*Purpose: Prior to the development of direct acting antiviral (DAA) therapy for hepatitis C virus (HCV), there was concern that patients who received lungs from HCV positive donors may have worse graft and patient survival, possibly due to transmission of a virus that led to liver disease and exposure to intravascular foreign material from intravenous drug use. Now, in the era of well tolerated and highly efficacious DAA, we compared pathologic findings attributable to donor exposures and clinical outcomes in patients who received lungs from HCV positive donors to patients who received lungs from HCV uninfected donors, stratified by donor risk profile.

*Methods: Surveillance transbronchial biopsies in lung transplant recipients within the first year post-transplant were evaluated for the presence of intravascular polarizable foreign material consistent with intravenous injection, anthrasilicosis and other chronic pathologic changes attributable to donor disease. The transplant recipient biopsy findings were compared among 3 groups based on donor risk profile: active HCV infection (NAT+), increased risk, non-HCV, and non-increased risk, non-HCV. Donor and recipient baseline characteristics and clinical outcomes were analyzed.

*Results: 52 lung recipients had adequate biopsy tissue for evaluation: 18 HCV NAT+ donors, 7 increased risk, non-HCV donors, and 27 non-increased risk, non-HCV donors. 3 of 18 (17%; 2 mild, 1 moderate) HCV NAT+ had intravascular polarizable foreign material compared to 1 of 7 (14%; 1 mild) increased risk, non-HCV and 0 of 27 non-increased risk, non-HCV. Anthracosis was a common finding in all groups, with 10 of 18 (56%; 3 moderate, 7 mild) HCV NAT+, 4 of 7 (57%; 1 moderate, 3 mild) increased risk, non-HCV and 16 of 27 (59%; 4 moderate, 12 mild) non-increased risk, non-HCV demonstrating this smoking or exposure associated finding. There was a numerical increase in the number of patients treated for acute cellular rejection (ACR) in the HCV NAT+ group (11 of 18, 61%) and the increased risk, non-HCV group (4 of 7, 57%) compared to 11 of 27 (41%) in the non-increased risk, non-HCV group. Other clinical outcomes including primary graft dysfunction at 72 hours, length of hospitalization, graft survival, and overall patient survival were similar among the 3 groups.

*Conclusions: There was not a significant difference in the degree of intravascular foreign material between HCV NAT+ and increased risk, non-HCV lungs in this selected population, but both appear to be greater than that seen in the non-increased risk, non-HCV lungs. The percentage of donor lungs with anthracosis and the severity thereof was similar in all groups. Further investigation is warranted to better understand whether the presence of exogenous material in the donor lung is associated with early ACR. The similarity of the other clinical outcomes across the 3 groups, suggests that the excess intravascular particulate material likely did not have a significant effect in the increased risk (HCV NAT+ and non-HCV) groups.

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