Reply
Authors: Jagpreet Chhatwal, Emily D. Bethea, Sumeyye Samur, Raymond T. Chung
Journal: Hepatology (2018)

Potential conflict of interest: Dr. Chhatwal consults for and received grants from Merck and Gilead. He consults for Cheors. Dr. Chung received grants from Gilead, AbbVie, Merck, Janssen, Bristol‐Myers Squibb, and Boehringer‐Ingelheim. We thank Cholankeril et al. for their interest in our study evaluating the transplantation of hepatitis C virus (HCV)–positive livers into HCV‐negative patients using preemptive direct‐acting antiviral (DAA) therapy. The purpose of our study was to evaluate this novel transplant strategy and determine if the benefit of accepting an HCV‐positive organ with preemptive DAA therapy would outweigh the risks associated with HCV allograft infection in HCV‐negative patients. Our model was constructed under the assumption that receiving an HCV‐positive liver is associated with a risk of HCV‐positive allograft failure similar to what was experienced during the interferon era. While we recognize that recent studies suggest improved graft failure rates with DAA use in the posttransplant setting for HCV‐positive recipients, there are no studies evaluating HCV‐negative patients receiving HCV‐positive livers. In our analysis, it was critical to avoid underestimating graft failure rates in this population because this could bias our conclusions in favor of using HCV‐positive organs by minimizing the risks associated with this transplant strategy. By choosing a relative overestimation of graft failure and finding that transplant of HCV‐positive livers is still beneficial, we can be confident in model results. Individual HCV‐positive donor age and comorbidity were not incorporated in our current model. We acknowledge that a significant number of HCV‐positive liver donors are procured from victims who are younger and without comorbid medical conditions. These are important considerations, and as more data become available on donor risk profiles this information can be incorporated into our analysis. Importantly, our current model likely underestimates benefit by not adjusting for the younger and often healthier livers recovered from drug overdose victims; if this information were incorporated, it would further increase the magnitude of the clinical benefit seen with HCV‐positive liver donor use. The clinical benefit of receiving an HCV‐positive donor liver may not be accurately determined by Model for End‐Stage Liver Disease (MELD) score alone. We want to emphasize that the primary take‐away from our analysis is not a specific MELD threshold at which a patient or provider should consider accepting an HCV‐positive organ. As always, patient preferences and medical urgency not captured by MELD should be taken into consideration. Additionally, it is imperative that transplant centers and all team members are comfortable with a mutually agreeable strategy guiding the listing of HCV‐positive donors. With our ability to successfully treat HCV infection with DAAs, we now have the opportunity to use additional HCV‐positive organs and increase a historically static donor organ pool. While not all waitlist patients will be approved for HCV‐positive organs, there are select patients who will clearly benefit. Our results can help identify such patients and should be used as a reference, not a directive, to facilitate conversation. We understand that the informed consent process for these patients is increasingly complex and that there is tremendous benefit to be gained from standardization and education across the transplant community when it comes to HCV‐positive organ use.