The use of direct-acting antiviral agents to treat chronic hepatitis C could allow for organ transplantation from donors with hepatitis C to recipients without the disease; however, potential delays in initiation of direct-acting antiviral agents for these transplant patients could have serious complications, such as hepatitis C-induced membranous nephropathy, according to research published in the American Journal of Transplantation.
Several studies using hepatitis C nucleic acid testing, all of which were clinical trials without limitations in access to direct-acting antiviral therapy, confirmed that it is possible to transplant organs from donors with hepatitis C to those without the virus, and sustain near complete hepatitis eradication post-transplant. The questions that remain concerning the timely approval of these medications by insurance providers introduces an ethical dilemma to performing transplants of hepatitis C nucleic acid test-positive organs outside a clinical trial, as the consequences of delays in direct-acting antiviral agent initiation are not fully known.
The current article described the case of a 61-year-old man with a history of diabetes and nonalcoholic steatohepatitis, but no history of hepatitis C who received a liver transplant from a hepatitis C nucleic acid test-positive donor, after he had consented to an institutional protocol.
The patient’s hepatitis C ribonucleic acid rose from undetectable on the day of transplantation to 25 million IU/ml 12 hours afterward and to 97 million IU/ml 4 days after the transplant. The patient’s insurance company denied his initial application to start direct-acting antiviral agent therapy, and his condition worsened.
A kidney biopsy showed that he developed immune-complex mediated glomerulonephritis and tubulo-reticular inclusions identified via electron microscope, which were consistent with a viral etiology for the injury. The patient began hemodialysis for hyperkalemia on day 22 after surgery, and treatment with pibrentasvir/glecaprevir on day 24. Three weeks later, his hepatitis C ribonucleic acid became undetectable and remained this way through his last follow-up. The patient’s most recent serum creatinine was 1.7 mg/dl, however, he continues to have 3.6 g proteinuria/day.
Study investigators concluded that “transplanting [hepatitis C] nucleic acid test-positive organs into [patients without hepatitis C] should be limited to situations where access to [direct acting antiviral] agents are available. When there is uncertainty regarding the source and timing of [direct acting antiviral] therapy, transplant programs should advance with caution.”
Wadei HM, Pungpapong S, Cortese C, et al. Transplantation of HCV-infected organs into uninfected recipients: advance with caution [published online October 29, 2018]. Am J Transplant. doi: 10.1111/ajt.15152