Use of hepatitis C-positive donors in transplantation.

Transplantation (Tx) is a therapeutic alternative intervention for terminal organ dysfunction, fatal disease or, in some cases, to improve the quality of life and reduce the risk of complications from chronic diseases. One of the major limitations in performing transplants is obtaining donor organs because of the difficulties in the process of organ donation of deceased donors and the unavailability of compatible living donors. In Brazil, there are many more patients on waiting lists, especially for liver and kidney transplants, than the number of procedures performed. Therefore, non-ideal donors are sometimes considered for transplantation, including those with a higher risk of primary graft dysfunction and infection transmission, such as hepatitis C virus (HCV)-seropositive donors. HCV-seropositive donors have routinely been used by a few groups or in cases of extreme urgency. However, the safety of transplantation from HCV-positive donors has not been clearly determined and may vary according to the type of transplant. To establish a set of recommendations, we performed an analysis based on the data available in the literature. The following items were considered according to the type of transplantation: 1) the position on the list, 2) the urgency of transplantation, 3) the HCV infection status of the donor (serology, viral replication and histological activity), 4) the HCV infection status of the recipient (serology, viral replication and histological activity) and 5) the safety data available regarding the use of HCV-seropositive donors. We analyzed liver, kidney, heart, lung and hematopoietic stem cell transplants (HSCTs). The IDSA (Infectious Diseases Society of America) rating system was used to establish levels of evidence.

1. Liver Transplantation

Chronic liver disease due to HCV accounts for almost one-half of liver Tx indications. The risk of the histological recurrence of hepatitis after transplantation is approximately 70%. The graft and recipient survival is lower compared with other etiologies. Descriptive and comparative studies and case-control analyses have shown that the use of seropositive donors for seropositive recipients does not interfere with graft or patient survival.

2. Kidney Transplantation

Some descriptive studies have shown that the use of seropositive donors for seropositive recipients does not interfere with graft or patient survival. However, one publication described five cases of discordant donor and recipient genotypes: in three of these cases, elevated enzyme levels and genotype substitution or association were observed in the recipient after transplant.

3. Heart Transplantation

Little data are available regarding heart Tx. One multicenter study reported a lower survival rate in patients who received organs from seropositive donors, regardless of the HCV serostatus of the recipient.

4. Lung Transplantation

Little data are also available regarding lung Tx. However, in a multicenter survey, 72% of the participating groups considered the use of HCV-seropositive donors for HCV-seropositive recipients. Nevertheless, there have been no descriptions of liver disease progression or graft and patient survival in positive viremia recipients. It is important to consider that treatment with interferon-gamma is usually not recommended after lung Tx due to the high risk of acute cellular rejection.

5. Hematopoietic Stem Cell Transplantation (HSCT)

In HSCT, there have been reports of a significantly increased risk of hepatitis in HCV-seronegative recipients of seropositive donors, especially when there is evidence of viral replication. Because HSCT often involves situations in which there is an imminent risk of death and the need for an HLA-matched living donor, the decision should be based on the urgency of the Tx and level of viremia in the donor.

In solid organ transplants, consider the use of HCV-seropositive donors only for HCV-seropositive recipients.

Informed consent should be obtained in all of the cases involving HCV-seropositive organ or cell donors.

Patients should be informed of the possibility that their donor will have a different HCV genotype, the lack of available time to determine the serotype before Tx (in cases of deceased donors) and the potential risk of HCV transmission in these cases (fact demonstrated after kidney Tx).

RECOMMENDATIONS

B. Specific

1. Liver Transplantation

Accept HCV-seropositive donor for HCV-seropositive recipient since donor liver biopsy has not provided evidence of liver disease in a recipient with positive HCV viremia.

2. Kidney Transplantation

Accept HCV-seropositive donors for HCV-seropositive recipients with positive viremia (BII).

3. Lung Transplantation

In centers that accept recipients with HCV-positive viremia, accept HCV-seropositive donors (CIII).

4. Heart Transplantation

Do not accept HCV-seropositive donors (DII).

5. Hematopoietic Stem Cell Transplantation

Follow the chart (CIII).

ACKNOWLEDGMENTS

The authors wish to thank Profs. José Otávio Costa Auler Júnior, Tarcísio Eloi Pessoa de Barros Filho and Eloísa Bonfá for their support as Clinical Directors of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.