Simultaneous Liver and Kidney Transplantation in Patients Aged 70 y and Older: Proceed With Caution.

Background: The number of elderly patients aged 70 y and older with liver and kidney failure is increasing, mainly because of increasing prevalence of metabolic dysfunction-associated steatohepatitis. At present, limited data are available on the outcomes of elderly patients who fit the criteria for dual organ transplantation since the implementation of the simultaneous liver and kidney (SLK) allocation policy. Methods: We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of adults aged 18 y and older undergoing SLK and kidney transplantation only from August 11, 2017, to December 31, 2022. We examined patient and graft survivals and compared the outcomes of the recipients aged 70 y and older undergoing SLK transplantation to those who received kidney transplant alone and kidney after liver transplant. Results: During the study period, there has been a significant rise in the number of patients aged 70 y and older undergoing SLK transplantation, with 6 patients undergoing SLK transplantation in 2017 and 63 in 2021. Patients aged 70 y and older had significantly lower survival with 82.9% at 1 y and 66.5% at 3 y compared with 89.3% and 78.8% in the 50-69 y age group and 93.2% and 88.6% in the 18-49 y age group, respectively. Overall, kidney allograft survival was significantly lower in the 70 y and older group, with 80.9% at 1 y and 66.4% at 3 y compared with 91.1% and 75.5%, respectively, in those undergoing kidney transplant alone. There was no difference in kidney allograft survival in those undergoing SLK and kidney after liver transplantation. Conclusions: Although the outcomes are inferior in recipients of SLK transplant aged 70 y and older, chronologic age should not preclude them from undergoing transplantation. Kidney transplantation after liver transplantation could be considered to avoid futile transplants.

Impact of Obesity on Kidney Transplant Outcomes in Older Adults.

BACKGROUND: The prevalence of obesity in older patients undergoing kidney transplantation is increasing. Older age and obesity are associated with higher risks of complications and mortality post-transplantation. The optimal management of this group of patients remains undefined. METHODS: We retrospectively analyzed the United Network for Organ Sharing database of adults ≥70 years of age undergoing primary kidney transplant from January 1, 2014, to December 31, 2022. We examined patient and graft survival stratified by body mass index (BMI) in 3 categories, <30 kg/m2, 30 to 35 kg/m2, and >35 kg/m2. We also analyzed other risk factors that impacted survival. RESULTS: A total of 14,786 patients ≥70 years underwent kidney transplantation. Of those, 9,731 patients had a BMI <30 kg/m2, 3,726 patients with a BMI of 30 to 35 kg/m2, and 1,036 patients with a BMI >35 kg/m2. During the study period, there was a significant increase in kidney transplants in patients ≥70 years old across all BMI groups. Overall, patient survival, death-censored graft survival, and all-cause graft survival were lower in obese patients compared with nonobese patients. Multivariable analysis showed worse patient survival and graft survival in patients with a BMI of 30 to 35 kg/m2, a BMI >35 kg/m2, a longer duration of dialysis, diabetes mellitus, and poor functional status. CONCLUSION: Adults ≥70 years should be considered for kidney transplantation. Obesity with a BMI of 30 to 35 kg/m2 or >35 kg/m2, longer duration of dialysis, diabetes, and functional status are associated with worse outcomes. Optimization of these risk factors is essential when considering these patients for transplantation.

Kidney retransplantation outcomes in adults aged 70 and older: Analysis of risk factors and survival.

BACKGROUND: An increasing number of older patients are undergoing kidney transplant. Because of a finite longevity, more patients will be faced with failing allografts. At present there is a limited understanding of the benefits and risks associated with kidney retransplantation in this challenging population. METHODS: We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 undergoing kidney retransplant from January 1, 2014 to December 31, 2022. We examined patient and graft survival of retransplanted patients compared to first time transplants. We also analyzed the risk factors that impacted the survival. RESULTS: During the study period there has been a significant rise in the number of retransplants performed, with 631 patients undergoing the procedure. Although clinically insignificant, overall graft, and patient survival rates were slightly lower in the retransplant group compared to the primary transplant group. With retransplant, patient survival was 91.3%, 75.6%, and 56.9% compared to 93.4%, 81.4%, and 64.4% with primary transplant at 1, 3, and 5 years, respectively. With retransplant, graft survival was 89.5%, 73.5%, 57.4% compared to 91.5%, 79.0%, and 63.6% in a primary transplant group at 1, 3, and 5 years, respectively. Multivariable analysis showed that factors predicting poor survival included longer time on dialysis before retransplantation and decreased functional capacity. No survival difference was noted between recipients of deceased versus living donor kidneys. Patients who underwent retransplantation before initiating dialysis had better patient and graft survival. CONCLUSION: Patients aged ≥70 achieve satisfactory outcomes following kidney retransplantation, highlighting that chronologic age should not preclude this medically complex population from this life-saving procedure. Improvement in functional status and timely retransplantation are the key factors to successful outcome.

Anti-GSTT1 antibodies and Null genotype correlate with histological changes of antibody mediated rejection in kidney transplantation.

BACKGROUND: The presence of anti-Glutathione S-transferase T1 (GSTT1) antibodies (abs) has been hypothesized as a pathogenic contributor in antibody-mediated rejection (AMR). METHODS: We aimed to evaluate the relationship between genetic variants of GSTT1, anti-GSTT1 abs and AMR in a cohort of 87 kidney transplant (KTx) patients using Immucor's non-HLA Luminex assay. Patients were classified according to biopsy-proven AMR and HLA-DSA status: AMR with positive anti-HLA-DSAs (AMR/DSA+, n = 29), AMR but no detectable anti-HLA-DSAs (AMR/DSA-, n = 28) and control patients with stable allograft function and no evidence of rejection (n = 30). RESULTS: At an MFI cut-off of 3000, the overall prevalence of anti-GSTT1 abs was 18.3%. The proportion of patients with anti-GSTT1 abs was higher in the AMR/DSA- group (25%), compared to the control (13.3%) and AMR/DSA+ group (3.4%) (p = 0.06). Among patients with anti-GSTT1 abs, the MFI was higher in AMR/DSA- and GSTT1-Null patients. Of 81 patients who underwent GSTT1 genotyping, 19.8% were homozygotes for the null allele (GSTT1-Null). GSTT1-Null status in the transplant recipients was associated with the development of anti-GSTT1 abs (OR, 4.49; 95%CI, 1.2-16.7). In addition, GSTT1-Null genotype (OR 26.01; 95%CI, 1.63-404) and anti-GSTT1 ab positivity (OR 14.8; 95%CI, 1.1-190) were associated with AMR. Within AMR/DSA- patients, the presence of anti-GSTT1 abs didn't confer a higher risk of failure within the study observation period. CONCLUSION: The presence of anti-GSTT1 abs and GSTT1-Null genotype is associated with AMR, but do not appear to lead to accelerated graft injury in this cohort of early allograft injury changes, with a limited period of follow-up.

Intention-to-treat Analysis of Patients Aged 70 Years and Older Awaiting Kidney Transplantation in Post-Kidney Allocation System Era.

BACKGROUND: The US population is aging, and so the number of patients treated for end-stage renal disease is on the rise. In the United States, 38% of people over 65 y old have chronic kidney disease. There continues to be a reluctance of clinicians to consider older candidates for transplant, including early referrals. METHODS: We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 y old undergoing kidney transplants from December 1, 2014, to June 30, 2021. We compared patient and graft survival in candidates who were transplanted while on hemodialysis versus preemptive with a living versus deceased donor kidney transplant. RESULTS: In 2021, only 43% of the candidates listed for transplant were preemptive. In an intention-to-treat analysis from the time of listing, candidate survival was significantly improved for those transplanted preemptively versus being on dialysis (hazard ratio 0.59; confidence interval, 0.56-0.63). All donor types, donor after circulatory death, donor after brain death, and living donor, had a significant decrease in death over remaining on the waiting list. Patients who were on dialysis or transplanted preemptively with a living donor kidney had significantly better survival than those receiving a deceased donor kidney. However, receiving a deceased donor kidney significantly decreased the chance of death over remaining on the waiting list. CONCLUSIONS: Patients ≥70 y old who are transplanted preemptively, whether with a deceased donor or a living donor kidney, have a significantly better survival than those who are transplanted after initiating dialysis. Emphasis on timely referral for a kidney transplant should be placed in this population.

Combining donor-derived cell-free DNA and donor specific antibody testing as non-invasive biomarkers for rejection in kidney transplantation.

Donor specific anti-HLA antibodies (DSA) and donor-derived cell-free DNA (dd-cfDNA) have lead to substantial progress in the non-invasive monitoring of the renal allograft by being able to detect or rule out subclinical rejection and guide immunosuppressive changes. In this study we sought to analyze the clinical, de novo DSA (dnDSA) and histological determinants of dd-cfDNA levels. The study included a cohort of stable renal function kidney transplant (KT) recipients who underwent anti-HLA dnDSA and dd-cfDNA testing between September 2017-December 2019. Statistical models were constructed to detect association with predictors of dd-cfDNA levels and other clinical characteristics. 171 renal allograft recipients were tested for dd-cfDNA and dnDSA at a median 1.06 years posttransplant (IQR: 0.37-4.63). Median dd-cfDNA was 0.25% (IQR: 0.19-0.51), 18.7% of patients having a dd-cfDNA ≥ 1%. In a multivariate linear regression model the presence of dnDSA MFI ≥ 2500 was the best independent determinant of dd-cfDNA level (p < 0.001). Among patients tested, 54 had concurrent dd-cfDNA determination at the time of an allograft biopsy. dd-cfDNA had an AUC of 0.82 (95% CI 0.69-0.91; p < 0.001) and of 0.96 (95% CI 0.87-0.99) to discriminate any rejection and ABMR, respectively. After multivariate adjustment, the models that included ABMR (R = 0.82, R2 = 0.67, p < 0.001), or ptc (R = 0.79, R2 = 0.63, p < 0.001) showed the best correlation with dd-cfDNA level. We are confirming a strong association of dd-cfDNA with dnDSA and underlying alloimmune-mediated injury in renal allograft recipients in a cohort of patients with unsuspecting clinical characteristics for rejection and excellent allograft function. Our findings support the need for noninvasive biomarker surveillance in KT recipients and we propose that dd-cfDNA may complement dnDSA screening.

Survival Benefit in Older Patients Transplanted With Viremic Hepatitis C Positive Kidneys When Compared With High KDPI Kidneys.

BACKGROUND: Because of the continued demand in kidney transplantation, organs from donors with risk criteria for blood-borne viruses, high Kidney Donor Profile Index (KDPI) kidneys, and hepatitis C virus (HCV)-positive kidneys are being considered. There continues to be reluctance on the part of the providers and the candidates to accept HCV-positive kidneys. METHODS: We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adult (≥18 y old) recipients undergoing kidney transplant from May 10, 2013, to June 30, 2021. We compared patient and graft survival in candidates who received HCV-positive kidneys versus non-hepatitis C (Hep C) high KDPI kidneys by estimated posttransplant survival (EPTS) groups. RESULTS: HCV-viremic kidneys were transplanted in 5.6% of patients in the EPTS >61% group compared with 5.1% of patients in the 21%-60% EPTS group and 1.9% of 0%-20% EPTS group ( P < 0.001). Of all transplants performed in the EPTS 61%-100% group, 11.9% were KDPI >85% compared with 5.2% in the EPTS 21%-60%, and 0.5% in the EPTS 0%-20%. Patient survival was significantly longer at 1, 3, and 5 y in the EPTS >61% group who received Hep C-viremic or -nonviremic allografts compared with non-Hep C kidneys with KDPI >85%. When it comes to listing, only 25% of candidates in the EPTS >61% group were listed for Hep C nucleic acid testing-positive kidneys in 2021. CONCLUSIONS: Our findings could be used for counseling candidates on the types of kidneys they should consider for transplantation. Also, listing practices for viremic Hep C kidneys need continued re-evaluation.

Misplaced emphasis, misunderstood risk: a cultural history of Public Health Service infectious disease guidelines.

PURPOSE OF REVIEW: To review and summarize the evolution of the Public Health Service (PHS) guidelines and Organ Procurement and Transplantation Network (OPTN) regulations for the prevention of blood borne virus transmission in solid organ transplant through the lens of popular culture, scientific evolution, patient and practitioner bias and outcomes research. RECENT FINDINGS: The most recent set of guidelines and regulations were released in 2020 and represent a culmination of decades of opinion, research and debate within the scientific and lay communities. SUMMARY: The guidelines were created to address public concern, and the risk of undiagnosed disease transmission in the context of the novel public health crisis of AIDS. We reviewed milestone publications from the scientific and lay press from the first description of AIDS in 1981 to the present to help illustrate the context in which the guidelines were created, the way they changed with subsequent editions, and offer critical consideration of issues with the current set of guidelines and a potential way forward. Further consideration should be given to the way in which the current guidelines identify donors with risk criteria for infectious disease transmission and mandate explanation of donor-specific risk factors to potential recipients, in our era of universal donor screening and recipient surveillance.

Acute liver failure secondary to acute antibody mediated rejection after compatible liver transplant: A case report.

BACKGROUND: The liver has traditionally been regarded as resistant to antibody-mediated rejection (AMR). AMR in liver transplants is a field in its infancy compared to kidney and lung transplants. In our case we present a patient with alpha-1-antitrypsin disease who underwent ABO compatible liver transplant complicated by acute liver failure (ALF) with evidence of antibody mediated rejection on allograft biopsy and elevated serum donor-specific antibodies (DSA). This case highlights the need for further investigations and heightened awareness for timely diagnosis. CASE SUMMARY: A 56 year-old woman with alpha-1-antitrypsin disease underwent ABO compatible liver transplant from a deceased donor. The recipient MELD at the time of transplant was 28. The flow cytometric crossmatches were noted to be positive for T and B lymphocytes. The patient had an uneventful recovery postoperatively. Starting on postoperative day 5 the patient developed fevers, elevated liver function tests, distributive shock, renal failure, and hepatic encephalopathy. She went into ALF with evidence of antibody mediated rejection with portal inflammation, bile duct injury, endothelitis, and extensive centrizonal necrosis, and C4d staining on allograft biopsy and elevated DSA. Despite various interventions including plasmapheresis and immunomodulating therapy, she continued to deteriorate. She was relisted and successfully underwent liver retransplantation. CONCLUSION: This very rare case highlights AMR as the cause of ALF following liver transplant requiring retransplantation.

Donor-derived Cell-free DNA Complements De Novo Class II DSA in Detecting Late Alloimmune Injury Post Kidney Transplantation.

We sought to evaluate the association between de novo donor-specific antibodies (dnDSAs) class and their mean fluorescence intensity (MFI) with donor-derived cell-free DNA (dd-cfDNA), aiming to further clarify the biomarker utility of these noninvasive tests in relation to renal allograft function and histology. METHODS: The study included kidney transplant recipients (n = 171) who underwent surveillance testing with DSA and dd-cfDNA as part of their clinical care between September 2017 and December 2019 at our center. RESULTS: We identified dnDSA in 43 patients (25%) at a median of 4.63 y (IQR, 1.5-7) posttransplant. The presence of DSA with MFI >2500 was associated with a median dd-cfDNA of 0.96% (IQR, 0.26-2.95) significantly higher than in patients with DSA MFI <2500 (0.28%; IQR, 0.19-0.39) or without detectable DSA (0.22%; IQR, 0.17-0.37; P < 0.001). Class II dnDSAs were the most prevalent dnDSA (88.3%), the majority with MFI >2500 (82.9%). Patients with DQ-dnDSAs (47.4%) had higher MFI and dd-cfDNA levels than other class II dnDSAs. By comparison, all patients that developed only class I DSAs had MFI <2500 and a low dd-cfDNA. In addition, the serum creatinine was 1.55 ± 0.48 mg/dL in those dnDSA-negative, 1.15 ± 0.37 mg/dL in those with dnDSA MFI <2500, and 1.53 ± 0.66 mg/dL in those with dnDSA MFI >2500 (P = 0.05). After multivariate adjustment, an elevated dd-cfDNA was independently associated with the presence of dnDSA with MFI ≥2500. We identified that both dd-cfDNA and dnDSAs were strongly associated with antibody-mediated rejection, whereas for individual Banff histological lesions, DSA MFIs ≥2500 had the strongest association with C4d staining score and dd-cfDNA >1% with microvascular inflammation. CONCLUSIONS: Our study identifies class II dnDSA as being strongly associated with late alloimmune injury post kidney transplant independent of allograft dysfunction and shows that dd-cfDNA may complement the clinical significance of dnDSAs.

Prescriptive Analytics Determining Which Patients Undergoing Simultaneous Liver-Kidney Transplant May Benefit From High-Risk Organs.

OBJECTIVES: Simultaneous liver-kidney transplant is a treatment option for patients with end-stage liver disease and concomitant irreversible kidney injury. We developed a decision toolto aid transplant programs to advise their candidates for simultaneous liver-kidney transplant on accepting high-risk grafts versus waiting for lower-risk grafts. MATERIALS AND METHODS: To find the critical decision factors, we used the prescriptive analytic technique of microsimulation.All probabilities used in the simulation model were calculated from Organ Procurement and Transplantation Network data collected from February 27, 2002 to June 30, 2018. RESULTS: The simulated patient population results revealed, on average, that high-risk candidates for simultaneous liver-kidney transplant who accept highrisk organs have 254.8 ± 225.4 weeks of life compared with 285.6 ± 232.4 weeks if they waited for better organs. However, critical decision factors included the specific organ offer rates within individual transplant programs and the rank of the candidate in each program's waitlist. Thus, for programs with lower organ offer rates or for candidates with a rare blood type, a high-risk simultaneous liver-kidney transplant candidate might accept a high-risk organ for longer survival. CONCLUSIONS: Our model can be utilized to determine when acceptance of high-risk organs for patients being considered for simultaneous liver-kidney transplant would lead to survival benefit, based on probabilities specific for their program.

Machine Perfusion Decreases Delayed Graft Function in Donor Grafts With High Kidney Donor Profile Index.

OBJECTIVES: Kidney transplant is the optimal treatment for patients with end-stage renal disease. The effects of using machine perfusion for donor kidneys with varying Kidney Donor Profile Index scores are unknown. We sought to assess the impact of machine perfusion on the incidence of delayed graft function in different score groups of kidney grafts classified with the Kidney Donor Profile Index. MATERIALS AND METHODS: We conducted a retrospective analysis from January 2008 through September 2017 of adult recipients (≥ 18 years old) undergoing kidney-only transplant from deceased donors. All transplant recipients were followed until December 2017. Recipients who received multiorgan transplants or kidneys from living donors were excluded from our analyses. Recipients were divided according to 5 donor categories of Kidney Donor Profile Index scores (0-20, 21-40, 41-60, 61-80, and 81-100). Logistic regression analysis was performed for each score group to determine the effects of machine perfusion on development of delayed graft function within each score group. RESULTS: Our study included 101222 recipients who met the inclusion criteria. Multivariate analysis revealed that machine perfusion was associated with significantly decreased development of delayed graft function only in donors with high-risk profiles: the 61 to 80 score group (odds ratio = 0.83; confidence interval, 0.78-0.89) and the 81 to 100 score group (odds ratio = 0.72; confidence interval, 0.67-0.78). CONCLUSIONS: Machine perfusion is beneficial in reducing delayed graft function only in donor kidneys with a higher risk profile.

Contemporary patterns in kidney graft survival from donors after circulatory death in the United States.

BACKGROUND: Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. MATERIALS AND METHODS: We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. RESULTS: Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). CONCLUSIONS: For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.

Hyperammonemia syndrome due to Ureaplasma infection after liver-kidney transplant.

Hyperammonemia syndrome, with high levels of ammonia and neurologic dysfunction, is a syndrome with historically high mortality that may occur after solid organ transplantation. Recently, this has been associated with infection due to Ureaplasma, mostly following lung transplantation. We describe the first case of hyperammonemia syndrome due to Ureaplasma infection after liver-kidney transplantation. Our patient rapidly recovered after specific antibiotic treatment. It is important to consider these infections in the differential diagnosis for encephalopathy post-transplant, as these organisms often do not grow using routine culture methods and polymerase chain reaction testing is typically required for their detection. This is particularly critical after liver transplantation, where a number of other etiologies may be considered as a cause of hyperammonemia syndrome.

Solid organ donation after death in the United States: Data-driven messaging to encourage potential donors.

US deceased donor solid organ transplantation (dd-SOT) depends upon an individual's/family's altruistic willingness to donate organs after death; however, there is a shortage of deceased organ donors in the United States. Informing individuals of their own lifetime risk of needing dd-SOT could reframe the decision-making around organ donation after death. Using United Network for Organ Sharing (UNOS) data (2007-2016), this cross-sectional study identified (1) deceased organ donors, (2) individuals waitlisted for dd-SOT (liver, kidney, pancreas, heart, lung, intestine), and (3) dd-SOT recipients. Using US population projections, life tables, and mortality estimates, we quantified probabilities (Pr) of (1) becoming deceased organ donors, (2) needing dd-SOT, and (3) receiving dd-SOT. Lifetime Pr (per 100 000 US population) for males and females of becoming deceased organ donors were 212 and 146, respectively, and of needing dd-SOT were 1323 and 803, respectively. Lifetime Pr of receiving dd-SOT was 50% for males, 48% for females. Over a lifetime, males were 6.2 and females 5.5 times more likely to need dd-SOT than to become deceased organ donors. Organ donation is traditionally contextualized in terms of charity toward others. Our analyses yield a new tool, in the form of quantifying an individual's own likelihood of needing dd-SOT, which may assist with reframing motivations toward deceased donor organ donation.

New Evidence Supporting Increased Use of Split Liver Transplantation.

BACKGROUND: Young children and small-statured candidates are dying on liver candidate waitlists. The Organ Procurement and Transplantation Network and United Network for Organ Sharing have proposed a split liver (SL) variance encouraging transplant programs to split more livers to aid these smaller statured candidates. METHODS: We evaluated the US experience of splitting donor livers during 2002-2016. The results of our analysis provide new evidence to support this variance. RESULTS: During 2002-2016, SL grafts from 935 donors were transplanted into 1870 recipients. Controlling for recipient factors and using time period and program identification as random variables, a multivariable mixed Cox proportional hazards model for graft failure revealed that donor aged 3-10 years had a relative risk (RR) of 3.94 (2.86-5.44), and donor aged >30 years had a RR of 1.94 (1.59-2.35) for graft failure. Donor-to-recipient body surface area ratio <0.90 had a RR of 1.40 (1.13-1.75). Programs with experience transplanting <23 SLs had a RR of 1.43 (1.21-1.75). The same program transplanting both split segments had a RR of 1.38 (1.20-1.59). CONCLUSIONS: Splitting protocols based on these findings could improve graft survival after SL transplantation, which would encourage programs to opt into splitting more livers. The new protocols may consider donor age restrictions, necessary program experience, donor with body surface area appropriate for recipient, and improved logistical factors to share segments between transplant programs. The result would likely be a drastic reduction in liver waitlist deaths for young children and small-statured candidates.

Listing practices and graft utilization of hepatitis C-positive deceased donors in liver and kidney transplant.

BACKGROUND: The opioid epidemic has resulted in increasing the incidence of hepatitis C virus in the general population and more deceased organ donors with hepatitis C in the United States. We aim to describe how the changing donor landscape affects patterns of liver and kidney transplantation among donors, waitlist candidates, and transplanted recipients. METHODS: Using data supplied by the United Network for Organ Sharing, we examined donor hepatitis C virus antibody (Ab) and nucleic acid testing (NAT) status, center waitlist patterns, and liver and kidney transplants and discards between 2015 and 2017 by 6-month periods. RESULTS: We observed an increase in donors with any marker of the hepatitis C virus (n = 283 [6.2%] in period 1 to n = 384 [7.4%] in period 5, P = .008) and antibody positive nucleic acid testing negative donors (n = 81 [1.8%] in period 1 to n = 131 [2.5%] in period 5, P < .001). We observed a significant increase in aviremic recipients of liver transplants from antibody positive nucleic acid testing negative donors (n = 1 [1.7%] in period 1, to n = 27 [31.0%] in period 5, P = .005) and a significant decrease in the antibody positive nucleic acid testing positive liver discard rate (P = .01). By the end of the study, 75.8% (n = 97) of recipients of antibody positive nucleic acid testing negative kidneys were hepatitis C virus negative, an increase from 10.6% (n = 5) in period 1. CONCLUSION: The number of donors with the hepatitis C virus is increasing. We observed a concomitant increase in the transplantation of kidneys and livers from aviremic donors, and the recipient population of these organs is increasingly hepatitis C virus negative.