Maximizing organ utility oct 2018

1. Maximizing Organ Utility
Uttam G. Reddy, MD
Assistant Professor of Medicine
Medical Director, Division of Transplantation
UCI Health

2. UCI Kidney Transplant Experience
Southern California is one of the most competitive
transplant markets in the country.
- Average wait time for kidney transplant typically 8-10 years
- Longest waiting times in the country
- Large Transplant Centers in the area
- UCLA, Cedars, USC

3. UCI Kidney Transplant Experience
Despite a competitive SoCal environment, UCI is
now the fastest growing transplant program in
California.
• Triple kidney transplant growth in 2 years
• Double growth in the past 1 year
• One of the largest Kidney Pancreas Transplant
programs in the region

4. UCI Kidney Transplant Experience
So, how was UCI able to achieve such a rapid growth in
transplants performed?
by Maximizing Organ Utility

5. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplant

6. Hepatitis C and Kidney
Transplantation:
A Blessing in Disguise

8. HCV Distribution Across United States

9. Hepatitis C + Kidney Transplantation
Hepatitis C causes renal disease in native and transplanted kidneys.
HCV infected renal transplant recipients have worse patient and allograft
survival after transplantation compared to non-infected renal transplant
recipients.
• HCV independent risk factor for graft loss
• Associated with proteinuria, chronic rejection, CTG, NODAT, HCV
associated GN
All patients evaluated for kidney transplant are screened for Hepatitis C.

10. Dealing with Hepatitis C Pre-Transplant
Any patient at UCI who is found to have Hep C who is considering kidney
transplantation is referred to Hepatology for further evaluation.
• Ultrasound
• Possible Liver Biopsy if concern for cirrhosis (Gold Standard)
o Can have complications (increased bleeding in CKD/ESRD, etc)
• Fibroscan (elastography) – measures stiffness
o Can help avoid liver biopsy (less invasive)
• Measuring portal pressures
• (HVPG > 10mmg – contraindication)

11. Hepatology Assessment
All HCV infected patients should be carefully evaluated and
closely followed by a hepatologist to determine:
• Liver function evaluation
• Kidney Transplant candidacy
o Kidney Alone
o Dual Liver Kidney
• Timing of therapy – pre or post treatment

12. Fibroscan
Ueu Uses Elastography, a technique similar to
Ultrasound that measures liver stiffness

13. Dealing with HCV Pre-Transplant
• If liver function is deemed to be too advanced, the patient
should be considered for dual liver kidney transplantation,
not kidney alone.
• Now with Hep C treatment, Transplant Centers are more
aggressive in doing kidney transplant alone, as we can now
treat HCV soon after kidney transplantation.
• Evolving pattern.

14. Cirrhosis
Question: Is Cirrhosis an absolute
contraindication to Kidney Transplant Alone?
• Not Necessarily.
• At UCI, if cirrhosis is not decompensated, we along with most
industry experts believe that kidney transplant alone can be done
successfully.
• For patients with Hepatitis C, since there is treatment of the disease
now, this further factors into the assessment.

15. Silver Lining – SHORTER WAIT TIMES!
• Programs that offer HCV infected organs can have the
benefit of much shorter waiting list time for their
patients.
• Average wait time for a Hepatitis C+ Kidney transplant is
1-2 years in Southern California!
• Much shorter than the 8-10 year wait for non-Hep C+
organs

17. Timing of Treatment – Pre or Post Txp
• Complicated topic – Treat before transplant or after?
• Patients with HCV infection but no evidence of cirrhosis on liver biopsy may be
treated for HCV infection prior to or after transplantation.
• In our area, given deceased donor wait times of 8-10 years for non HCV kidneys, if
a patient does not have a living donor, we suggest waiting to treat the Hep C until
AFTER transplantation
• Deceased donor HCV kidney list is significantly shorter at approximately 1-2 years in our OPO.
• For patients with kidney transplants already, if GFR >30, they should be treated
immediately.

18. What is Worse? – HCV or HD
• Postponing treatment will likely benefit patients who face long
waiting times if they only have mild fibrosis.
• More urgent treatment may be required if there are more advanced
histological findings, extra-hepatic manifestations, or prolonged
wait anticipated.
• Hepatology and Transplant Teams must have good communication
to allow patients to get potential advantage of shorter wait times
with HCV kidneys.

19. New Generation DAAs
• Within past couple years.
• Sofosbuvir combined with
– Daclatasvir
– Semeprevir
– Ledipasvir (Harvoni)
– With or Without Ribavirin
• Has been shown to be effective in treating HCV patients in cirrhotic and non cirrhotic immuno-
competent patients, liver transplant recipients, and combined liver kidney transplant patients.
Lawitz E, et al. NEJM, 2014.
Afdal n, et al. NEJM, 2014.

20. May 2016

21. Results – Week 12 Virologic Response
• At 12 weeks, HCV RNA was undetectable in ALL patients.
• At 4 and 12 weeks after DAA was completed, HCV viremia was
negative.
• The SVR at 12 weeks after completing therapy was 100%.
• At 24 weeks after DAA was completed, data was available for
8 patients – all 8 had SVR.

22. Efficacy and Safety of Sofosbuvir‐Based Antiviral Therapy to Treat Hepatitis C Virus Infection After
Kidney Transplantation
American Journal of Transplantation
Volume 16, Issue 5, pages 1474-1479, 20 NOV 2015 DOI: 10.1111/ajt.13518
http://onlinelibrary.wiley.com/doi/10.1111/ajt.13518/full#ajt13518-fig-0001
EOT = END OF THERAPY

23. Discussion
Rapid virological response defined by undetectable viremia
at week 4 after starting DAA therapy, in 88% of patients.
All patients were cleared of the virus after completion of
therapy
SVR at 100% at 12 weeks after completion.
Anti HCV is safe and no drug-drug interactions were
observed.

24. UCI Experience
• In the past 2 plus years, UCI has done 10 Hepatitis C
kidney transplantations.
• All 10 patients have completed treatment with new Hep
C treatment medications and are now Hepatitis C PCR
negative.
• 3 patients were transplanted within the same
week as being listed.

25. UCI Strategy
• Prior to Zepatier, treating ESRD patients with Hepatitis C was
difficult. Now that Zepatier has been introduced, many ESRD
patients are being treated for Hepatitis C, thereby losing
their transplant shorter wait time advantage.
• In 2016, w e called every single Hepatitis C patient on our
waiting list and explained to them the dynamics and in most
cases, treatment has been delayed until after transplant.

26. UCI Hepatitis C Experience
• 3 of our patients were planning to start Zepatier by their hepatologist,
but we stopped them. They got transplanted first, and have been since
treated after.
• We also have had at least 5 patients who were unable to get Hep C
kidneys because they were ALREADY treated for their Hep C, and now
face a dialysis waiting time of 8-10 years.
• 1 of these patients, we elected to treat first because of how advanced their
disease was.
• The rest were either treated before we got to them or were told by another
center they needed to be treated first, only to be declined there later.

27. Hepatitis C Organ Selection
• Because there are much fewer Hep C Waitlist patients, we can be
patient about which Hep C organs we want to take for our patients.
These tend to be very good kidneys, other than the Hep C infection.
• Currently, we do not have any Hepatitis C wait listed patients at UCI
because we zeroed out our Hepatitis C waiting list.
• One of our most recent Hep C Transplant patient was a patient who
found out they had Hep C during our pre transplant evaluation, and
they have since already been transplanted.

28. If I was on HD, should I just
get Hepatitis C, so I don’t
have to wait as long ???

29. Transplanting Hepatitis C Kidney into
non-Hepatitis C Recipients

30. Transplanting Hep C Kidney into non-Hep C Recipients
More than 500 high quality Hepatitis C kidneys are discarded annually.
Direct acting antiviral agents which are associated with high HCV cure rates have
created the potential to substantially increase the number of kidney transplants by
making HCV infected kidneys available to non-HCV infected recipients.
University of Pennsylvania Transplant Researchers recently published some of their
recent work looking at transplant Hep C kidneys into non-Hep C recipients.
• Yes, you heard that right!!!
• It was published in New England Journal of Medicine last month.
• Of note, a similar trial is going on at Johns Hopkins, as well.

31. NEJM Correspondence 4/30/17

32. Study Highlights
• In this open-label, single-group, pilot trial at the University of
Pennsylvania, the authors sought to determine the safety and
efficacy of transplantation of kidneys from HCV genotype 1–
viremic donors into HCV-negative patients, followed by
elbasvir–grazoprevir (Zepatier) treatment.
• Zepatier has not been FDA approved for genotype 2 or 3, so
these donors were excluded from the study.

33. Study Highlights
• The HCV viral load was measured in recipients on
postoperative day 3; elbasvir–grazoprevir was initiated
when the results became positive, and therapy was
maintained for 12 weeks.
• 10 patients received Hepatitis C Kidneys
• By day 3, all had tested positive for HCV viral load
• All recipients achieved SVR after 12 weeks of therapy.

35. Future Possibilities ?
• Transplanting Hepatitis C organs into non-Hepatitis C
recipients may be a difficult sell
• One thing to realize is that the amount of non-Hep C patients
waiting for kidneys is quite high, so this may increase donor
pool, but unlikely to lead to dramatic change in wait times.
• Treatment of Hep C with Direct Anti-viral Agents is extremely
expensive, and insurance companies may thwart attempt to
treat such patients receiving voluntary Hep C organs.

36. Final Thoughts on Hepatitis C
• With current Hep C treatment options, patients that have ESRD
and Hep C should likely wait until AFTER transplantation before
getting treatment for their Hepatitis C.
• Shorter Transplant wait times (1-2 years vs 8-10 years) is the
primary reason, if their clinical condition does not necessitate
urgent treatment.
• Transplanting Hep C organs into non-Hep C patients may not be
the answer. But ongoing data is being accumulated.

37. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplants
• HIV Transplantation

38. Public Health Service Increased
Risk Kidneys

39. PHS Increased Risk Kidneys
• In July 2013, the U.S. Public Health Service (PHS) published new guidelines
for reducing human immunodeficiency virus (HIV), hepatitis B virus (HBV),
and hepatitis C virus (HCV) transmission through organ transplantation.
• These new guidelines, called "increased risk" guidelines, replaced earlier
guidelines from 1994 called "high risk" criteria.
• The phrase "increased risk" refers to the donor characteristics that could
place the potential recipient at increased risk of disease transmission.
– The phrase is not a reference to organ quality, nor should it be interpreted to
be a predictor of graft survival.

40. PHS Increased Risk Kidneys
• A potential organ donor may be labeled as increased
risk for a variety of different exposures, and these
exposures carry different risks of transmitting recent
infection with HIV, HBV, or HCV.
• Helping transplant patients understand the potential
risks of disease transmission from increased risk organs
versus refusing an organ for transplant is an important,
but challenging topic.

41. What constitutes PHS increased risk?
PHS Risk Factors PHS Risk Factors
MSM in past 12 months Child less than 18 months and born to a mother who either
has or is risk for HIV, HBV, HCV
IV drug use in past 12 months Child who has been breastfed in the past 12 months by a
mother who either has or has risk factors for HIV
Sex for money in past 12 months Someone who has been to jail or correctional facility for
more than 72 hours in the past 12 months
Sex with someone with HIV, HBV, HCV in the past 12
months
Diagnosed or treated for syphillis, gonorrhea, chlamydia,
genital ulcers in the past 12 months
Woman who had sex with a man who had MSM behavior
in the past 12 months
People who have been on hemodialysis in the past 12
months
Sex with someone with had sex for money/drugs in the
past 12 months
When donor risk factors are totally unknown
Sex with someone who injected IV drugs in the past 12
months
When potential organ donor blood specimen is hemo-
diluted

42. PHS Increased Risk Kidneys
• Since implementation of the new policies, the number of potential deceased
donors classified as increased risk has increased to almost one in five donors
nationally.
Kucirka, LM, et al. AJT. 2015.
• Research studies have demonstrated that organs from donors classified as
increased risk are less likely to be used than organs from non-increased risk
donors.
Duan, KI, Englesbe, MJ, Volk ML, AJT. 2010.
• This finding persists despite the fact that post-transplant graft and patient survival
with increased risk organs is equal to or better than that with non-increased risk
organs.

43. PHS Increased Risk Features
• The increased risk donor classification serves principally to identify those donors
most at risk of having recent infection with HIV, HBV, or HCV.
• Increased risk donor classification does not mean that the organ is of lower quality.
• Choosing to accept an organ from an increased risk donor entails balancing donor
and recipient characteristics. In many cases, the risks of declining such an organ
offer may be greater than the risk of donor-derived viral infection.
• The risk of window period infection with HIV, HBV, or HCV, and therefore the risk of
virus transmission from donor to recipient, is extremely small if a risk behavior
occurred more than three weeks prior to NAT.

44. PHS Increased Risk Features
• There is wide variation in viral transmission risk even within donors
classified as increased risk donors. Donors with a history of incarceration or
less safe sexual practices are generally much lower risk than donors with a
history of intravenous drug use (IVDU).
• Even under the highest risk behavior, the risk of HIV, HBV, or HCV
transmission from a NAT negative donor organ is low (around 1% or less).
• Ultimately, with appropriate counseling and informed consent, we aim to
maximize organ availability.

45. RISK

46. UCI Experience
• We consent close over 95% of our patients with PHS increased risk
kidneys.
• We are aggressive in taking PHS increased risk kidneys compared to other
programs
– One area where we may decline is if there is suspicion of active IV drug use
(track marks, found with needle)
• If patients get PHS Increased Risk kidneys, we check the recipient
serologies at time of transplant, 4-6 weeks after transplant, and 1 year
post transplant to evaluate for disease transmission.

47. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplants
• HIV Transplantation

48. What Is KDPI?
The Kidney Donor Profle Index (KDPI) is a numerical
measure that combines ten donor factors, including clinical
parameters and demographics, to summarize into a single
number the quality of deceased donor kidneys relative to
other recovered kidneys.

49. Factors that affect KDPI
• Age
• Height
• Weight
• Ethnicity/Race
• HTN
• DM
• Cause of Death
• Creatinine
• HCV Status
• DCD donor

50. Assessing KDPI
• Though it is impossible to predict the longevity of any
particular transplant, it is generally thought that the lower
the KDPI, the better the kidney.
• KDPI <20% (the best kidneys) are typically reserved for
younger, healthier recipients
• KDPI >85% are typically used in recipients who tend to be
older, who stand to benefit more by getting off dialysis.

52. UCI Experience
• Not all KDPI >85% are necessarily “bad”
• Thorough analysis of high KDPI cases with frequent request for
biopsy to help make educated decision on whether to accept
kidneys or not.
• Patient are counseled and consented for KDPI >85% when deemed
appropriate.
• Rapid growth over past 2 years has included higher acceptance of
KDPI>85% kidneys. Outcomes have remained good.

53. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplants
• HIV Transplantation

54. Directed Kidney Donation

55. Directed Donation
• If a family of a potential deceased donor has a patient in
mind they would like to offer the kidney to and that
patient is on the kidney transplant waiting list, they can
do a directed donation
• Directed donation bypasses the waiting list order, and
the directed donor recipient moves to the top of the list.

56. UCI Experience
• Over 5 directed donations in the past year alone
• Patients are educated about directed donation
• The more people that know about a
patients condition, the higher the odds
of them finding a living or directed donor.

57. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplants

58. Pediatric En Bloc / Dual Kidneys

59. Pediatric En Bloc / Dual Kidneys
• In some very young donors, if the kidneys are
too small (usually <6cm), we tend to transplant
both kidneys together, en bloc.
• The idea is that each individual kidney is too
small, but together, the recipient stands to
gain 2 young kidneys which could last for a
long time.

60. Pediatric En Bloc Kidney Transplantation
• Some programs shy away from pediatric en
block kidneys due to surgical complexity.
• Higher rates of leaks, thrombosis, bleeds,
complications.
• Once patients get through first few months,
outcome tends to be very good.

61. Dual Kidneys
• Sometimes, if programs are not interested in taking 1
marginal kidney, and no one else is interested in the organs,
a Dual Kidney transplant can be done.
• Taking 2 marginal kidneys into one recipient
• Could increase kidney utilization
• Not as prevalent as in the past
• Complexity of organ allocation

62. Dual Kidney Transplantation
• We have not done this at UCI in quite some time
• We are looking at potentially doing more of this
• Will have to work with One Legacy to try this more
• We were considering this on Thursday for a
transplant
• Biopsy of each kidney did not seem adequate enough

63. Outline – Maximizing Organ Utility
• Hepatitis C Kidney Transplantation
• PHS Increased Risk Kidneys
• KDPI >85% Kidneys
• Directed Donation
• Pediatric En Bloc/Dual Kidneys
• Kidney Pancreas Transplants

64. UCI Kidney Pancreas (SPK) Transplantation
• For mostly Type 1 DM patients, but also Type 2
• 7 kidney pancreas transplants in the last year
• UCI with a full commitment to sustained and
continued growth in Kidney-Pancreas
transplantation.
• Dr. Ichii will discuss further…

65. Conclusion
• UCI has achieved tremendous growth in the past few
years.
• Increased transplants to complex recipient population,
advanced age patients, Hep C/HIV patients, etc.
• Increased organ utilization – Hep C, PHS, KDPI>85%, SPK
• Despite increase in volume and complexity, we have
achieved excellent outcomes during this growth period.