Transmitted Donor Immunology Not Infection: Common Persistence of Donor Hepatitis C Antibody Production in Aviremic Lung Transplant Recipients

Since 2018 The American Society of Transplant has recommended that Hepatitis C Virus seropositive positive, non-viremic donors (HCVAb+/NAT-) be considered non-infectious and safe for transplantation. This report describes clinical outcomes and HCV serological and virological outcomes following lung transplantation (LTx) utilizing such donors. This retrospective cohort study describes seven HCVAb+/NAT- donors used for bilateral LTx. Donor information was sourced from the national organ donation service and recipient information from the institutional LTx database. Seven deceased donors (three female, median age 53, range 37-63 years) acquired HCV from injecting drug use (n=4), blood products (n=1), unknown (n=1). Four donors had been previously treated and cleared of HCV (sustained virological response at 24 weeks) before death. Seven recipients (2 female, median age 56, range 51-71 years), with pulmonary fibrosis (n=4), re-do LTx (n=3), were waitlisted a median of 87 days (range 8-362). At post-LTx follow up, six of seven are alive with excellent graft function at a median 1625 days (range 779-2582). No patient developed clinical, biochemical or virological evidence of HCV infection, however five recipients demonstrated persistent HCVAb+ (all consistently NAT-) for a median 414 days (range 332-872) post-LTx. Two patients HCVAb sero-reverted at d731 and d1461. Two other recipients remained HCVAb- at d1621 and d1398 on repeat testing. There was no evidence of HCV transmission to seven LTx recipients from HCVAb+/NAT- life-saving lung donors, however persistent HCV Ab positivity was seen in 5 LTx recipients with two demonstrating remote sero-reversion. We postulate this may be a form of Passenger Lymphocyte Syndrome.