Over the last several years, the new lung allocation system has resulted in broader, more equitable sharing of organs across the United States. At some individual transplant centers, this means wait times and the level of illness of patients on the waitlist are increasing.
To expand opportunities for patients to receive a lung transplant, Baylor University Medical Center at Dallas (Baylor Dallas), part of Baylor Scott & White Health, has begun accepting hepatitis C positive and hepatitis B core antibody positive donors for lung transplantation. The first transplant of this kind at Baylor Dallas was performed in July.
“This is becoming standard practice for most solid organ transplants, but for lung, we are still in the early stages of this innovative approach,” says Todd Grazia, MD, Chief of Transplant Pulmonology, Baylor Dallas. “A large percentage of transplant programs aren’t using hepatitis C lungs. We hope this will be a way to provide some of our patients with a lung transplant before they become gravely ill when the risk of surgery is higher. If we can get them an organ at an earlier stage, outcomes are likely to be better.”
Where once lungs from deceased donors infected with hepatitis C were discarded, the development of direct-acting antiviral therapy has made it possible to successfully transplant these lungs into hepatitis C-negative recipients and treat the hepatitis C that develops post transplant. These antiviral medications cure hepatitis C nearly 100 percent of the time, virtually eliminating the risk of developing liver disease at a later stage.
“Once a patient converts to being hepatitis C positive, we work with our hepatology colleagues to put the patient on an eight- to twelve-week, continuous outpatient regimen of antiviral therapy,” Dr. Grazia says. “While this is not considered standard of care yet, we hope to expand our donor pool because patients are waiting longer than they did even two to three years ago.”
When hepatitis B lungs are low risk
Unlike hepatitis C, there are no curative drugs for hepatitis B. When a potential donor is determined to have hepatitis B through nucleic acid testing (NAT), the lungs will be discarded. However, one particular antibody test may indicate the lungs are safe to use. Potential donors who are hepatitis B isolated core antibody positive may have had exposure to the virus but cleared it on their own or less commonly have a low level of the virus in their body.
“In this scenario, there is a good chance that the donor will not pass the virus on to the recipient,” Dr. Grazia says. “Because there is a small chance that they could, we will treat these patients prophylactically with antiviral medications that can reduce the chance they will develop hepatitis B. Of course, none of this is done without the patient’s consent, who may opt to wait for an organ that isn’t hepatitis B or C positive. It may be that we steer hepatitis B positive donors toward sicker patients who are at risk of not making it to transplant.
“As we gain more experience in this approach and the field becomes more standardized, I can envision it becoming the standard of care,” Dr. Grazia continues. “I think ultimately most transplant centers will do this. When lungs for transplant are so scarce, this gives us an edge to utilize more donors than we otherwise would. It’s a win-win for everyone.”