Successful Transplantation of 58 Hepatitis C-Exposed Donor Hearts in the Era of Direct-Acting Antiviral Therapies

Abstract

Purpose The shortage of suitable donors for heart transplantation (HT) contributes to wait-list mortality and increased reliance on mechanical circulatory support. Since the advent of direct-acting antivirals (DAA) for treatment of hepatitis C (HCV), utilization of hepatitis C-exposed donors is now a viable strategy to expand the donor pool and potentially reduce waitlist time. Methods Between September 2016 and October 2018, 58 patients underwent HT from HCV-exposed donors. All patients were treated with standard immunosuppression and, for those who developed HCV infection, with a course of DAA. Data collection and analysis were performed after obtaining informed patient consent and IRB approval. Results Baseline characteristics: Mean age of recipients at time of HT was 52 ± 13 years (72% male, 69% Caucasian, 41% on left ventricular assist device support). Mean age of donors was 30 ± 7 years. Among donors, results of HCV antibody (Ab) and nucleic acid testing (NAT) were: 47 Ab+/NAT+, 9 Ab+/NAT-, 2 Ab-/NAT+. Time to transplant: Among all patients, active waitlist time from time of consent to accept HCV-exposed donors was median 4 days (IQR 1, 17). Hepatitis C testing and treatment: No recipients of NAT- donor hearts developed HCV infection. Of the 49 patients who received NAT+ donor hearts, 46 (94%) developed HCV infection, including 27 patients who completed DAA therapy with cure demonstrated by absence of viremia at 12 weeks post-treatment (SVR12), 7 patients in whom treatment is ongoing or recently completed, and 7 patients who have yet to initiate treatment. By the time of ISHLT 2019, we expect to have SVR12 data for all infected patients who have completed treatment, 30 of whom will be at least one year post-HT. To date, there has been no suggestion of increased rates of rejection, graft dysfunction or vasculopathy among infected patients, nor has there been a suggestion of liver injury. Conclusion In the era of highly effective HCV pharmacotherapy, the use of HCV-exposed donors safely allows for expansion of the donor pool.