 2015 who had been reported to Eurotransplant were included in our analyses. Liver utilization was defined by transplant status as the primary outcome to evaluate the performance of the Eurotransplant-developed Discard Risk Index.

RESULTS

Of 11670 potential livers, 9565 (81%) were actually transplanted. Donor sex, age, history of diabetes, drug abuse, use of vasopressors, body mass index category, serum sodium, cause of death, donor type, and levels of C-reactive protein, bilirubin, aspartate and alanine aminotransferases, international normalized ratio, and gamma-glutamyltranspeptidase were associated with discard and combined in the Eurotransplant-developed Discard Risk Index. Correlation between the two Discard Risk Indexes was high (r = 0.86), and both achieved high C statistics of 0.72 and 0.75 (P < .001), respectively. Despite strong calibration, discard rates of 0.8% for overall donors and 6% of donors after circulatory death could be predicted with 80% accuracy.

CONCLUSIONS

The Eurotransplant-developed Discard Risk Index showed a high prognostic ability to predict liver utilization in a European setting. The model could therefore be valuable for identifying livers at high risk of not being transplanted in an early stage. These organs might profit the most from modified allocation strategies or advanced preservation techniques.

Temporal trends and impact of willingness to accept organs from donors with hepatitis C virus

Direct-acting antivirals (DAA) transformed hepatitis C virus (HCV) treatment in 2014; however, their impact on transplant candidates' willingness to accept (CWTA) organs from HCV⁺ donors remains uncertain. We retrospectively studied Organ Procurement and Transplantation Network data from 2008 to 2019, investigating CWTA different organs from HCV⁺ donors over time, using segmented multivariable logistic regression, and how that influenced wait-time and deceased-donor transplantation (DDTx) probability, using multivariable logistic or linear regression. We found that DAA availability was associated with a marked increase in CWTA in all organs from HCV⁺ donors except intestine. By December 2020, 40% of kidney, 33% of kidney-pancreas, 42% of pancreas, over 50% of liver, heart, lung, heart-lung, and 9% of intestine candidates waitlisted were CWTA an organ from HCV⁺ donors. Compared with pre-DAA, yearly CWTA kidney from HCV⁺ donors increased post-DAA _1.78 1.81_1.83 -fold, kidney-pancreas ₂ .₅₂ 2.78 _3.07 -fold, pancreas _3.15 3.69 _4.43 -fold, liver _1.53 1.54_1.56 -fold, heart ₁ .₉₂ 2.0₂ .₀₈ -fold, and lung _2.00 2.1₂ .₂₀ -fold. CWTA kidney and liver from HCV⁺ donors significantly increased DDTx probability post-DAA (_1.98 2.04_2.1 -fold and _1.24 1.29_1.33 -fold, respectively) and shortened kidney candidates' wait-time₇₈ 90₁₀₁ days (Mean with 95% CI). CWTA organs from HCV⁺ donors rose significantly with DAA availability, benefitting kidney and liver candidates with increased DDTx rates and shortened kidney candidates' wait time. Further long-term outcomes investigation and standardized organ from HCV⁺ donors' education could improve both provider and patient acceptance and utilization.

Outcomes of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants

Trials describing 4- to 12-week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R- transplants) may be limited in "real-world" application by costs and delayed access to DAAs. We previously reported HCV transmission of 13% among D+/R- transplants with 2- to 4-day pangenotypic sofosbuvir/velpatasvir (SOF/VEL) perioperative prophylaxis, where one patient with HCV transmission was a nonresponder to first-line full-course DAA. Here, we report new data with a 7-day prophylaxis protocol (N = 50), as well as cumulative treatment and outcome data on all HCV D+/R- transplants (N = 102). Overall, nine patients (9/102; 9%; 95% CI: 5%-16%) developed HCV transmission, with a significant decline noted in the 7-day group (2/50; 4%; 95% CI: 0%-13%) compared with 2- to 4-day prophylaxis (7/52; 13%; 95% CI: 5%-25%). All patients with HCV transmission achieved sustained virologic response post full-course therapy (including one nonresponder from initial trial). A 1:1 matched analysis (N = 102) with contemporary HCV D-/R- transplants (controls) showed that although the pretransplant wait time was significantly shorter for D+/R- compared with D-/R- (mean: 1.8 vs. 4.4 years; p < .001), there were no differences in infections, rejection, development of de novo donor-specific antibody, or transplant outcomes up to 6 months of transplant.

Changing Demographics, Temporal Trends in Waitlist, and Posttransplant Outcomes After Heart Transplantation in the United States: Analysis of the UNOS Database 1991-2019

BACKGROUND

We sought to investigate temporal trends in patient characteristics, waitlist, and posttransplant outcomes after heart transplantation in the United States.

METHODS

Using data from the United Network of Organ Sharing, we identified adults listed for heart transplantation between 1991 and 2019. Patients were divided into 4 eras based on the 3 time points in which changes were made to the patient selection/allocation policy (Era 1=January 1991-January 1999; Era 2=January 1999-July 2006; Era 3=July 2006-October 2018; and Era 4=October 2018-March 2020), and patient characteristics, waitlist, and posttransplant outcomes were evaluated for each era.

RESULTS

Between 1991 and 2019, 95 179 patients were added to the heart transplantation waitlist. Compared with Era 1, patients listed in Era 4 were older (mean age: 50 versus 52 years) and with higher risk comorbidities (eg, 10% versus 28.8% diabetes, 23.3% versus 35.6% obese). Over the study period, 22 738 patients died or were permanently delisted for deterioration on the waitlist while 61 687 were transplanted. Compared with the preceding era, there was significant decrease in death or deterioration in the last 2 eras (sub-hazard ratio, 0.67 [95% CI, 0.65-0.70] for Era 3 versus Era 2 and sub-hazard ratio, 0.65 [95% CI, 0.58-0.73] for Era 4 versus 3). Across the years, 27.1% to 40.5% of those on the waitlist were transplanted. Among those transplanted, there was increase in the rates of in-hospital stroke (2.8% in Era 1 to 3.7% in Era 4), renal failure requiring dialysis (7.2%-17.1%), and length-of-stay (14-17days), P<0.001. However, this did not negatively impact short-term survival when compared with the preceding era (1-year graft survival from Era 1 to Era 4=84.1%, 86.4%, 90.4%, and 89.7%, respectively).

CONCLUSIONS

There have been significant changes in the characteristics of patients listed for heart transplantation. Although transplant volume has increased, the wide supply-demand gap persisted. The last two changes in the allocation policy achieved their primary objective of reducing waitlist mortality.

Protocol for Optimizing the Use of Kidneys From Donors With Seropositivity for Hepatitis C Virus in Seronegative Recipients

BACKGROUND

The rapid identification of the viral load from hepatitis C virus (HCV) in seropositive donors enables the determination of their infection capacity and the subsequent design of a strategy to optimize the use of direct-action antivirals (DAA) in seronegative recipients. In 2017, we designed an optimization protocol; this study aims to assess its efficacy and safety.

METHODS

This is a prospective, multicenter observational study that complies with the Declarations of Helsinki and Istanbul. Donors were HCV seropositive. The HCV and human immunodeficiency virus loads were immediately determined in the donors. For viremic donors, recipients were treated with DAA for 8 weeks. For nonviremic donors, DAA was started if a viral load was detected during the follow-up period. The minimum follow-up period was 6 months posttransplant.

RESULTS

This study recruited 28 donors. Just over half of the donors (n = 15; 53.5%) had a nonactive history of injection drug use. Eight (22.4%) donors were viremic, and 20 (87.6%) were nonviremic; 13 (65%) had been treated previously. Nine grafts were ineligible for the protocol. We performed a total of 47 transplants. Procedure I (viremic donors) was performed in 13 recipients (27.7%). Posttransplant viremia was observed in 6 participants. Posttransplant viremia was low (<100 IU/mL) in 4 participants but high (36,000 and 138,000 IU/mL) in 2 participants who had initiated DAA after the transplant; all these patients had a sustained viral response. Seroconversion was observed in 11 of 13 (84.6%) patients. Procedure II (nonviremic donors) was undertaken in 34 (82.3%) patients. No positive viral loads were observed. Seroconversion occurred in 7 of 34 (20.5%) recipients. All recipients maintained kidney function at 6 months posttransplant, except 1 patient with a graft that had never been functional and another patient who died of pancreatitis. Both patients had received kidneys from nonviremic donors.

CONCLUSIONS

Our experience supports the efficacy and safety of this protocol.

The Surge in Deceased Liver Donors Due to the Opioid Epidemic: Is It Time to Split the Difference?

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.

Pretransplant Hepatitis C Virus Treatment Decreases Access to High-quality Livers

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 = _0.973.86_15.4) (P = 0.06).

Conclusions

Deferring HCV treatment improves access to higher-quality donors and may improve post-LT survival.

Curative Therapies for Hepatitis C Virus Infection in Patients with Kidney Disease

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.