Five-year outcomes of heart transplantation from HCV-viremic donors: insights from the national registry

Background The use of hepatitis C (HCV) viremic donors has expanded the heart donor pool, reducing both waitlist time and mortality rates among heart transplantation (HT) candidates. While short-term post-HT outcomes between adult recipients of HCV-viremic and non-viremic donor grafts are comparable, long-term outcomes remain unknown. Methods Data from the United Network for Organ Sharing (UNOS) registry were analyzed for all adult first-time, single-organ HTs performed in the United States between 2016 and 2020. Recipients were categorized based on the donor's HCV nucleic acid amplification test (NAT) status. Survival outcomes were compared between recipients of grafts from HCV-viremic and non-viremic donors. Results During the study period, 13,211 first-time single-organ adult HTs were performed, of which 587 (4.4%) utilized grafts from HCV-viremic donors. The proportion of HCV-viremic HTs increased from 0.5% in 2016 to 7.8% in 2019 (p<0.01). Recipients of HCV-viremic donor grafts were more frequently male (76.7% vs. 72.9%, p=0.04), with blood type O (47.7% vs. 39%, p<0.01), higher diabetes prevalence (32.7% vs. 27.5%, p<0.01), lower panel reactive antibody levels (8.5 ± 19.8 vs. 11.2 ± 23.5, p<0.01),and were less often supported with inotropes at the time of HT (32.4% vs. 37%, p=0.02). No significant differences were observed between groups regarding cardiomyopathy etiology, creatinine or bilirubin levels, hemodynamics, use of mechanical circulatory support, waitlist time, HLA, ABO, CMV, predicted heart mass, and donor-recipient gender mismatch rates. HCV-viremic and non-viremic donors showed similar demographic and comorbidity profiles, except for the cause of death. Brain anoxia was more frequently reported among HCV-viremic donors (72.7% vs 38.6%, p<0.01). There were no significant differences in primary graft failure (2.0% vs 1.7%, p=0.1) and acute rejection rates during the first year post-HT (20.3% vs 18.6%, p=0.3) between the two groups. Similarly, at five years, there was no difference in cardiac allograft vasculopathy rates between the two groups when analyzed separately for patients with and without pre-HT diabetes. Survival outcomes were also comparable, with rates of 91.8% vs. 91.0% at 1 year (p = 0.5) and 82.3% vs. 80.7% at 5 years (p = 0.4) (Figure). Conclusions The current study provides evidence that long-term outcomes for adult recipients of HCV-viremic heart grafts are acceptable, with survival rates comparable to those of recipients of HCV-non-viremic donor hearts.