Donor-recipient matching in HCV-infected patients

Abstract

The current organ shortage scenario has prompted the increasing use of high-risk donor livers. These include livers from elderly donors, which have been convincingly shown to have an unfavorable impact on liver transplantation of hepatitis C virus (HCV)-infected patients. In addition, other donor-related risk factors include an unfavorable pattern of IL28B genotype, the donation after cardiac death (DCD), and the previous exposure of donors to hepatitis viruses. On the other hand, recipient-related risk factors in HCV-positive patients include ethnicity, female gender, again the pattern of IL28B genotype (CT or TT), and the presence of an HIV coinfection. Based on these data, the following recommendations can be made: First, grafts from donors aged >∈70 years (in the Italian scenario) and, possibly, aged >∈60 years (in other settings) should not be allocated to HCV-positive recipients. This policy is difficult, but can be implemented, and should be strongly encouraged, unless when it is plausible that it could lead to increased waiting list mortality. Second, great attention should be paid to donor-recipient matching in well-compensated HCV-positive recipients carrying hepatocellular carcinoma (HCC) within Milan criteria, in whom the final prognosis can be dramatically influenced by the age of the donor. If an elderly donor is being used, one should always carefully consider how to best balance the risk of dying/dropping out from the list because of HCC progression before liver transplantation (LT) and the risk of severe recurrence of HCV after LT. There are no data as yet to provide an evidence-based solution to this crucial issue, thus the decision should rely on a thorough and judicious clinical evaluation of both risks. Finally, some gender combinations may be deleterious in HCV-positive recipients and, accordingly, transplanting a male donor graft into a female recipient should be considered with caution, not only in the case of an elderly donor.