Liver Transplant From Increased-Risk Donors in the Era of Direct-Acting Antivirals for Hepatitis C

Objectives: The opioid epidemic and the associated deaths have increased the availability of increased-risk donor organs. Here, we assessed factors associated with increased-risk donor liver transplant and determined their impact on survival and response to direct-acting antivirals. Patients and Methods: We analyzed anti-hepatitis C virus-positive deceased-donor liver transplant recipients from August 2013 through December 2017. We compared recipient and donor clinical and virologic features, response to direct-acting antivirals, and graft and patient survival rates in increased-risk versus traditional or non-increased risk donor organ transplants. Results: Of 153 transplant recipients, 89 (58%) were anti-hepatitis C virus positive, with 42/89 receiving increased-risk donor livers (mean age 62 years, 1 female, 80% white, and 60% with hepatoma). On univariable analysis, receipt of increased-risk donor liver was associated with simultaneous liver-kidney transplant, lower Model for End-Stage Liver Disease score, hepatitis C virus RNA positivity, pretransplant direct-acting antiviral nonresponse, and younger donor age. On multivariable analysis, only donor age and Model for End-Stage Liver Disease score were associated with increased-risk donor transplant. Among increased-risk donors, 12 (29%) were hepatitis C virus RNA positive, including one who was anti-hepatitis C virus antibody negative. Among recipients, 62 were hepatitis C virus RNA positive (35 with increased-risk livers), with 50 recipients (81%) having genotype 1. Posttransplant, recipient genotype changed in 6 and was mixed in 4 recipients. Of 55 recipients treated with direct-acting antivirals, 54 98%) achieved viral clearance. Overall 1-year graft and patient survival was 93%. Conclusions: Increased-risk donor organs provided high levels of utility in liver transplant recipients who were anti-HCV positive, showing optimal graft and patient survival. Increased-risk donors were younger and preferably transplanted in hepatitis C virus RNA-positive recipients with lower Model for End-Stage Liver Disease score. Posttransplant direct-acting antiviral therapy was highly efficacious irrespective of pretransplant recipient and donor virologic status.