Expanding the Donor Pool With Use of Hepatitis C Infected Hearts

More than 25 years ago, experts in the field of cardiac transplantation met in Bethesda, MD, to discuss challenges to the field, including the static level of organ procurement and growing waitlist times.1 In addition to creating objective criteria for transplant listing (and delisting) and thereby limiting the waitlist size, much discussion focused on expanding the donor pool. Around the same time, increasing numbers of adults in the general population were becoming infected with hepatitis C virus (HCV) through blood transfusions and increased-risk behaviors.2 The question as to whether organs from these donors could be used safely was hotly debated in national forums, as well as at local selection committee meetings. Early surveys found that 69% to 74% of programs accepted HCV-positive donor organs but restricted these to status 1, high-risk, or HCV-positive recipients.3,4 A similar proportion of programs listed candidates that were HCV positive. Since that time, much has been learned about the outcomes of heart transplant recipients receiving organs from increased-risk donors. In early reports of heart transplantation using HCV-positive donors,5–9 many important clinical observations were made: (1) the transmission rate of HCV as documented by RNA testing was high, ≈80%, and occurred within weeks of transplant; (2) acute transaminitis followed by the development of chronic liver disease, including fibrosing cholestatic hepatitis and cirrhosis, occurred and appeared more aggressive than in the general population; (3) factors associated with the development of chronic liver disease included high donor viral load, high-dose steroids, and the use of mycophenolate mofetil; and (4) as suggested by earlier surveys, centers were targeting HCV-positive donors to patients at risk of imminent death or in the case of UCLA to alternate list recipients. In 2001, the American Heart Association released a consensus report on maximizing donor organs stating that HCV-positive donors may be appropriate in selected higher-risk recipients.10 With growing use of HCV-positive donors, investigators sought to explore longer-term clinical outcomes in transplant recipients. In a study from the Cleveland Clinic, Haji et al11 first reported the association between HCV viremia and development of cardiac allograft vasculopathy (CAV). The risk for any CAV was increased 3-fold and for advanced CAV up to 9-fold, with risk increasing further with allosensitization. In retrospect, this proinflammatory effect was not surprising given earlier data showing that renal transplant patients with chronic HCV infection EDITORIAL