There are some new controversies surrounding organ transplantation. In recent weeks I heard two highly respected liver specialists discuss dilemmas they are facing with their patients. Let’s dissect these issues.
Dilemma #1: Should cirrhotic patients with hepatitis C be treated before they need a liver transplant, or wait until they decompensate, get transplanted, and them treat hep C?
Hepatitis C cure rates are better than ever, even among those with advanced cirrhosis. Some of the new hepatitis C antivirals may be used on those with decompensated cirrhosis. However, should they be used? Doctors are rethinking this. New HCV medications are so effective that they are curing hep C, but they are leaving people in kind of a MELD purgatory. (MELD scores are used to determine transplant priority.) Before when a patient’s cirrhosis was Child-Pugh B or C and they had a MELD over15, it was too dangerous to treat their hep C. You just wanted until they decompensated sufficiently to move to the top of the transplant wait list. Now, if you treat them when their MELD is in the 15 to 25 range, with no HCV destroying the liver, they may end up sitting there for a long time. It’s becoming the practice to treat people whose MELD score is <15 (C, Lhild-Pugh A). As for people whose MELD is >15 (Child-Pugh B/C), treat them after they are transplanted.
Dilemma #2: Should we give people the option of being transplanted with hep C-positive organs, or only use these for patients who are already HCV-positive?
There is an organ shortage in the U.S. Current wait times for a cadaver kidney is 3 to 5 years. That means years of staying alive because of dialysis. However, if you have hep C and will accept an HCV-positive kidney, the wait time is weeks. Now that we can cure hep C, should we offer hep C-positive organs to everyone, and then treat them immediately? I must admit feeling conflicted about this. What if someone had a resistant strain and could not be cured? “Do no harm,” is an important principle in medicine. I’m inclined to say no. However, I bet that if I was on the transplant list, I’d elect to take an organ earlier rather than wait, even if it meant an HCV reinfection.
What’s your opinion about these hep C controversies?