While 45% of liver candidates are hepatitis C (HCV) (+) and might benefit from an HCV (+) donor liver, only 7.1% receive one, and HCV (+) livers are discarded at 2.9 times the rate of HCV (-)s. Direct acting anti-retrovirals (DAAs) for the treatment of HCV were introduced in 2011 and are superior to interferon-only regimens. The goal of our study was to identify changes in the utilization, discard and outcomes associated with HCV (+) donor livers for HCV (+) recipients since the advent of DAAs.

Methods: We studied 22,071 HCV (+) recipients as captured in SRTR. Relative risk of discard and hazard of all cause graft failure were compared for patients transplanted between 2005-2010 (interferon-only era), and 2011-2014 (DAA era), adjusting for potential confounders.

Results: The use of HCV (+) livers for HCV (+) recipients increased 63% from 6.9% in 2010 to 11.3% in 2014 (Figure 1). There was a corresponding decrease in discard, with HCV (+) livers 44% less likely to be discarded in the DAA era (RR interaction =0.66, 95% CI: 0.55-0.79, p<0.001, Table 1). In the interferon-only era hazard of all cause graft failure was similar between recipients of HCV (+) and HCV (-) livers (HR = 0.96, 95% CI: 0.82-1.13, p=0.6). In the DAA era, HCV (+) recipients of HCV (+) livers had a lower hazard of all cause graft failure (HR = 0.75, 95% CI: 0.57-0.99, p=0.03); the decrease in hazard under DAAs compared to interferon-only was statistically significant (RR interaction =0.72, p=0.03).

Conclusion: HCV (+) livers are associated with improved survival for HCV (+) recipients in the era of DAAs, but are still discarded at over twice the rate of comparable HCV (-) livers. Increased utilization could expand the liver supply and improve outcomes for HCV (+) transplant candidates.

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