In a new perspective paper published in The New England Journal of Medicine, researchers from Perelman School of Medicine at the University of Pennsylvania urged clinicians to consider transplanting kidneys infected with hepatitis C virus to uninfected people waiting for a kidney, as it could reduce mortality rates among this population.
Researchers, including David S. Goldberg, MD, MSCE, assistant professor of medicine and medical director of living donor liver transplantation at Perelman, stated in the paper that due to the new antiviral therapies for HCV, using the HCV-positive kidneys could be a good opportunity for transplant candidates.
David S. Goldberg
“Transplant teams often discard kidneys from donors with hepatitis C virus infection because of the many complications and historical barriers to successful treatment of HCV,” the researchers wrote. “We believe, however, that new antiviral therapies with cure rates exceeding 95% should prompt transplant leaders to view HCV-positive organs as a valuable opportunity for transplant candidates with or without pre-existing HCV infection.”
According to the paper, the kidney transplant waiting list has over 100,000 candidates, with the average wait time being 5 years in the U.S. In addition, the average rate of mortality among wait-listed patients is 4% per year.
“These grim realities have prompted aggressive efforts to procure kidneys that would previously have been considered unacceptable, including kidneys from donors older than 70 years of age, kidneys that have sustained acute injury, and kidneys with diverse infections,” the researchers wrote.
Using the national registry database, the researchers identified 3,273 deceased HCV-positive donors between 2005 and 2014. Of these, 6,546 kidneys were available, while only 2,402 were transplanted and 91% of the recipients had HCV.
“These discarded kidneys could have benefited more than 4,000 patients during that period and provided more than 12,000 years of graft life by 5 years after transplantation,” the researchers wrote.
The researchers wrote that HCV genotype 1 is the most common and difficult strand of HCV to treat, so this is why HCV-positive kidneys are rarely used for patients negative for HCV. However, the new therapeutic regimens available for HCV genotype 1 could and should change the way clinicians think in terms of HCV-positive kidneys, according to the researchers, due to the fact there are 95% cure rates and the regimens do not require interferon.
“Acceptance of transplantation of HCV-positive kidneys would result in shorter waiting times,” the researchers wrote.
Despite the positives of utilizing these organs, there are many barriers that could prevent them from being used including costs, guarantee of treatment, viral complications and risk of transmission.
“These concerns may be allayed by recent experience with treatment of HCV in liver-transplant recipients,” the researchers wrote. “When an HCV-positive patient receives an HCV-negative liver, the allograft is immediately exposed to HCV from the recipient and becomes infected. Clinical studies have demonstrated that these patients have high HCV cure rates, suggesting that immunosuppression does not impede HCV eradication and that interactions between HCV and transplant drugs can be successfully managed.”
In addition to the concerns and risks, ethics could play a role in whether a clinician wants to transplant an infected organ into an uninfected person.
“The ethics of knowingly infecting transplant recipients with HCV depends on the rigor of informed consent and the willingness of medical professionals to give greater weight to patients’ autonomy than to minimizing the possibility of iatrogenic harm. In our view, transplant physicians should offer HCV-positive organs to uninfected patients who have a high risk of health deterioration if they continue dialysis, [have] disadvantageous blood types, or other conditions that probably mean many years of waiting before an appropriate HCV-negative kidney can be obtained.”
The researchers concluded: “Novel antiviral therapies will gradually transform how we think about HCV. HCV-positive kidneys could become a valuable resource for patients who would otherwise have little chance of kidney transplantation. Taking advantage of this resource will require providers, regulatory authorities, and payers to reconsider notions of reasonable risk.” – by Melinda Stevens
Disclosures: Please see the full study for a list of the authors’ relevant financial disclosures.