2960 National Variation in Approach to HCV in Patients Listed for Liver Transplant

Abstract

INTRODUCTION: Due to recent progress in the treatment of hepatitis C virus (HCV), many providers specializing in transplant medicine face the difficult clinical decision of whether to treat HCV in patients before or after liver transplantation (LT). Eradicating HCV in the pre-LT population has a powerful impact on both the LT waitlist and on the types of donors offered to recipients. Concurrently, increasing availability of organs from high-risk donors is occurring, largely due to the US overdose epidemic. We sought to better understand how some of these clinical and social dynamics impact decisions at US transplant centers. METHODS: We surveyed all medical and surgical transplant directors from adult US. LT centers via an online survey in 2017. The survey queried directors about their program's specific approach to waitlisted patients with HCV pre-LT. The survey posed broad questions about patient demographics as well as more specific questions relating to the frequency with which Public Health Service-increased risk (PHS-IR) and HCV+ donors are offered, the degree to which PHS-IR and HCV+ offers are declined due to a lack of waitlisted patients with HCV, and the existence of any cutoffs for transplantation. RESULTS: 28 respondents (17% response rate), representing programs in 10/11 UNOS regions, answered the survey. Respondents were primarily from university-affiliated LT programs (92.3%) and represented variably-sized programs (LT volume ≤50 in 46.4%, 51-100 in 35.7%, >100 in 17.9%). 93% of programs reported seeing >10% are PHS-IR offers, and 19% of programs reported >30% PHS-IR offers. 39.3% of programs reported >10% offers are from HCV+ donors. 50% of programs reported turning down offers for HCV+ organs due to lack of available HCV+ recipients on the waitlist. A minority of programs (14.3%) continue to use donor age cutoffs for HCV+ recipients and many programs do not attempt to treat chronic HCV in non-HCC patients with CPT-B (42.3%) and CPT-C (77.8%) cirrhosis. CONCLUSION: Significant heterogeneity in US LT centers' approach to HCV patients on the waitlist exists. There is a trend to leave the sickest HCV+ patients untreated, though organs may be discarded due to lack of available HCV+ recipients in some parts of the country. As utilization of HCV+ organs into HCV- recipients begins to increase in the US, consideration for a separate allocation strategy for these organs may be warranted.