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Increasing multiorgan heart transplantation with hepatitis C virus donors in the current-era

https://doi.org/10.1016/j.healun.2021.05.018Get rights and content

The trends and outcomes of multiorgan heart-transplantation (HT) using hepatitis C virus (HCV) donors in the contemporary era are sparsely known. Using UNOS registry, 1322 adult multiorgan-HTs (n = 986 heart-kidney, n = 155 heart-lung, n = 181 heart-liver) between August-2015 and August-2020 were identified, of which 109 were performed using HCV-donors (n = 77 HCV nucleic-acid-amplification testing [NAT] positive irrespective of antibody status [HCV-viremic]; and n = 32 HCV Ab+/NAT-[HCV antibody + nonviremic]). The percentage of HCV-donors used for multiorgan-HT increased from 0% in 2015 to 14% in 2020 (p < 0.001), but there was wide variation across UNOS regions and center volumes. Recipients of multiorgan heart-kidney transplants from HCV-donors (n = 90) and HCV-naïve (HCV Ab-/NAT-) donors (n = 896) had similar 1-year survival using unadjusted and adjusted Cox-proportional hazards-regression models including in propensity-score matched cohorts. Post-HT rates of cardiac-allograft-vasculopathy (5.4% vs 5.8%) and chronic-dialysis (7.3% vs 4.9%) at 1-year were also similar. Use of HCV-donors (HCV-viremic, HCV Ab+ nonviremic) for multiorgan-HT has increased significantly. Encouraging 1-year outcomes in heart-kidney recipients from HCV-donors should support further expansion of heart-kidney transplantation using HCV-donors.

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Study population and definitions

Patient level non-identifiable information was retrieved from United Network for Organ Sharing (UNOS) registry. All adult(≥18-years) multiorgan-HTs between August-2015 and August-2020 where donor HCV antibody (Ab) and NAT status was available were identified. August-2015 was chosen as start date as UNOS mandated routine reporting of donor HCV NAT status during this time.3 Based on donor HCV status, multiorgan-HTs were subdivided into HCV-viremic (HCV NAT positive irrespective of Ab status, HCV

Statistical analysis

Baseline characteristics were compared using Fisher's exact-test for categorical and Kruskal-Wallis test for continuous variables. After meeting study criteria, data was available for all transplants except as indicated. Recipient mortality up to 1-year follow-up post-HT was compared using unadjusted and adjusted Cox-proportional hazards-regression models and Kaplan-Meier (KM) analysis. Cox-models met the proportional hazards assumption as assessed by Schoenfeld's residuals and all recipients

Results

We identified 1322 adult multiorgan-HTs between August-2015 and August-2020 (n = 986 heart-kidney, n = 155 heart-lung, n = 181 heart-liver) where donor HCV Ab/NAT status was available (n = 1,213 HCV-naïve; n = 109 HCV-donor [n = 32 HCV Ab+ nonviremic; n = 77 HCV-viremic], Supplement-Figure-1). The percentage of HCV-donors (HCV Ab+ nonviremic and HCV-viremic) used for multiorgan-HT increased from 0% in 2015 to 14.0% in 2020 (p < 0.001 overall trend, Figure 1A, Supplement-Table-1). Use of both

Variation across UNOS regions and transplant centers

There was a wide variation in use of HCV-donors for multiorgan-HTs across UNOS regions; and regions 11,10,9,5 and 1 together accounted for >80% of multiorgan-HTs performed using HCV-donors (Figure 1B, Supplement-Table-3). Interestingly, there was also a wide discrepancy between the proportion of multiorgan-HTs performed in a UNOS region and the proportion of multiorgan-HTs performed using HCV-donors (Supplement-Figure-3, Supplement-Table-3).

Further, 5 centers accounted for >50% of the total

Post-transplant outcomes

Due to limited number of heart-lung and heart-liver transplants with HCV-donors, we focused on assessing outcomes of the most common multi-organ combination, namely heart-kidney(HK) transplants. Compared to HK-transplants using HCV-naïve donors(n = 896), HK-transplants with HCV-donors (Ab + nonviremic/viremic) (n = 90) had higher recipient creatinine at transplant(3.0[2.1-4.1] vs 2.5[1.8-3.7] mg/dL), more blood-type O(54.4% vs 39.9%), older donors (33[27-40] vs 30[23-39] years), longer

Discussion

We present the first analysis (to the best of our knowledge) of multiorgan-HT using HCV-donors in the contemporary era of DAAs and NAT. Our principal findings are: first, the use of HCV-donors (HCV-viremic and HCV Ab+ nonviremic) for multiorgan-HT has increased significantly in the U.S., paralleling the overall increase in multiorgan-HTs; second, there is a wide variation in the use of HCV-donors for multiorgan-HT across UNOS regions and transplant center volumes, such that it appears only few

Disclosure statement

The authors have no conflicts of interest to declare.

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    Heart-liver transplantation, performed en bloc or sequentially, has been performed successfully at experienced centers for patients with complex congenital heart disease, restrictive cardiomyopathy, or cardiac amyloidosis with associated liver disease.56 Notably, the increasing availability of HCV-infected donors has also contributed to the rise in MOT.57 Given the marked rise in MOT over the past decade, a major ethical implication is that many younger patients from minority groups have not received timely kidney-alone transplants and have been delisted for being “too sick.”

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