MORTALITY, REJECTION AND EXTRA-HEPATIC MANIFESTATIONS FROM TRANSPLANTATION OF HEPATITIS C + LUNGS: A QUATERNARY CENTER EXPERIENCE

Introduction:
Transplantation of hepatitis C (HCV) positive lungs has been shown to be a safe means of combating organ shortages in the era of direct-acting antivirals against HCV. While short-term data is promising, few studies have reported on survival beyond 12 months and incidence of rejection post-transplant.
Our study aimed to compare post-transplant graft survival at 2 years in lung recipients in aviremic recipients (R-) of viremic donors (D+), and to characterize rates of rejection and extra-hepatic manifestations of HCV.
Methods:
Through a retrospective cohort study design, we identified all lung transplants done at our center from January 2018-September 2022 from the UNOS database. Baseline recipient demographics, status at transplant and donor hepatitis status were extracted, both manually and using the UNOS database. Biopsy and management data were obtained to determine incidence of rejection, fibrosing cholestatic hepatitis and extra-hepatic HCV manifestations.
Results:
A total of 479 D- and 31 D+ lung transplants were performed during the study period. Despite apparent difference in crude mortality rate between D+/R- and D-/R- patients, no statistical difference was found (23.33 vs 16.67, p=0.49). Hazard models for post-transplant 2-year mortality revealed D+ status was not a significant mortality predictor (HR 1.17, p=0.7; table 1). Similarly, D+ status did not impact graft failure in our 2-year prediction model (HR 0.65, p=0.5). Subgroup analysis based on recipient and donor HCV status revealed no difference in 2-year patient or graft survival in any subgroup (figure 1). In D+/R- patients, rate of acute cellular rejection (ACR) was 60%, while rates of chronic and antibody-mediated rejection were 6.67% and 16.67% respectively. Post-transplant HCV viremia occurred in 73.3% of cases, with 100% rate of sustained viral response (SVR) at 12 weeks on glecaprevir-pibrentasvir, though 2 patients died prior to SVR. None were documented to develop fibrosing cholestatic hepatitis or extra-hepatic HCV including neuropathy, nephropathy, cryoglobulinemia or dermatitis. None were co-infected with hepatitis B or HIV.
Conclusion:
Consistent with prior data on short term outcomes, donor HCV positivity did not impact mortality or graft failure at 2 years. Relative to prior studies, we report on a larger cohort of lung recipients. Despite theoretical fear of infectious disease transmission with high-risk donors, incidence of extrahepatic manifestations of HCV and fibrosing cholestatic hepatitis, none of these occurred in our cohort. With timely management of viremia, our data support current practice of utilizing organs from HCV+ donors to reduce waitlist times.