*Purpose: The practice of transplanting organs from hepatitis C viremic donors (HCV NAT+) into negative recipients hinges on the ability to ensure direct acting antiviral (DAA) therapy post-transplantation. To date, DAA coverage by third party payers for acute HCV infection cannot be guaranteed. Here we report our center experience with obtaining DAA therapy via third party payers for recipients of HCV infected organs

*Methods: Patients who met center’s criteria were consented to receive HCV NAT+ organs. We utilized a team of pharmacists and reimbursement analysts with expertise in handling DAA prior authorization process. We also allocated a fund to help pay the cost of DAA therapy for patients denied coverage. HCV Polymerase Chain Reaction (PCR) was checked on day 3 after transplant then weekly until seroconversion. Prior authorization process was started upon first positive PCR

*Results: Between February and September of 2019, 28 HCV naïve patients ranging in age between 32 to 72 years received HCV NAT+ organs. 17 patients received a kidney and 11 received a liver transplant. 27 of the 28 patients had detectable HCV PCR by day 10 post-transplant. One liver transplant recipient did not seroconvert. Time to insurance approval varied with a median of 5.5 days (Min-Max: 0- 57). Median time to therapy from transplant was 28.5 days (Min-Max: 9-75). DAA therapy consisted of velpatasvir-sofosbuvir in 68% of the patients, glecaprevir-pibrentasvir in 25% and ledipasvir-sofosbuvir in 7%. Appeal was required in 35% of the kidney and 10% of the liver recipients. One kidney recipient (5%) was denied coverage and was treated via an Abbvie Patient Assistant Program. To date, 3 patients remain on therapy while 24 patients had completed 12 weeks of therapy. 14 of the 24 patients have met criteria for sustained viral response, 8 had negative 90 days PCR and 2 had detectable HCV PCR at the end of therapy. One kidney recipient had high viral load and was started on a different DAA agent. Another kidney recipient had viral load < 100 copies/ml with two negative subsequent checks and did not require further therapy. We did not observe any treatment related adverse effects, episodes of sclerosing cholestatic hepatitis, rejection, patient or graft loss

*Conclusions: Organs from NAT+ donors appear to be a safe and effective method to expand the donor pool. However, exploitation of such a resource requires commitment of third-party payers to deliver the appropriate post-transplant DAA therapy. So far, insurance appeal rates remain high and a safety net for drug coverage outside patients’ insurance remains necessary

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