Organ Transplant in the Direct-acting Antiviral Era

August 3, 2018

Can DAA therapy remove patients from transplant waiting lists? Are HCV-infected livers--and hearts--safe for uninfected organ recipients? Three new studies explain.

Three recent studies shed light on emerging issues in organ transplantation, issues being driven by the advent of highly effective direct-acting antiviral therapy. Scroll through highlights of the studies in these slides and learn more about:

What are the long-term outcomes in HCV-infected liver transplant candidates removed from transplant waiting lists due to liver function improvement after viral eradication?
Should HCV-infected individuals receive HCV-infected or HCV-uninfected kidneys?
What are the outcomes-to-date for patients receiving HCV-infected donor hearts?

Delisting HCV-infected liver transplant candidates who improved after viral eradication: Outcome 2 years after delisting

DAA Therapy: What Impact on Transplant Wait List? ELITA investigators previously reported that direct-acting antiviral therapy allowed 1 in 4 HCV-infected liver transplant candidates to be delisted due to improvement in liver function. The latest report from this group is a prospective follow-up of delisted patients to evaluate clinical outcomes including mortality risk, cancer development, and relisting.

1. Belli LS, et al. J Hepatol. 2016;65:524-531.

After Delisting, Low Risk of Complications. The percentage of delisted patients was higher than in the original report due to additional patients being delisted long after starting DAA therapy. A total of 4 patients were relisted, including 1 due to hepatocellular carcinoma and 3 who developed ascites. There was one death due to rapidly progressing HCC after delisting. Overall, the results suggest a “very low” risk of liver-related complications after delisting, according to study authors. Read study details.

Transplanting hepatitis C virus-infected versus uninfected kidneys into hepatitis C virus-infected recipients: a cost-effectiveness analysis

DAA –> Transplant vs Translplant –> DAA. The availability of direct-acting antiviral (DAA) agents to treat chronic HCV infection in patients with end-stage renal disease (ESRD) has led to a dilemma: is it better to treat HCV and then transplant an HCV-uninfected kidney, which would have a longer wait time for the procedure; or to transplant an HCV-infected kidney and then treat HCV, which would have a shorter wait time? Eckman and colleagues developed a decision analytic model to evaluate the comparative cost-effectiveness of these two approaches.

Results: Translplant –> DAA. Researchers found that transplant of an HCV-infected kidney followed by HCV treatment was the most effective, less costly approach. In sensitivity analysis, transplanting HCV-infected kidneys remained the preferred approach in most cases. Based on these results, they concluded that in HCV-infected patients, transplantation of HCV-infected kidneys may improve quality-adjusted life expectancy with reduced costs compared to transplantation of HCV-uninfected kidneys. Read study details.

Accepting hepatitis C virus-infected donor hearts for transplantation: multistep consent, unrealized opportunity, and the Stanford experience

DAA Therapy May Expand Transplant Opportunity. This report describes the experience at Stanford University with successful transplantation of two HCV-infected donor hearts followed by DAA therapy. Many centers are starting to accept HCV-infected organs due to broaden the donor pool.

Patients, Outcomes. Both patients received hearts from HCV-positive men, infected with HCV genotype 1A. They were both treated 2 weeks after transplantation with a 12-week course of DAA and achieved sustained viral response (SVR).

Cautious Optimism. Short-term outcomes have been excellent so far in the Stanford experience, according to authors of this report. These results suggest that the availability of HCV-infected donor hearts may be a reasonable strategy to expand a limited donor pool, though longer-term data are needed to evaluate the potential long-terms risks versus the benefits of shorter wait times and increased organ supply. Read study details.