Organs from hepatitis C virus (HCV)-positive donors have historically been used for transplantation only in recipients who already had HCV; otherwise the donated organs were discarded. But, because demand for organs continues to exceed supply, transplant teams have begun using organs from HCV+ donors in HCV- recipients, counting on direct-acting antivirals to treat any resulting HCV infection.

Robert Montgomery, director of the NYU Langone Transplant Institute, recovers after a routine heart biopsy following a heart transplant a few months earlier. He had received the heart of a heroin user who had hepatitis C, which Dr. Montgomery initially contracted and then recovered from. Photo by Caitlin Ochs.

Organs available for transplant are in chronically short supply. For example, there are nearly twice as many people awaiting livers in the United States as there are livers available, and the mortality rate for those on the wait list is 20%. There are also more than 90,000 people awaiting a kidney.

Recently, the number of organs available for transplant has surged, a direct result of overdose deaths associated with the current opioid epidemic. Many of those who have died are relatively young and therefore likely to have well-functioning organs. A downside is the high rate of HCV seropositivity in IV drug users, although up to one-third may be nonviremic. However, transplant teams are now reconsidering the once discarded organs from these infected donors owing to the availability of direct-acting antivirals that provide sustained virologic response rates exceeding 95%.

In 2015, the University of Cincinnati Medical Center (UCMC) began offering livers from HCV+ nonviremic donors to non-HCV recipients. To date, nearly 60 patients have undergone these transplants, according to Travis Doty, pre-liver transplant nurse coordinator at UCMC. Between 9% and 10% of the patients have converted to HCV seropositivity and were treated successfully with antivirals. "We changed our patient education to include discussion of what organs are available," Doty told AJN. "Our informed consent process changed, as did our monitoring process, including our protocol for monitoring for viremia."

Transplantation with a less-than-ideal organ favors survival more than waiting for a "better" organ. One study showed that candidates who accepted kidneys from HCV+ donors waited a year less than those waiting for organs from HCV- donors. UCMC has taken its program a step further and now offers livers to HCV- recipients from HCV+ donors who are viremic and treats the transmitted HCV after transplantation. The ability to successfully offer these types of organs has the potential to decrease wait-list mortality and substantially change the field of transplantation.-Joan Zolot, PA

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