OPTN offers recommendations as unexpected, donor-derived hepatitis C transmissions increase
Tuesday, April 23, 2019
The opioid epidemic has affected nearly every Organ Procurement and Transplantation Network (OPTN) region by increasing the number of organ donors dying from drug overdoses. While the tragic epidemic has increased the number of organs available for transplant, many worry that the donors’ drug abuse increases the recipients’ risk of unexpected, donor-derived hepatitis C virus (HCV) transmissions.
The age-standardized rate of death from drug overdose has more than tripled in the United States, according to research published in the New England Journal of Medicine, from 6.8 per 100,000 persons in 1999 to 20.8 per 100,000 persons in 2016. That study also found that the percentage of drug overdose donors from whom hearts were recovered for transplantation increased from 1.5 percent in 1999 to 17.6 percent in 2017.
More transplants, particularly from donors that could increase the recipient’s risk of disease transmission, are being completed.
Research details the successful use of organs from donors who are currently abusing drugs. Patients and clinicians continue to be cautious about using these organs, though, especially when it comes to the risk of inadvertently acquiring viral hepatitis and/or HIV.
While the safety and efficacy of HCV treatments in transplants are improving, unexpected hepatitis C donor-derived transmissions have been trending upwards. The OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) reviewed these cases and, based on their findings, has made several recommendations.
OPTN Ad Hoc DTAC Recommendations
HCV seropositive, non-viremic (Ab+/NAT-) donors
Among HCV seropositive, non-viremic (Ab+/NAT-) donors, the only cases of HCV transmission occurred from donors actively using drugs.
The committee recognized that a personal history of HCV does not offer protection against reinfection, especially if the donor still uses intravenous drugs. The committee suggests basing the risk of HCV transmissions in these donors solely on their behavioral risks, and as the same as their HCV seronegative donor counterparts.
Recent studies, such as those examining cardiac transplantation from non-viremic hepatitis C donors and the use of HCV antibody-positive donor livers in HCV non-viremic liver transplant recipients, support these recommendations.
Most of the recent cases of donor-derived HCV are associated with donors who were active drug users, and the majority of these were intravenous (IV) drug users. The risk of acute HCV infection in donors who are active IV drug users is high, and meaningfully greater than nearly any other behavioral risk factor.
Donor serology and NAT testing
To ensure timely donor testing and organ placement, many organ procurement organizers are now running donor serology and NAT testing sooner — in some cases, as soon as the patient arrives in the hospital.
While such efficiency does have its benefits, the OPTN Ad Hoc Disease Transmission Advisory Committee warns organizers to view negative HIV and hepatitis tests cautiously, and reminds organizers that the NAT window for HCV is still three to five days, and the window is five to six days for HIV. Reexposure to HCV and HIV within that window is possible, and no currently available test can detect such reexposure.
OPTN Ad Hoc Disease Transmission Advisory Committee suggests balancing the available data against the realization that the efficacy and safety of HCV in transplant patients continues to improve, and that OPTN data can help organ procurement and transplant organizations adjust to the ongoing opioid epidemic, improve patient consent processes, and ultimately optimize the safe utilization of organs.
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