*Purpose: There is variability between programs in the acceptance of organ offers. This paper examines offer, acceptance and program performance with HCV NAT positive donor offers.

*Methods: In a 3 year period, between 9/1/2016 and 9/1/2019, HCV-NAT positive to HCV-NAT negative recipients occurred. On these patients all donor, recipient and procurement data was analyzed.

*Results: Recipients: The most common indications were non-alcoholic steatohepatitis (7/22), primary sclerosing cholangitis (6/22) & alcohol (4/22) with 3/22 having concurrent hepatocellular carcinoma & 1/22 cholangiocarcinoma. Recipients were male (63.6%), median age 49 yrs (IQR 35.7-63), blood group O (50%), median laboratory MELD 24 (14-35) and median allocation MELD 25.2 (17-40). One simultaneous liver & kidney transplant occurred. Donors: 8/22 (81.8%) were male, median donor age 32.5 (IQR: 24-36.2) and median BMI 25.6 (IQR 21.8-27.4) kg/m2. The common causes of death were Anoxia – Drug intoxication (16/22) 72.7% & head trauma (3/22) 13.6%. 20/22 (90.9%) had IV drug use while 2/22 D+ not categorized as PHS increased risk. Liver biopsies at donation had some degree of inflammation with macrovesicular steatosis ≥5% present in 6/22 with 2/22 having ≥25%. 7/22 donors had fibrosis with 3/22 stage 2 and none >2. The most common genotypes were 1 (11/22) 50%, & 3A (7/22) 31.8%. Allocation: The sequence for offers was 41.3 with 3/22 sequence 1, 9/22 at a sequence < 10 with 10/22 a sequence > 10; the highest sequence 338. Most procurements (59%) were national offers, with 5 (38.4%) from UNOS region 10. The median distance traveled was 1002 nautical miles (IQR: 511-1266), median flight time 158.5 min (IQR: 85.75-180), median cold ischemia time 445 min (IQR: 347.5-565), & median warm ischemia time of 35.5 min. Outcomes: Both patient and graft-survival were 95.4% with median follow up 576 days. Average length of stay was 10.2 days (range 5-37). The isolated post-transplant death was a ruptured hepatic artery on day 38 in a recipient transplanted for cholangiocarcinoma. HCV treatment was commenced within 90 days and all treated patients attained SVR 12. 5 patients had biopsies for abnormal liver enzymes with 3 having changes consistent with acute rejection, 2 of which were treated while one had a hepatitis in the absence of HCV and distant to the HCV SVR. Protocol biopsies were performed in all but one recipient (14/15) at 1 year with only one showing fibrosis from a steatohepatitis and possible alloimmune hepatitis.

*Conclusions: HCV offers are most often national offers and refused by more than one program before being transplanted at ours. Clinical outcomes for recipients of these previously declined offers are excellent and pre-transplant fibrosis appears to reverse.

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