Hepatitis C–positive grafts for hepatitis C–negative recipients in liver transplantation: Buried treasure or depleting resource?

Long-term outcomes of using HCV-positive donors in HCV-negative recipients in liver transplantation (LT) are not well established. Data from the United Network for Organ Sharing (UNOS) database between July 1, 2015, and December 31, 2023, were analyzed. The cohort included 44,447 HCV antibody-negative (Ab-) candidates who underwent deceased donor LT. Changes in case numbers and utilization rates of HCV-positive donors, divided into HCV-viremic (NAT+) or Ab+ nonviremic (Ab+/NAT-), were assessed. Kaplan-Meier analysis and propensity score matching were used to evaluate 5-year graft survival. The number of HCV-viremic donation after brain death (DBD) donors and their use in LT for HCV Ab- recipients peaked at 640 donors in 2019 and 289 LTs in 2022. In contrast, Ab+ nonviremic DBD donations are rising, with 536 donors and 284 LTs in 2023. The utilization rate of viremic DBD grafts has continuously decreased despite increased willingness by waitlist candidates to accept them. HCV-positive donation after circulatory death donors were seldom utilized in the study period. The 5-year graft survival rates for HCV-viremic, Ab+ nonviremic, and naïve donors were not significantly different in either DBD ( p = 0.56) or donation after circulatory death ( p = 0.52). Furthermore, Ishak stage 2 or 3 fibrotic DBD grafts had similar 5-year graft survival to nonfibrotic grafts. The findings suggest that the long-term outcome of using HCV-viremic DBD or donation after circulatory death grafts for HCV-negative recipients is comparable to that of other graft types and that fibrotic grafts have the potential to expand the DBD donor pool.