Introduction and Background
Acceptance of Hepatitis C donor kidneys is a big topic of conversation today. Are we underutilizing these donor organs for kidney transplantation? With our ever-expanding wait list, more advanced testing (nucleic acid testing (NAT)) and newer hepatitis C medications able to be used now in our kidney population, we should be reconsidering how best to utilize these donor organs. Risk of transmission and current treatment options need to be weighed against the risk of waiting on the wait list.
Primary Query
Can we safely utilize hepatitis C Virus seropositive non viremic donor kidneys (HCV Ab positive/NAT negative) for hepatitis C Virus non viremic recipients?
Discussion
Online conversation focused on three issues. First whether or not the safety profile/rate of transmission when utilizing hepatitis C seropositive non viremic donor (HCV ab positive/NAT negative) kidneys appears favorable. Risk of donor transmission appears to be small. Informed consent is essential.
The second issue brought up by multiple participants was the availability and clinical implications of newer, even pan-genotypic direct-acting antiviral (DAA) therapy for hepatitis C.
The third issue focused on understanding the difference between hepatitis C seropositive and either NAT positive or NAT negative donor. There are key differences here with regards to rates of transmission.
Conclusions
Using additional data to utilize organs intelligently
With hepatitis C nucleic acid testing (NAT) being mandated by UNOS, physicians have the ability to differentiate a donor kidney not only as simply being hepatitis C seropositive but also as being either NAT negative or NAT positive. With this additional data, we have the capability of utilizing hepatitis C organs more intelligently.
Utilizing hepatitis C seropositive non viremic donors (HCV Ab positive/NAT negative) for hepatitis C naïve (HCV Ab negative/NAT negative) or a hepatitis C seropositive non viremic recipient is not yet common practice. The utilization of such donors (whether they be non PHS increased risk or not) seems safe with low risk of donor HCV transmission (with the risk of transmission being the lowest in the non PHS increased risk group since NAT testing must take into account the window period in the PHS increased risk group). The hepatitis C seropositive non viremic kidney most often comes from younger donors. Many of these donors will also be PHS increased risk. In the 2017 American Journal of Transplantation article by Kling et al utilization of this type of donor kidney would result in 48 additional kidneys nationally. Though this is small, it is still important and contributes to the ever expanding recipient need.
Since the risk of HCV transmission appears to be small with HCV seropositive non viremic Donor (HCV Ab(+) NAT(-) donor), adding this potential donor to our donor pool would seem logical. With informed consent and in conjunction with our Infectious Disease colleagues this is the type of donor kidney we are currently hesitant to use in our hep C non viremic recipient but should consider. Close monitoring will be important. Whether the donor kidney meets criteria for PHS increased risk or not, physicians should consider monitoring it as such.
Do not use a hepatitis C viremic donor for a non viremic recipient
As of right now, utilizing a hepatitis C viremic donor for a non viremic recipient is not recommended in kidney transplantation. Transmission of hepatitis C is likely. In the future, however, with additional studies (Trial of Transplantation of HCV-Infected Kidneys into Uninfected Recipients NEJM 2017) and more reassuring data along with the availability of new, even pan-genotypic DAA therapies, the net of potential recipients could potentially be widened to include this donor population.
Transplanting a hepatitis C viremic donor kidney into a hepatitis C viremic recipient is currently being accomplished at most centers. Direct-acting antiviral (DAA) therapy is typically introduced post-transplant. By doing this, the wait time for a hepatitis C viremic recipient may be shortened.
Please read the full discussion.