Letter to the Editor: Safety First: Favoring Prophylactic/Preemptive Over Delayed Treatment in D+/R− Transplants
Authors: Norah A. Terrault, Jordan J. Feld
Journal: Hepatology (2020)

Potential conflict of interest: Dr. Feld consults and received grants from AbbVie, Gilead, and Janssen. Dr. Terrault consults for Intercept and received grants from Gilead. To The Editor: The report from Kapila et al.(1) on their use of hepatitis C virus (HCV)–viremic donors as a transplant center protocol that accessed direct‐acting antivirals (DAAs) through the recipient's insurance is important, giving us a glimpse into the "real world" on using HCV‐viremic donors and contrasting with much of the published data thus far. Similar to other reports, high rates of sustained virological response (SVR) were achieved, although a small percentage failed initial treatment, even when conventional durations of DAAs were used, and serious complications, specifically fibrosing cholestatic hepatitis (FCH), occurred, albeit infrequently. Rates of rejection and renal complications were not mentioned but there are other reports of indirect HCV complications, including FCH, glomerulonephritis, BK viremia, and possibly higher rates of acute rejection, occur early after transplant in these viremic recipients.(2,3) Consistent reporting of hepatic and extrahepatic complications in all publications would bring clarity to the risks incurred by recipients. Additionally, in the case of FCH or glomerulonephritis, in which permanent injury to the graft may be incurred even if SVR is subsequently attained, longer‐term follow‐up of patients with HCV‐associated complications is important. The authors conclude that their approach offers advantages over the preemptive/prophylactic strategies used by others, where access to DAAs at the time of transplant was not limited. Before the transplant community "jumps on that band wagon," it is worth emphasizing that the American Association for the Study of Liver Diseases/Infectious Diseases Society of America recently endorsed prophylactic‐preemptive over delayed treatment, given the concerns of increased recipient risks when therapy is delayed.(4) The practical issue of accessing DAAs at the time of transplant can be easily accomplished if transplant programs provide the DAAs for the full course or until an insurance‐approved drug is available. As the costs of the DAAs have declined, the need for insurance approval should not preclude transplant programs from offering treatment. Indeed, prophylaxis for other infections (e.g., cytomegalovirus, hepatitis B) are routinely provided and costs included in usual transplant care. It is time for the same to occur for HCV. Another advantage of starting therapy early is the potential to shorten treatment duration(5); this cost reduction may make prophylactic‐preemptive treatment more palatable to transplant programs. Given the well‐recognized need to maximize use of all recovered organs, continued transplantation of these donors should be encouraged under informed consent. To aid in those discussions, the transplant community needs to report its results as completely as possible, with both direct and indirect complications acknowledged.