Increased Rates of Rejection in Discordant Hepatitis C Heart Transplantation

Purpose In 2017, discordant hepatitis C (HCV) heart transplantation was initiated in an attempt to expand the donor pool in the era of curable treatments for HCV with direct anti-viral therapies. However, long term outcome data in these patients remains limited. In addition, within current data published, significant variability in rates of cardiac allograft vasculopathy (CAV) along with rejection have been reported thus far. The purpose of our study is to examine long term outcomes specific to both rejection and CAV in our discordant HCV transplants in comparison to our non-HCV cohort. Methods Our center started performing discordant HCV heart transplantation in 2018. We retrospectively reviewed the baseline demographics along with outcomes, specifically rates of rejection and CAV. Results Forty-six patients underwent discordant HCV heart transplantation at our center since 2018 with 89% of those donors being nucleic acid test (NAT) positive. 80% became viremic within 7 days post transplantation. All but 3 NAT+ patients became viremic with 80% of those converting within 7 days of transplantation. All viremic patients were treated within 3 months of transplantation. Seventeen (37%) developed rejection, most frequently within 1st year (94%), with 30% within the 1st month. Rejection episodes consisted mostly of cellular rejection (> 1R) with only 30% of episodes with hemodynamic significance. In comparison, the non-HCV cohort only experienced > 1R rejection in 18% (10/55) during the same time frame with 40% of episodes being hemodynamically significant. At 1 year, 8% of patients (3 of 34) developed CAV with two of those with patients with a history of rejection within the 1st year, similar to the rate of CAV in the non-HCV cohort. One patient (2%) died within the first year due to a combination of both rejection and infection. Conclusion In this population of discordant HCV transplant patients that were predominantly NAT+, we observed a higher incidence of rejection as compared to the non-HCV cohort of the same timeframe. Thus far, overall graft function, mortality and CAV outcome have not been affected. Longer term, multi center data is necessary regarding outcomes of patients with discordant HCV transplantation.