No need to discontinue hepatitis C therapy at the time of liver transplantation

No need to discontinue hepatitis C virus therapy at the time of liver transplantation
Catarina Skoglund, Martin Lagging, Maria Castedal

Published: February 22, 2019
 https://doi.org/10.1371/journal.pone.0211437

Abstract
Objectives
Direct antiviral agents (DAA) has dramatically improved the therapy outcome of hepatitis C-virus (HCV) infection, both on the waiting-list and post liver transplantation (LT). DAA are generally well-tolerated in patients with mild to moderate liver and kidney failure, but some DAAs are contraindicated in patients with severe dysfunction of these organs. Today there are few studies of peri-LT DAA use and treatment is commonly discontinued at the time of LT. We report here our experience of DAA therapy given continuously in the perioperative LT period in a real-life setting in Sweden.

Material
In total 10 patients with HCV-cirrhosis, with or without hepatocellular carcinoma, and a median age of 60.5 years (range, 52–65) wsere treated with DAAs on the waiting list for LT, and continued in the early postoperative period without any interruption, on the basis of not having reached a full treatment course at the time of LT. Sofosbuvir and a NS5A inhibitor with or without ribavirin, or sofosbuvir and ribavirin only, were given. The distribution of genotypes was genotype 1 and 3, in 4 and 6 patients, respectively. Six of the 10 patients had previously been treated with IFN-based therapy.

Results
There were no adverse events leading to premature DAA discontinuation. All recipients achieved a sustained viral response 12 weeks after end-of-treatment (SVR12). At the time of LT the median MELD-score was 16.5 (range 7–21), CTP-score 9.0 (range 5–10), creatinine 82.5 μmol/L (range 56–135, reference 60–105), bilirubin 33 μmol/L (range 16–79, reference 5–25) and PK-INR 1.5 (range 1.1–1.8). The median duration of DAA therapy was 60 days (range 18–132) pre-LT, 54 days post-LT (range 8–111 days) and in total 15.5 weeks (range 12–30 weeks).

Conclusion

Interferon-free DAA therapy of HCV-infection given in the immediate pre- and post-operative LT period is safe, well-tolerated and yields high SVR rates.

Full-text available online:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211437

No need to discontinue hepatitis C virus therapy at the time of liver transplantation

PLoS One. 2019
No need to discontinue hepatitis C virus therapy at the time of liver transplantation
Catarina Skoglund, Martin Lagging, Maria Castedal

Published: February 22, 2019 https://doi.org/10.1371/journal.pone.0211437

Full-text
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Abstract
Objectives
Direct antiviral agents (DAA) has dramatically improved the therapy outcome of hepatitis C-virus (HCV) infection, both on the waiting-list and post liver transplantation (LT). DAA are generally well-tolerated in patients with mild to moderate liver and kidney failure, but some DAAs are contraindicated in patients with severe dysfunction of these organs. Today there are few studies of peri-LT DAA use and treatment is commonly discontinued at the time of LT. We report here our experience of DAA therapy given continuously in the perioperative LT period in a real-life setting in Sweden.

Material
In total 10 patients with HCV-cirrhosis, with or without hepatocellular carcinoma, and a median age of 60.5 years (range, 52–65) were treated with DAAs on the waiting list for LT, and continued in the early postoperative period without any interruption, on the basis of not having reached a full treatment course at the time of LT. Sofosbuvir and a NS5A inhibitor with or without ribavirin, or sofosbuvir and ribavirin only, were given. The distribution of genotypes was genotype 1 and 3, in 4 and 6 patients, respectively. Six of the 10 patients had previously been treated with IFN-based therapy.

Results
There were no adverse events leading to premature DAA discontinuation. All recipients achieved a sustained viral response 12 weeks after end-of-treatment (SVR12). At the time of LT the median MELD-score was 16.5 (range 7–21), CTP-score 9.0 (range 5–10), creatinine 82.5 μmol/L (range 56–135, reference 60–105), bilirubin 33 μmol/L (range 16–79, reference 5–25) and PK-INR 1.5 (range 1.1–1.8). The median duration of DAA therapy was 60 days (range 18–132) pre-LT, 54 days post-LT (range 8–111 days) and in total 15.5 weeks (range 12–30 weeks).

Conclusion
Interferon-free DAA therapy of HCV-infection given in the immediate pre- and post-operative LT period is safe, well-tolerated and yields high SVR rates.

Full-text: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211437

Why Liver Transplant Waitlists Might Misclassify High-Risk Patients

Why Liver Transplant Waitlists Might Misclassify High-Risk Patients

A new study has uncovered that the standard method for ranking patients on the waitlist for lifesaving liver transplantation may not prioritize some of the sickest candidates for the top of the list.

"Ultimately, we hope this information will help clinicians recognize that certain patients with a high risk of mortality may not be captured by our current organ-allocation policy," said Vinay Sundaram, MD, director of Hepatology Outcomes Research at the Cedars-Sinai Comprehensive Transplant Center. He is the co-first author of the multicenter study published recently in the peer-reviewed medical journal Gastroenterology, the most frequently cited journal in its field.

Liver transplants are performed as a last resort for liver failure, when the vital organ is too damaged to sustain life. The most common damage is caused by cirrhosis—severe scarring that can result from various conditions, including injuries, the hepatitis C virus, metabolic disease and long-term alcohol abuse. While more than 8,000 liver transplants were performed in the U.S. last year, the need exceeds availability of viable organs. According to the United Network for Organ Sharing (UNOS), the nonprofit that manages the U.S. organ transplant system, more than 13,000 patients were on its liver-transplant waitlist as of Jan. 18.

To decide which patients should be first in line for liver transplants, medical professionals rely on a standardized assessment of liver and kidney function known as the MELD (Model for End-Stage Liver Disease) score. The goal is to determine who among the many patients needing transplants are the sickest and yet also able to withstand surgery and to recover and thrive. A lower score indicates less urgency for a transplant; a higher score indicates greater urgency.

The study found that the MELD score does not fully identify patients with a life-threatening syndrome known as ACLF-3, or acute on chronic liver failure grade-3. This syndrome involves a sudden worsening of chronic liver failure accompanied by multiple organ-system failures, such as circulatory, respiratory or neurologic failures.

"ACLF-3 patients, even with relatively low MELD scores, have the highest risks of being removed from the waitlist due to being too sick for a transplant or of dying while waiting for a liver transplant," Sundaram said. "We sought to understand how this happens and how the standardized system of prioritization can unintentionally disadvantage these patients."

The team analyzed UNOS data from 100,594 patients on liver-transplant waitlists from 2005 through 2016.

"Our study goals were twofold," Sundaram said. "First, we set out to determine the mortality rate of patients with ACLF-3 awaiting liver transplantation, and second to analyze how patients with ACLF-3 fared when they did receive liver transplants."

Sundaram said the team discovered that ACLF-3 patients are sicker than the MELD scores would indicate because that assessment takes into account only liver and kidney function, whereas ACLF-3 patients have other organ-system failures as well. They found that nearly 44 percent of ACLF-3 patients in a certain category died or were removed from the transplant waitlists within 28 days of listing.

The team also found that when transplants were performed within 30 days of ACLF-3 patients being placed on the waitlists, their one-year post-transplant survival rate was more than 80 percent—equivalent to patients without this syndrome.

They concluded that ACLF-3 classification may help identify candidates on the list who are at high risk for short-term mortality. "Time is of the essence because it is clear that survival declines with increased waiting time for these patients," Sundaram said.

Rajiv Jalan, MD, PhD, of UCL Medical School, London, is co-first author of the study, along with Sundaram. Robert J. Wong, MD, from the Alameda Health System, Highland Hospital, in Oakland, Calif., is the senior author. The study also involved Loma Linda University in Loma Linda, Calif., and Baylor University Medical Center in Dallas.

"This study makes a major step toward improving the clinical relevance of waitlists for liver transplant candidates," said Andrew S. Klein, MD, the Esther and Mark Schumann Chair in Surgery and Transplantation Medicine, director of the Cedars-Sinai Comprehensive Transplant Center, professor of Surgery and a co-author of the study. "If further research expands and confirms these findings, they can lead to better transplant outcomes."

The Cedars-Sinai Comprehensive Transplant Center recently was reported by the Scientific Registry of Transplant Recipients to have the best one-year survival outcome for liver transplants of all hospitals in California.

DOI: 10.1053/j.gastro.2018.12.007

Alcohol-Linked Disease Overtakes Hep C As Top Reason For Liver Transplant

Alcohol-Linked Disease Overtakes Hep C As Top Reason For Liver Transplant
By Rachel Bluth
An estimated 17,000 Americans are on the waiting list for a liver transplant, and there’s a strong chance that many of them have alcohol-associated liver disease. ALD now edges out hepatitis C as the No. 1 reason for liver transplants in the United States, according to research published Tuesday in JAMA Internal Medicine.

One reason for the shift, researchers said, is that hepatitis C, which used to be the leading cause of liver transplants, has become easier to treat with drugs.

Another could be an increasing openness within the transplant community to a candidate’s history of alcohol and addiction and when a candidate combating these issues can qualify for a liver.

For years, conventional wisdom suggested that people with a heavy drinking past who did not have a period of sobriety under their belts would not be good candidates to receive a new liver. But, of almost 33,000 liver transplant patients since 2002 who were studied, researchers from the University of California-San Francisco found 36.7 percent of them had ALD in 2016, up from 24.2 percent in 2002.

“Across the country, and we show in a prior study, people are changing their minds,” said Dr. Brian P. Lee, the study’s lead author and a UCSF gastroenterology and hepatology fellow. “More and more providers are willing to transplant patients with ALD.”

The debate, roiling for decades, culminated in 1997 when a group of doctors and medical societies and the U.S. surgeon general published a paper that recommended patients with alcoholic liver disease be sober at least six months before they could be considered for transplant.

This “six-month rule” became the gold standard. The idea was that a patient who could stay sober for that long had a lower chance of returning to harmful drinking behavior. There was also concern that the public would stop donating organs if they thought livers would be going to people with alcohol addictions.

“Neither of those attitudes are based on any facts or data,” said Dr. Robert Brown, director of the Center for Liver Disease and Transplantation at Weill Cornell and New York Presbyterian.

The changing attitude plays out at many transplant centers where what once was viewed as a hard-and-fast requirement for six months of sobriety is now more nuanced. Specifically, a team of doctors, psychologists and social workers look at a range of factors, including financial stability and family support, to determine if a patient will relapse after the transplant.

An analysis published in 2010 by researchers from the University of Pittsburgh and a 2011 study in France showed that, in any given year, there was little evidence to suggest six months of abstinence before the transplant decreased the chance of relapse.

The central point, experts say, does not necessarily come down to a patient’s record of sobriety before the procedure. Foremost is determining that a patient is unlikely to drink again after receiving a new liver — that he or she is “committed to lifelong abstinence,” said Lee.

Five years after transplantation, patients who were abstinent for six months and those who weren’t had about the same survival rates, according to Lee’s research. After 10 years, the patients who didn’t have six months of sobriety before the procedure had slightly worse survival rates. Lee said more research is needed to find out exactly why.

There is nothing magical about six months, according to Dr. Michael Lucey, medical director of the University of Wisconsin liver transplant program. He said it shows a poor understanding of alcohol abuse as a “very complex behavioral disorder.”

“Drinking isn’t a stable phenomenon,” Lucey said. “People with ALD may have long periods of drinking and abstinence.”

Although advocates are glad that policy is changing, it didn’t change swiftly enough to save Chelsea Oesterle.

Oesterle, who was 24 and had battled alcohol addiction since age 16, went to the emergency room in Peoria, Ill., in 2013, already in liver failure. Doctors told her in the first few days that survival depended on a transplant.

When it became clear she wasn’t going to get that transplant, her mother, Terri Oesterle, had her daughter transferred to another hospital, and between both facilities she spent six weeks hospitalized. During that time, she was never put on a transplant list.

The stigma around her daughter’s condition was palpable, her mother said. Doctors and nurses lectured her about quitting drinking.

“They kept telling her she had to go to rehab,” Terri Oesterle said. “She couldn’t even leave the hospital, how on earth was she supposed to go to a rehab program?”

One doctor point-blank asked Terri Oesterle why she thought her daughter deserved a liver over someone else.

“She was dismissed from the get-go,” Terri Oesterle said. “It’s just heart-wrenching because she was such a sensitive soul. She was so scared and hopeful.”

Chelsea Oesterle died in the hospital July 4, 2013.

Alcohol use disorder has often been thought of as a “self-inflicted” disease that results from bad habits or moral failing, Lucey said. That attitude is changing in the medical community, but vestiges remain.

“For some people, it’s not accepting that alcohol use disorder is an illness,” Lucey said.

While support for the changing approach is growing, Lee, the new study’s lead author, said it continues to be a polarizing issue.

“There are still detractors and still strong opposition,” he said. “Our study suggests that is certainly present, because regional differences are disparate.”

That troubles Lee, because it means a patient’s life is dependent on the attitudes of local providers, creating an unequal system. There’s “certainly value” in a national policy on the issue, he said.

The United Network for Organ Sharing (UNOS), the organization that manages the U.S. transplant list, nearly two decades ago wrestled with the idea of formalizing the six-month rule, but never took final action.

As a result, some centers have such a sobriety rule, others don’t. And even when a transplant center gives its approval, insurers often have their own set of requirements about how long a patient must be abstinent before they will cover the transplant.

Dr. David Klassen, chief medical officer for UNOS, agreed that the “rule” is arbitrary and not evidence-based, but said that it should be up to transplant centers to decide who gets listed for an organ.

“From our perspective, dictating medical care doesn’t lead to the best solutions or the best outcomes,” Klassen said. “I think transplant programs and society as a whole are moving in generally the same direction.”

https://khn.org/news/alcohol-linked-disease-overtakes-hep-c-as-top-reason-for-liver-transplant/

Region’s 1st hepatitis C heart-transplant recipient is cured

Region’s 1st hepatitis C heart-transplant recipient is cured
Brian Donohue
UW Medicine is declaring success with the Pacific Northwest’s first heart-transplant recipient to purposely acquire the hepatitis C virus (HCV) from the donor organ and then have the disease eradicated by antiviral medication.

Kerry Hayes, 49, of Anacortes, Washington, was deemed clinically cured of hepatitis C (HCV) on Dec. 20 after a blood test detected no viral load. He had acquired HCV during a transplant July 3, 2018, at UW Medical Center in Seattle and subsequently completed an eight-week course of daily antivirals.

“I’m happy and, yeah, it’s a relief,” said Hayes. “The treatment was a piece of cake, nothing to be scared of. I haven’t had any problems – no rejection or issues with the heart at all.”

Last summer, UW Medical Center formalized a transplant protocol to increase the viability of hearts from HCV-infected donors. Typically such organs are discarded unless they are a match for transplant candidates who already have the virus.

Only a fraction of U.S. transplant centers make such use of organs. The HCV heart protocol is the only one of its kind in the Pacific Northwest, according to LifeCenter Northwest, the region’s organ-procurement agency.

Currently, 30 to 35 heart-transplant candidates are on a waiting list at UW Medical Center. Each is given a thorough explanation of the HCV protocol and, at multiple junctures, given the opportunity to accept such an organ if a match becomes available, explained Jason Smith, the cardiothoracic surgeon directing the protocol.

“We hope Mr. Hayes’ positive outcome gives confidence to other transplant candidates who might benefit by opting in to this protocol,” he said. “Patients have been very receptive to being listed for these organs because it gives them the chance to get a heart potentially much sooner than they would otherwise.”

Hayes, an oil refinery worker, had lived with an underperforming heart for more than two decades. At age 28, he underwent the first of five open-heart surgeries. In early 2017, UW Medicine cardiac specialists recognized that his heart, despite earlier repairs, was failing. Hayes’ health was so dire that they implanted him with a total artificial heart, a high-tech device that keeps blood circulating and is powered by a percussive external pump. The device is a bridge to transplant for people who would likely die without it.

The device kept him going for 17 months – about a year longer than most UW Medicine patients wait for a donor heart. Hayes was grateful to be alive but said it was emotionally harrowing to wait so long for a match while being tethered 24/7 to the machine.

“It takes a lot of mental strength to live that way. Your whole body pulsates with artificial heart. It’s in your ears. It’s loud inside and out. And I was starting to get to a point where I was getting worried about still having my job and my health insurance.”

Just two weeks after Hayes consented to be considered for a HCV-donor organ, the call came with a matching organ. There was no doubt about accepting it, he said. The transplant went smoothly, and tests showed he developed HCV within two weeks of the transplant. On Aug. 4 he started the eight-week course of the antiviral Mavyret.

Hayes was cooking dinner Dec. 20 when got a phone call from Renuka Bhattacharya, the liver specialist overseeing his post-transplant care. She said his most recent blood draw detected no HCV and that Hayes had achieved a 12-week “sustained virologic response” to the Mavyret. He was cured.

“My wife was out, so I was alone. I sent a text to my whole family – my kids and brother and sisters and my mom,” he said.

Hayes’ outcome suggests that the antivirals can be well tolerated by heart-transplant recipients, Bhattacharya said. “We didn’t see significant interactions with the anti-rejection meds.” Additionally, UW Medicine’s liver-transplant program just had its first patient complete the HCV protocol, with similar success, she said.

If a patient's first round of antivirals does not eradicate the HCV, the team would re-treat with a longer course, Bhattacharya added.

It was more than two years ago, as the HCV curative regimens were becoming more readily available, that Smith, Bhattacharya and colleagues started discussing an expanded use of infected donor organs.

Devising a protocol meant addressing myriad what-ifs. Stakeholders in cardiac surgery, transplant and liver-care services needed to feel very confident about patient safety. And it was unknown whether insurance would cover the antivirals, which in 2016 cost upward of $80,000 per patient. Those prices have dropped considerably, making the protocols viable.

“Now it’s just about spreading the word to organ-procurement organizations around the U.S. that we’re willing to take HCV-positive donors,” Smith said. UW Medical Center could see as much as a 10 percent increase in transplants because of the new protocol, he estimated.

For patients like Hayes who are wait-listed for a heart transplant, the benefit of an increased donor pool is obvious. But there is also an upside for the families of intended donors whose organs have, in the past, had no chance of transplant because of hepatitis C.

“Transplant is a great social gift that donors and donor families give back to society,” Smith said. “One thing I’ve learned over the years in transplant: I don’t think donor families see donation as a sacrifice. They see it as an opportunity. So anything we can do to make better use of that gift can give them solace.”

https://newsroom.uw.edu/news/regions-1st-hepatitis-c-heart-transplant-recipient-cured

A Surgeon Reflects On Death, Life And The 'Incredible Gift' Of Organ Transplant

NPR heard on Fresh Air 

A Surgeon Reflects On Death, Life And The 'Incredible Gift' Of Organ Transplant

Dave Davies 
When Joshua Mezrich was a medical student on the first day of surgical rotation, he was called into the operating room to witness a kidney transplant.

What he saw that day changed him.....

He went on to become a transplant surgeon and has since performed hundreds of kidney, liver and pancreas transplants. He also has assisted in operations involving other organs.

Each organ responds to transplant in a different way.

"The liver will start pouring bile. The lungs start essentially breathing," Mezrich says. "Maybe the most dramatic organ, of course, is the heart, because you put it in and you kind of hit it like you hit a computer, maybe you give a little shock and it just starts beating, and that's pretty darn dramatic."

Read the article, here …..

African-Americans may live longer after liver transplant if their donors are the same race

African-Americans may live longer after liver transplant if their donors are the same race
Journal of the American College of Surgeons study authors report that donor race-matching may aid in future organ allocation

American College of Surgeons

CHICAGO (January 10, 2019): Among African-American adults undergoing liver transplant to treat liver cancer, patients whose organ donor was also African-American lived significantly longer than those with a racially unmatched donor, report authors of a new study using national data. The study is published online as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication.

These research findings suggest a possible way to improve long-term survival in a patient population that typically fares worse than other racial groups with liver cancer, which is the second deadliest cancer worldwide.1 Compared with other races, African-American patients with hepatocellular carcinoma (HCC)--the most common form of liver cancer--tend to have the poorest long-term survival and have worse outcomes after liver transplant.2 A liver transplant is the preferred and curative treatment option for some patients with early-stage HCC, according to the study authors.

Although past studies have linked unmatched donor-recipient race to worse overall survival in recipients of kidney, lung, and heart transplants, the role of donor race in liver transplantation has not been well defined, said principal investigator T. Clark Gamblin, MD, MS, MBA, FACS, professor and chief of surgical oncology at the Medical College of Wisconsin, Milwaukee.

For this study, Dr. Gamblin and his colleagues used the Organ Procurement and Transplantation Network's (OPTN's) national database. The researchers identified 15,141 adults with first-time HCC who received a transplant of a whole liver from a deceased donor between 1994 and 2015. Of those transplant recipients, 1,384 (9.1 percent) were African-American, and their records were further analyzed for the donor's race. A total of 325 patients (23.5 percent) received livers from African-American donors--labeled "matched"--and the other 1,059 patients (76.5 percent) were unmatched.

Five years after transplant, 64.2 percent of race-matched patients were still alive compared with 56.9 percent of unmatched patients, the researchers found. On average, race-matched patients lived 4.75 years longer after transplant than the unmatched patients, with a median overall survival of 135 months versus 78 months.

This effect of donor race continued even after the researchers statistically matched the two groups on multiple donor and recipient characteristics that are important to transplant success and patient survival. On these adjusted analyses, a race-matched transplant independently predicted improved overall survival, the investigators reported. Specifically, African-American transplant recipients had 34 percent greater odds of long-term survival when the donor's race was the same. African-Americans who received a liver from a white person--the most common race among donors--had a reported 53 percent increased risk of death.

The survival advantage with race-matching reportedly did not become apparent until after one year.

"Our data are intriguing," said Dr. Gamblin. "But our results require validation through further investigation of the role of race in optimizing outcomes of liver transplant for treatment of HCC."

"It is certainly premature to recommend a change in compatibility screening criteria based on our findings alone," continued Dr. Gamblin, who noted that race is not currently a consideration during compatibility screening of donors for liver transplant. "Likewise, recipients should not turn down a liver based on the race of the donor because they may not get another one," he added, referring to the nationwide organ shortage.

Less than one-fourth of the African-American liver transplant recipients in this study had race-matched donors, which corresponds to national statistics showing low organ donation rates by African-Americans. Although 29.8 percent of all U.S. candidates waiting for an organ transplant are African-American, only 13.5 percent of all organ donors in 2015 were African-American.3

Asked if their study might encourage more African-Americans to become organ donors, Dr. Gamblin replied, "It is my hope that everyone consider liver donation. There are not enough donors, and people on the waiting list are dying every day waiting for an organ."

More than 13,500 people are on the liver transplant waiting list based on OPTN data as of December 18, 2018.4

Nearly 33,000 Americans were diagnosed with liver cancer and liver bile duct cancer in 2015, the Centers for Disease Control and Prevention estimates.5 Risk factors for HCC include persistent infection with hepatitis B or C and cirrhosis of the liver. A liver transplant not only treats liver cancer but also allows the liver to function normally again.

Dr. Gamblin's coauthors are Jack P. Silva, MD, formerly a research fellow at the Medical College of Wisconsin and now a general surgery resident at the University of Southern California, Los Angeles, as well as Meghan N. Maurina; Susan Tsai, MD, MHS, FACS; Kathleen K. Christians, MD, FACS; Callisia N. Clarke, MD, FACS; Harveshp D. Mogal, MD, FACS; and Kia Saeian, MD, all from the Medical College of Wisconsin.

"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

This study was presented in August 2018 at the Sixth Annual Solid Organ Transplant Symposium in Milwaukee, Wis.

Citation: The Effect of Donor Race-Matching on Overall Survival for African American Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma. Journal of the American College of Surgeons. Available at: https://www.journalacs.org/article/S1072-7515(18)32235-X/fulltext.

1 Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-E386.
2 Artinyan A, Mailey B, Sanchez-Luege N, Khalili J, Sun CL, Bhatia S, et al. Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States. Cancer. 2010;116(5):1367-1377.
3 US Department of Health and Human Services Office of Minority Health. Organ donation and African Americans. 2016. Available at: https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=27. Accessed December 17, 2018.
4 Organ Procurement and Transplantation Network. Data. Available at: https://optn.transplant.hrsa.gov/data/. Accessed December 18, 2018.
5 Centers for Disease Control and Prevention. Liver and Intrahepatic Bile Duct Cancer, United States--2006-2015. United States Cancer Statistics (USCS) data brief, No. 5. Atlanta, GA: Centers for Disease Control and Prevention; 2018.

About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.

The Liver Meeting® African-Americans Face Significant Delays in Liver Transplantation Despite High Priority Scores

African-Americans Face Significant Delays in Liver Transplantation Despite High Priority Scores
November 9, 2018

Data from a new study presented this week at The Liver Meeting® found that African-American patients on waitlists for liver transplantation, despite severe disease and high scores for prioritization, persistently face significant disparities and delays in referral. 

SAN FRANCISCO – Preliminary data from a new study presented this week at The Liver Meeting® – held by the American Association for the Study of Liver Diseases – found that African-American patients on waitlists for liver transplantation, despite severe disease and high scores for prioritization, persistently face significant disparities and delays in referral.

To prioritize liver transplantation recipients, the Model for End Stage Liver Disease, or MELD, scoring system is widely used. However, disparities in timely referral for liver transplantation persist. This study by researchers in the Alameda Health System in Oakland, Calif., evaluated race- and ethnicity-specific disparities in the severity of liver disease of patients at the time of waitlist registration and the time of liver transplantation across the United Network for Organ Sharing, or UNOS, regions in the United States.

“Prior studies had conflicting data on how the adoption of the MELD scoring system for liver allocation had affected racial disparities in liver transplantation. In particular, ethnic minorities − specifically African-Americans − consistently had lower rates of receiving liver transplantation and higher rates of death while awaiting liver transplantation,” says Ann Robinson, MD, an internist at Highland Hospital in Oakland, Calif., and the study’s co-author. “We aimed to specifically evaluate whether these disparately worse outcomes among African-Americans also extended to differences in liver disease severity at [the] time of waitlist registration. The finding of more severe liver disease, as manifested by higher MELD scores, suggests potential delays in referral for liver transplantation among African-Americans. This is critical information to understand, as delays in timely referral may ultimately affect survival outcomes.”

The researchers retrospectively evaluated UNOS liver transplantation data from 2005 to 2016 to compare race- and ethnicity-specific MELD scores at the time of waitlist registration and at the time of liver transplantation among U.S. adults without hepatocellular carcinoma, a type of liver cancer. They compared MELD scores between the groups, and adjusted race- and ethnicity-specific comparisons of these scores for factors like age, sex, year, liver disease etiology, body mass index, ascites and hepatic encephalopathy.

Among 88,542 waitlist registrants for liver transplantation, the researchers found the overall average MELD at the time of registration was 17.4 ± 8.6. African-American patients had a significantly higher average MELD score at waitlist registration than all other race/ethnic groups across all years and regions. All non-white racial and ethnic minorities were significantly more likely to have a higher MELD scores at time of waitlist registration compared to non-Hispanic white patients, with African-American patients having the greatest disparity, the study shows. Similar trends were seen at the time of liver transplantation, with African-American and Hispanic patients having significantly higher MELD scores compared to non-Hispanic whites.

“African-Americans had significantly higher MELD scores at time of liver transplantation waitlist registration, which was observed even after correcting for potential geographic variations. This is particularly important, given that prior data suggested that ethnic disparities may be a direct result of geographic differences,” explains Dr. Robinson of the study’s findings. “While the process of liver transplantation referral is complex and affected by multiple factors, our observations raise serious concerns about persisting race/ethnicity-specific disparities in liver transplantation in the U.S. that need to be studied further so that targeted interventions may be developed to mitigate these disparities.”

Editor’s note: This study was sponsored by AASLD Foundation (link is external) through its Clinical and Translational Research Award in Liver Diseases.

Dr. Robinson will present these findings at AASLD’s press conference in Room 312-314 at the George R. Moscone Convention Center in San Francisco on Saturday, November 10 from 4:00 PM – 5:30 PM. The study entitled “African Americans Have Significantly Higher Model for End Stage Lier Disease Scores at Time of Liver Transplant Waitlist Registration across All Liver Transplant Regions” will be presented on Sunday, November 11 at 4:30 PM in Room 153/155. The corresponding abstract (number 0164) can be found in the journal, HEPATOLOGY (link is external).
About AASLD

AASLD is the leading organization of clinicians and researchers committed to preventing and curing liver disease. The work of our members has laid the foundation for the development of drugs used to treat patients with viral hepatitis. Access to care and support of liver disease research are at the center of AASLD’s advocacy efforts.

Press releases and additional information about AASLD are available online at www.aasld.org.
Read the press release.

The Liver Meeting® Under-Immunization Still a Major Problem in Pediatric Liver Transplant Patient Population

Under-Immunization Still a Major Problem in Pediatric Liver Transplant Patient Population

SAN FRANCISCO – Data from a new study presented this week at The Liver Meeting® – held by the American Association for the Study of Liver Diseases – found that more than half of pediatric liver transplant recipients are under-immunized at the time of their transplant and are at increased risk for vaccine-preventable infections.

Vaccine-preventable infections are a serious complication for pediatric patients following a liver transplantation. These infections can lead to significant co-existing diseases and conditions, graft rejection, death and increased medical costs. In a prior study published in The Journal of Pediatrics, researchers at Children’s Hospital Colorado demonstrated that one in six pediatric liver transplant recipients is hospitalized with a vaccine-preventable infection in the first two years following transplantation.

Immunizations are a minimally invasive and cost-effective way to reduce such infections. The research team has continued their work in this project to learn more about the reasons behind the high number of under-immunized pediatric patients.

“Our study, which used the Pediatric Health Information System database, demonstrated that one in six liver transplant recipients was being hospitalized in the first two years post-transplant with an infection that was potentially vaccine preventable,” says Amy Feldman, MD, MSCS, program director, Liver Transplant Fellowship at Children’s Hospital Colorado, and the study’s co-author. “Therefore, we became interested in investigating whether immunizations were an actionable gap in practice that could lead to significantly improved transplant outcomes.”

The researchers collected immunization records at the time of liver transplantation for patients undergoing transplant at one of 39 North American centers in the Studies of Pediatric Liver Transplantation Consortium, or SPLIT, from August 2017 through May 2018. Immunization records were available for 106 of 119 potential subjects (89 percent) from 27 centers.

Using the CDC’s Immunization Schedule, 51 percent of the patients who received their transplant before the age of two, and 40 percent of patients who received their transplant at age two or older, were completely up to date for their age on immunizations. Using an accelerated schedule of immunizations allowed for children awaiting transplantation (published by the American Society of Transplantation and the Infectious Diseases Society of America) only four percent of patients were fully up to date on age-appropriate immunizations at the time of transplant. Out of all 106 patients in the study, five percent had delayed transplant listing to allow time for them to become up to date on their immunizations.

The immunizations most frequently missed were DTaP (diphtheria, tetanus, pertussis) and PCV13 (the pneumococcal conjugate vaccine). The study found that out of 23 children who were six to 11 months old at transplant, who would have been eligible for accelerated live immunizations, only 13 percent had received the MMR (measles, mumps, rubella) vaccine and only nine percent were immunized against varicella prior to surgery. The study also found that out of 79 patients one year or older at transplant, only 80 percent were immunized against hepatitis A despite eligibility. Of 20 children age 11 or older at the time of transplant, only 70 percent had received the DTaP booster and 65 percent had received the HPV (human papilloma virus) vaccine. The researchers found that age, gender, race, ethnicity; and underlying diagnosis were not associated with under-immunization.

The study’s data show that 56 percent of pediatric liver transplant patients are under-immunized at the time of their transplant, leaving a significant portion of transplant recipients at increased risk for vaccine-preventable infections.

“Our study highlights under-immunization as a problem in the transplant population. In future studies, we plan to investigate what are the specific barriers faced by parents, primary care providers and hepatologists that prevent transplant candidates from being fully immunized at the time of transplant,” explains Dr. Feldman. “We then hope to develop tools within the healthcare system that can overcome these barriers and improve immunization delivery to transplant candidates and recipients, ultimately leading to improved post-transplant outcomes.”

Editor’s note: This press release contains updated data that is not reflected in the published abstract, but will be presented at The Liver Meeting®.

Dr. Feldman will present the study entitled “Immunization Rates at the Time of Pediatric Liver Transplant: A Prospective Multicenter Study through the Studies of Pediatric Liver Transplantation (SPLIT)” on Monday, November 12 at 10:30 AM in Room 312/314. The corresponding abstract (number 0240) can be found in the journal, HEPATOLOGY (link is external).

About AASLD
AASLD is the leading organization of clinicians and researchers committed to preventing and curing liver disease. The work of our members has laid the foundation for the development of drugs used to treat patients with viral hepatitis. Access to care and support of liver disease research are at the center of AASLD’s advocacy efforts.

Press releases and additional information about AASLD are available online at www.aasld.org.

Liver Meeting® 2018 - AASLD Poster Roundup: Gender, Insurance, Weight and Waitlists

Meeting Coverage > AASLD

AASLD Poster Roundup: Gender, Insurance, Weight and Waitlists
Selections from poster sessions at the annual Liver Meeting

• by Elizabeth Hlavinka, Staff Writer, MedPage Today November 10, 2018

SAN FRANCISCO -- Women and liver transplant waitlists, the impact of insurance on waitlist outcomes, and the tie between obesity and waitlist representation were highlighted in a group of poster presentations at the annual Liver Meeting, sponsored by the American Association for the Study of Liver Diseases (AASLD).

Rubin said it has been well-established that women waiting for a liver transplant may have worse outcomes than men, but the mechanisms for this disparity remain unclear. She told MedPage Today her group hypothesized that hospitalization would be a sufficient surrogate marker for disease severity, and that "if there were differences in hospitalization, maybe that could explain how the disease trajectory is different in women compared with men."

Read more: https://www.medpagetoday.com/meetingcoverage/aasld/76248

Meeting Coverage

Liver Meeting to Focus on Practice Matters Along with Science

Topics range from 'day in the life' of a hepatology consultant to novel NASH therapies 

View all coverage at MedPage Today

Would you rather die of liver failure or live with HIV?

Would you rather die of liver failure or live with HIV? 

4 October 2018 - Wits University 

Living donor liver transplantation from an HIV positive mother to her HIV negative child in South Africa 

This was the ethical dilemma faced by doctors at Wits Donald Gordon Medical Centre to save a child's life.

In 2017, doctors from the Transplant Unit at the Wits Donald Gordon Medical Centre performed what is believed to be the world's first intentional liver transplant from a mother living with HIV to her critically ill HIV negative child, who had end-stage liver disease.

Now, more than a year later, the mother and child have fully recovered, however, doctors are unsure the HIV-status of the child.

In South Africa, a country with the largest anti-retroviral therapy (ART) programme in the world, people with HIV live long and healthy lives.

The success of this world-first operation thus presents a potential new pool of living donors that could save additional lives.

Leveraging "living positive" to save more lives
In a paper published in prestigious, peer-reviewed journal AIDS on October 4, 2018, scientists in surgery, ethics, and HIV from the University of Witwatersrand, Johannesburg (Wits) explain how a chronic shortage of organs compromise their efforts to save lives, and how the decision they made to perform a world-first operation could advance transplantation.

Jean Botha, principal investigator and transplant surgeon is Professor of Surgery in the Department of Surgery in the School of Clinical Medicine, Faculty of Health Sciences at Wits University.

"Two aspects of this case are unique. Firstly, it involved intentional donation of an organ from a living HIV positive individual. Secondly, pre-exposure prophylaxis [medication to protect at-risk individuals from contracting the HI virus] in the child who received the organ may have prevented the transmission of HIV. However, we will only know this conclusively over time," says Botha, who is also Director of Transplantation at the Transplant Unit at the Wits Donald Gordon Medical Centre.

Currently, the Wits Donald Gordon Medical Centre is the only Transplant Programme doing living donor liver transplantation in southern Africa. It is also the first privately administered teaching hospital in Johannesburg and, as a Wits hospital, advances specialist training and research.

Stringent adherence to ethical guidelines
In this case of transplanting a liver from an HIV positive donor to a non-infected recipient, the transplant team had to unpack the potential risks and benefits to both. The Human Research Ethics Committee (Medical) at Wits University approved the liver transplantation from the mother living with HIV to her HIV negative child. Their personal details remain confidential.

The child - on the waiting list for a deceased donor for 180 days (the average is 45 days) - was frequently admitted for life-threatening complications of end-stage liver disease. Without transplant, the child would certainly have died. However, saving the child's life needed to be balanced against harm to the donor and the risk of almost certainly transmitting HIV if the mother was the donor.

Dr Harriet Etheredge is a medical bioethicist who holds an honorary position in the Department of Internal Medicine, School of Clinical Medicine at Wits, and oversees Ethics and Regulatory Issues at the Wits Donald Gordon Medical Centre.

"Extensive efforts were made to identify either a deceased liver donor or an HIV negative living donor for the child before considering an HIV positive parent donor. Transplanting HIV positive organs is not illegal in South Africa; however, it is not considered best practice internationally because of the risk of HIV transmission to the recipient. To minimise risk to donors and recipients, this operation is offered only under exceptional circumstances. Full consent is required from the parents who must be able to care for a child infected with HIV," says Etheredge, whose PhD is in the field of medical ethics and organ transplantation.

In this transplantation case, the mother asked a number of times for the opportunity to save her child's life by donating a segment of her liver. For this mother, quantifying the risk was simpler for the transplant team. Dr Francesca Conradie, HIV clinician, notes, "When considering an HIV positive parent, it is important that they have an undetectable viral load. This means that they know they are HIV positive and that they have been taking their antiretroviral medication properly for at least six months".

This made the risk of donation equivalent to that of an HIV negative living donor. However, living liver donation is never a risk-free procedure, and the team took care to ensure that the mother understood the full ambit of the risk she was undertaking.

"Our Independent Donor Advocate helps the parents understand the risks, makes representations to the transplant team on behalf of the donor if necessary, and provides emotional support throughout the process," says Etheredge.

Intentional transmission of HIV to save a life
The transplant team faced the dilemma of saving the child's life whilst at the same time knowing that the child might end up HIV positive because of this decision. However, because this intentional HIV positive living donor liver transplant is likely a world first, the actual chance of transmitting HIV was unknown.

The team decided to work on the basis that the child would contract HIV, and provide management accordingly. But in the time since the transplant, there have been some surprises when it comes to the child's HIV status.

"In the weeks after the transplant, we thought that the child was HIV positive, because we detected HIV antibodies," says Botha.

The transplant team then accessed specialised testing by HIV experts at the National Institute of Communicable Diseases (NICD) who subsequently could not find any active HIV infection in the blood stream of the child, meaning there is a chance that the child is HIV negative.

Caroline Tiemessen is Research Professor in the School of Pathology at Wits and head of Cell Biology within the Centre for HIV and STIs.

"At the moment, we are developing new methods for testing the child, and we hope to be able to have a definitive answer to the question of seroconversion in future. For now the child will remain on ART until we have a more comprehensive picture," says Tiemessen who, in 2017, led the laboratory investigations in the case where of a South African child living with HIV had remained in remission without ART since 2008.

Seroconversion is the period of time during which a specific antibody develops and becomes detectable in the blood. After seroconversion has occurred, HIV can be detected in blood tests for the antibody.

Expanded organ donor pool to advance transplantation in Africa

More than a year since the intentional liver transplantation from a mother living with HIV to her HIV negative child, both donor and recipient have recovered and are well.

Dr June Fabian, a nephrologist and Research Director at Wits Donald Gordon Medical Centre says, "We have formalised this procedure as a research programme. As we offer this type of transplantation to more children, we hope to be able to draw more definitive conclusions."

Organ transplantation at the Wits Donald Gordon Medical Centre is offered to any person irrespective of income or demographic according to "sickest first" criterion. This is possible through an existing partnership between the Wits Donald Gordon Medical Centre and the Gauteng Department of Health.

"We hope that this ground-breaking operation will be the first of many like it and will contribute towards promoting justice and equity in liver transplantation in South Africa," says Fabian. 

University of the Witwatersrand

http://www.wits.ac.za/news/latest-news/research-news/2018/2018-10/worlds-first-intentional-hiv-liver-transplant-1.html

Hepatitis C Infection May Be a Blessing for Patients in Need of a Transplant

Hepatitis C Infection May Be a Blessing for Patients in Need of a Transplant
Lara C. Pullen PHD
First published: 27 September 2018
https://doi.org/10.1111/ajt.15091

This month's installment of “The AJT Report” looks at how transplanting HCV‐positive organs can reduce risks for patients awaiting organs. We also report on Bristol Myers Squibb's recent easement of restrictions in prescribing belatacept (Nulojix).

“We are very proactive about our hepatitis C patients,” says Uttam Reddy, MD, medical director of the kidney transplant program at the University of California, Irvine (UCI) Medical Center. This is because in Southern California, the average wait time for a hepatitis C virus (HCV)‐negative organ is 8 to 10 years. If, however, a patient with HCV is willing to receive an HCV‐positive organ, the typical wait time is less than two years, a difference that Dr. Reddy describes as a “notably significant benefit.” In fact, he adds, “Before treating HCV in patients with advanced kidney disease, we recommend that they be evaluated at UCI first to assess the degree of their liver disease. If their liver disease is not advanced, we recommend proceeding with transplant and then treating their HCV after transplantation.”

Key Points
• Hepatitis C virus (HCV)-positive patients who elect to receive HCV-positive organs may cut years off their wait time.
• While the risk from an HCV-positive organ is difficult to quantify, it needs to be weighed against known risk from years on dialysis.
• Direct-acting antivirals (DAAs) lower risks associated with receiving HCV-positive organs.
• More frequent HCV diagnoses, greater use of DAAs and a potential ebbing of the opioid epidemic mean that fewer HCV-positive organs will be available in the future.

Read online: https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.15091

Download PDF: https://onlinelibrary.wiley.com/doi/epdf/10.1111/ajt.15091

HCV Next October Issue - Research continues to invalidate link between DAA treatment, liver cancer

HCV NEXT September/October Issue

Greetings, the following articles appeared in this months issue of HCV NEXT, published online over at Healio.

Table of Contents
HCV vaccine could reduce transmission in people who inject drugs

AASLD invests $4.06 million in liver disease research, development

Cover Story
HCV-Positive Organs: A Viable Option for Uninfected Transplant Patients

In the Journals
Research continues to invalidate link between DAA treatment, liver cancer

Novel ‘genotype 8’ surfaces among four patients with HCV

Treating HCV in prison ‘microenvironment’ reduces transmission

Heart transplant with HCV-positive organs successful, virus cleared

In the Journals Plus

Patients with chronic HBV die at younger age

Begin here....

Children lose out on liver transplants, study finds

“Children with chronic liver disease who are in need of transplant may be at a disadvantage compared with adults in a similar situation,” they wrote in their report, published in the journal JAMA Pediatrics.

Children lose out on liver transplants, study finds
by Maggie Fox / Sep.17.2018
The system for allocating liver transplants is stacked against kids, a new study finds.

Children who need lifesaving liver transplants are losing out to adults, according to a new study released Monday.

A system used to determine who is most in need of a transplant significantly underestimates the risk of death for younger children with liver disease, the team at the University of Pittsburgh found
Continue reading....

Canadian team reports success in transplanting hepatitis C organs

Toronto doctors safely transplant lungs from hepatitis C-infected donors
by Sheryl Ubelacker, The Canadian Press

Last Updated Jun 14, 2018 at 8:24 am EDT

Toronto doctors have successfully transplanted lungs from deceased donors with hepatitis C into patients in need of the lifesaving organs, followed by treatment to prevent them from becoming infected with the potentially liver-destroying virus.

Since October, surgeons at Toronto General Hospital have performed the transplants in 11 patients as part of a pilot study to evaluate the safety of using lungs from hepatitis C-infected donors — a previously untenable idea.

That’s because antiviral drugs can now cure the disease in 98 per cent of people infected with hepatitis C, which affects an estimated 250,000 Canadians, about 40 to 70 per cent of them unaware they harbour the blood-borne virus.

“With the opioid crisis and persistent high rates of intravenous drug use, we have a great number of potential lung donors who are hepatitis C-positive, many of whom didn’t even know they were sick when they were alive,” said Dr. Marcelo Cypel, a thoracic surgeon at TGH and principal investigator of the study.

Continue reading: https://toronto.citynews.ca/2018/06/14/hepatitis-c-lung-transplant/

Canadian team reports success in transplanting hepatitis C organs

WASHINGTON: A long-running shortage in donor organs has pushed doctors to find ways to use those with hepatitis C, an infection that is increasingly common in the United States due to the opioid crisis, and which can be cured with medicine.

Some US hospitals, particularly in Boston, have already transplanted infected donor organs into people without hepatitis C. These patients are swiftly treated with drugs to eliminate the virus.

In Toronto, Canada, another team of doctors on Thursday announced early results from a trial using a different technique, involving 10 people who received lung transplants from donors with hepatitis C.

Continue reading: 

https://www.nst.com.my/world/2018/06/380180/canadian-team-reports-success-transplanting-hepatitis-c-organs

HCV/HIV-coinfection - Successful direct acting antiviral (DAA) treatment before and after liver transplantation

PLOS ONESuccessful direct acting antiviral (DAA) treatment of HCV/HIV-coinfected patients before and after liver transplantation

Julia M. Grottenthaler, Christoph R. Werner, Martina Steurer, Ulrich Spengler, Thomas Berg, Cornelius Engelmann, Heiner Wedemeyer, Thomas von Hahn, Wolfgang Stremmel, Anita Pathil, Ulrich Seybold, Eckart Schott, Usha Blessin, Christoph P. Berg

Published: June 6, 2018 https://doi.org/10.1371/journal.pone.0197544 

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Abstract
Objectives
The aim of this multicenter retrospective study was to investigate safety and efficacy of direct acting antiviral (DAA) treatment in the rare subgroup of patients with HCV/HIV-coinfection and advanced liver cirrhosis on the liver transplant waiting list or after liver transplantation, respectively.

Methods
When contacting 54 German liver centers (including all 23 German liver transplant centers), 12 HCV/HIV-coinfected patients on antiretroviral combination therapy were reported having received additional DAA therapy while being on the waiting list for liver transplantation (patient characteristics: Child-Pugh A (n = 6), B (n = 5), C (n = 1); MELD range 7–21; HCC (n = 2); HCV genotype 1a (n = 8), 1b (n = 2), 4 (n = 2)). Furthermore, 2 HCV/HIV-coinfected patients were denoted having received DAA therapy after liver transplantation (characteristics: HCV genotype 1a (n = 1), 4 (n = 1)).

Results
Applied DAA regimens were SOF/DAC (n = 7), SOF/LDV/RBV (n = 3), SOF/RBV (n = 3), PTV/r/OBV/DSV (n = 1), or PTV/r/OBV/DSV/RBV (n = 1), respectively. All patients achieved SVR 12, in the end. In one patient, HCV relapse occurred after 24 weeks of SOF/DAC therapy; subsequent treatment with 12 weeks PTV/r/OBV/DSV achieved SVR 12. One patient underwent liver transplantation while on DAA treatment. Analysis of liver function revealed either stable parameters or even significant improvement during DAA therapy and in follow-up. MELD scores were found to improve in 9/13 therapies in patients on the waiting list for liver transplantation; in only 2 patients a moderate increase of MELD scores persisted at the end of follow-up.

Conclusion
DAA treatment was safe and highly effective in this nation-wide cohort of patients with HCV/HIV-coinfection awaiting liver transplantation or being transplanted.

Full article: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197544

Editorial - If Hepatitis C therapy is so great, why isn’t everyone doing it?

Editorial
If Hepatitis C therapy is so great, why isn’t everyone doing it? 
Robert S. Brown, Jr., M.D., M.P.H

Am J Transplant. [Epub ahead of print]

First published: 04 June 2018

https://doi.org/10.1111/ajt.14960
In this issue of the journal, Drs. Axelrod et al. aimed to investigate the impact of direct-acting antiviral agents for Hepatitis C (HCV) on liver and kidney transplant outcomes and cost for HCV positive patients.

Link
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Given that hepatitis C therapy is recommended for all patients who do not have a short life expectancy, certainly all transplant recipients should be treated for hepatitis C in the early post-transplant period prior to developing any significant liver disease in the liver allograft or progressive disease in the renal transplant recipient. Early therapy would also prevent any cases of cholestatic hepatitis. Given that hepatitis C therapy is likely cost-effective in the non-transplant setting, it would certainly be cost-effective in the transplant setting. One would hope that we are doing better with pangenotypic lower cost DAA options with fewer drug-drug interactions now available. Given the WHO's recommendation for HCV elimination by 2030, the fact that the transplant community has not been able to eliminate HCV in our transplant recipients remains a concern. Better education of our providers, advocacy for our patients, and better access to medications are the only solution to this problem. I certainly hope we get there soon.

Continue reading: Download PDF Article 

More patients with severe alcoholic hepatitis receiving liver transplants

More patients with severe alcoholic hepatitis receiving liver transplants
Medical centers willing to perform transplants without mandated six-month wait

Washington, DC (May 22, 2018) -- Increasingly, liver transplant centers are changing a long-standing practice of delaying potentially life-saving liver transplantation for patients with severe alcoholic hepatitis until after they stopped drinking alcohol for six months, according to a new study scheduled for presentation at Digestive Disease Week® (DDW) 2018.

Study implications
"Liver transplant for severe alcoholic hepatitis is being increasingly accepted, with positive outcomes, and the hope is that more and more patients will be evaluated for transplants," said Saroja Bangaru, MD, chief resident in internal medicine at the University of Texas Southwestern Medical Center, Dallas, and co-author of the study. "The hope is that survival rates are encouraging enough for centers, so that even more of them will reverse past practices."

Severe alcoholic hepatitis has an extremely high mortality rate. The primary treatment option has been the use of steroids, predominantly prednisolone. But, many patients do not respond to steroids, and a significant percentage of them will die within three months.

Historically, centers would not perform transplants until patients had stopped drinking for six months due to concerns about a return to drinking after transplant. Additionally, there was a perceived high risk that patient's continued drinking would cause them to miss medical appointments and failure to take their immunosuppressant medications, which prevent organ rejection, all of which could contribute to transplant failure.

Only in recent years have limited studies begun to show greater success for transplants for severe alcoholic hepatitis, Bangaru said. These studies have also shown that a variety of other factors -- aside from recent drinking -- influence whether a patient relapses. These include whether the patient has good social support, suffers from psychiatric ailments and accepts that they have an alcohol problem. "These studies suggest that predicting risk of relapse is much more complicated than just duration of abstinence," Bangaru said.

Study design and results
Researchers gathered data from 45 transplant centers, of which 23 said they were now performing such transplants. Among those, 17 centers reported that patients had a one-year survival rate of more than 90 percent, which is higher than that reported in several previous studies.

The survey found that centers have become more willing to perform transplants, as long as patients are carefully screened. Researchers reported that centers use highly selective criteria in approving candidates for transplant, assessing their medical history, social support system and whether they have additional health problems, particularly psychiatric disorders.

"If patients are selected well, according to these criteria, it allows for the excellent survival that we are seeing post-transplant," Bangaru said. Past policy has done a disservice to those patients who were previously unaware that they had liver disease. "Some patients come in for the first time with severe alcoholic hepatitis, and no one has ever told them to stop drinking. Because they are not eligible for transplant, they have a really high mortality rate."

The survey also concluded that most transplant centers had "inadequate" post-transplant support for patients. While most offered the services of social workers, only a limited number provided psychiatric or group therapy support that could be very important in helping patients avoid relapse and further medical problems.

Next steps
Dr. Bangaru said further study is needed to encourage more transplants, in particular a controlled clinical trial that follows survival rates over one, three and five years, along with an assessment of rates of alcoholic relapse.

DDW presentation details
Dr. Saroja Bangaru will present data from the study, "Increased use of liver transplantation as therapeutic option for severe alcoholic hepatitis," abstract Sa1457, on Saturday, June 2, at noon EDT. For more information about featured studies, as well as a schedule of availability for featured researchers, please visit http://www.ddw.org/press.

Digestive Disease Week® (DDW) is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT), DDW takes place June 2-5 at the Walter E. Washington Convention Center in Washington, DC. The meeting showcases more than 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology. 

More information can be found at http://www.ddw.org.

https://www.eurekalert.org/pub_releases/2018-05/ddw-mpw051818.php

Life of a liver awaiting transplantation - Machine that preserves livers might offer a way forward

Nature

NEWS AND VIEWS
18 April 2018

Life of a liver awaiting transplantation

Stefan Schneeberger

People waiting for a liver transplant can die before an organ is found, or, if one is available but of poor quality, there is a risk of transplant failure. A machine that preserves livers might offer a way forward.

The concept of machine perfusion of an organ awaiting transplantation is not new. Indeed, machine-assisted perfusion was in use before cold storage became the method of choice owing to its simplicity and reproducibility2. However, interest in revisiting perfusion as a transplant approach has been gaining momentum.

The main outcome monitored in the latest trial was the post-transplantation level of the enzyme aspartate transaminase in patients’ blood. This measurement is commonly used to assess liver damage and to estimate the risk of transplant failure. The authors found that the use of NMP was associated with less liver damage than that found in livers preserved on ice. Moreover, preservation by NMP reduced the number of organs that were discarded as unsuitable for transplantation compared with livers preserved on ice, and was associated with a better blood-flow profile in the recipient.

Continue reading: https://www.nature.com/articles/d41586-018-04458-w

Every Cloud Has a Silver Lining: Overdose-Death Donors in Organ Transplantation

HIV and ID Observations
Hepatitis C Positive Organ Donors — Coming Soon to a Transplant Center Near You
There’s one immutable fact in solid organ transplantation — the number of patients awaiting transplant exceeds the number of available organs.
Continue reading...

Reuters Health

Organs from overdose-death donors a viable option for transplant
Last Updated: 2018-04-16
By Marilynn Larkin
NEW YORK (Reuters Health) - Transplantation with overdose-death donor (ODD) organs has increased dramatically in the U.S., with equivalent outcomes to non-ODD organs, and therefore these organs should not be routinely discarded, researchers in Maryland say.

"Most Americans know that the U.S. faces an epidemic of deaths due to drug overdose, and many are also aware that there is a critical shortage of organs available for transplant," Dr. Christine Durand of Johns Hopkins University School of Medicine in Baltimore told Reuters Health.

"Perhaps less widely known is that today, more than one in every 10 deceased organ donors died from a drug overdose," she said by email.

"Patients who received transplants from these donors had excellent outcomes; patient survival and organ function were similar to cases when donors died due to trauma, and similar or better than cases when the donor died due to medical causes of death like heart attack or stroke," she added.

Dr. Durand and colleagues examined data from January 2000 to September 2017 on 138,565 deceased donors and 337,934 transplant recipients at 297 transplant centers in the U.S.

Continue reading: http://www.chronicliverdisease.org/reuters/article.cfm?article=20180416Other2030196131

Ann Intern Med 2018

Editorial |17 April 2018

Every Cloud Has a Silver Lining: Overdose-Death Donors in Organ Transplantation

Nearly 115 000 candidates currently await organ transplantation in the United States (mostly kidneys [81%] and livers [12%]) (1). Because of the profound organ shortage, many candidates awaiting transplant experience significant morbidity and mortality each year. In this issue, Durand and colleagues (2) review the use of overdose-death donor (ODD) organ transplants involving 138 565 deceased donors and 337 934 solid organ transplant recipients from 2000 to 2017. The study used the Scientific Registry of Transplant Recipients, which includes U.S. national data collected by the Organ Procurement and Transplantation Network (OPTN). The authors found that ODD transplants increased 24-fold, from 149 in 2000 (1.1% of donors) to 3533 in 2016 (12.7% of donors). For the most part, outcomes with ODD organs were noninferior to those with organs from trauma-death donors (TDDs) and medical-death donors (MDDs). Compared with MDDs, ODDs were less likely to have hypertension, diabetes, or prior myocardial infarction but had slightly higher creatinine levels and were more likely to donate after circulatory death. Cold ischemic time of transplanted kidneys was similar across all donor types. In an adjusted analysis, recipients of ODD kidneys and livers had a lower risk for death than recipients of MDD organs and a similar risk for death and graft loss compared with recipients of TDD organs.

Abstract
The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study