LAUSR

I have read with interest the paper by Dr. Bari et al. reporting on the use of livers from hepatitis C virus (HCV) antibody–positive, nucleic acid test– negative (nonviremic) donors into HCV negative recipients and would like to congratulate the authors for such important contribution.(1) I would like to emphasize that, due to increasing mortality on the waitlist and excellent antiviral treatment, the transplant community should also use livers from HCV viremic donors for selected HCV negative recipients. In the United States, the rate of death from drug overdoses has increased exponentially.(2) Using the United Network for Organ Sharing database from 2015 to 2016, Kling et al. showed that 4.35% of all donors were viremic for HCV, and this number is increasing with the opioid epidemic.(3) The transplant community’s interest in the use of HCV positive donors for HCV negative recipients has recently increased.(2) However, it is controversial which HCV negative patients should receive those livers.(2) Until more data on long-term direct-acting antiviral treatment is available, it makes sense to use them in patients with increased risk of mortality or patients with very poor quality of life and low chance of receiving a transplant. Recently, Chhatwal et al., using a Markov-based simulation model, reported that accepting any liver regardless of HCV status versus accepting only HCV negative livers resulted in an increase in life expectancy only when Model for End-Stage Liver Disease (MELD) was ≥20, and the benefit was highest at MELD 28, resulting in 0.172 additional life years.(4) Another important issue with the allocation of viremic donors into uninfected patients is the high cost associated with treatment. However, this type of liver allocation will likely be cost-effective because transplanting HCV negative patients with HCV positive donors will happen sooner, reducing costs associated with the treatment of complications of end-stage liver disease. Very recently, a study showed that this type of allocation in kidney transplant patients was cost-effective, with the costs breaking even only 4 years after transplant when compared with hemodialysis treatment.(5) The use of livers from both aviremic and viremic donors could significantly decrease the waiting time and the mortality on the waitlist of HCV negative potential recipients.