Jorge Reyes, M.D., is a board certified surgeon, University of Washington Medicine’s Chief of Transplant Surgery, Medical Director for Life Center Northwest, UW’s Roger K. Giesecke Distinguished Professor in Transplant Surgery, a Professor of Surgery, and adjunct Professor of Pathology, talks about finding the cure for Hepatitis C, and how this has expanded the ability to match patients in need of organ donations with otherwise perfect organ matches, aside from being Hep C positive.
Interview conducted by Ivanhoe Broadcast News in November 2019.
Tell us a little bit about that Pepsi donated organs. It’s kind of new and different.
Dr. Reyes: It’s new and it’s not new. We’ve been using Hepatitis C donor organs for some time. But in very unusual or unique situations, it’s the first one being patients who already have Hepatitis C that have not responded to treatment whereby they would be getting a Hepatitis C organ and then after transplant be treated. But treatment let’s say five years ago was not good, for many patients it was a very arduous treatment. Many patients didn’t respond and Hep C can be varying shades in terms of the types of viruses within the Hep C group. So we were very cautious and specific about using it clearly to save somebody’s life. On some occasions, which are also very unusual, we would use Hep C or Hep C liver in somebody with acute liver failure who sometimes has less than a day to live. The only organ potentially available would be a Hep C positive donor, and it was done before, it’s done now. But we had not done it, though we would have if we were in that situation.
How did the idea come about to use a Hep C organ with somebody who didn’t have Hep C?
Dr. Reyes: This is where the exciting part is, where on many occasion over my life in transplantation we would have a situation where it was a Hep C donor and nobody would use the organ. And when you went there to procure other organs, the delivery looked great, or we would use a Hep C positive donor in other patients that had Hep C already. Again these donors looked completely normal and their biopsies look normal. So we’ve known for a while that patients can be exposed to Hepatitis C and then resolve it on their own. And many of those patients did not have circulating virus. The first step in the development of this knowledge and experience was the ability to test for circulating virus by a test called a PCR, and we could. That was introduced maybe about eight plus years ago. Once we were able to detect that we could be more specific with the use of Hep C positive donors, and we started using just the Hep C antibody positive where there was no circulating virus. Then when we had the test we knew which ones were for Hepatitis C with circulating virus, those organs we would avoid. But always in the background of this wanting to be more aggressive; we knew that they were going to find a cure to Hep C. I mean everybody was talking about it; it was just a matter of time. And when it happened, when these new drugs came about it was truly amazing. It was amazing the efficacy of the drug therapy and how quickly the cure would be achieved. And with such a high rate of cure it was just very exciting. Previously there were lower rates of the cure with long months and months of therapy. Some patients were even just too sick to be treated. With this new treatment and with our new technology of being able to detect virus in the blood of any potential person and specifically donors… The idea to move forward with this was in the minds of all transplant surgeons. Interestingly the heart teams were the first ones to take the first steps because the selection criteria for all the other thing other factors for a successful heart were so specific that to turn down an organ that was otherwise perfectly great except for the history of Hepatitis C was for them to, forgive the pun, heart wrenching. So they took the first step. We were, I was very happy when they did that. And with our herpetologist and in a group team fashion, we went through the steps of, well, how do you conceptualize this because again none of this is research right? We already know that the cure is there. We’ve already previously used Hepatitis C organs anyway in other in other fashions and the weightless mortality was very high for the heart. So they were able to through our team meetings and also with a very focused work on our hematology team, because they’re the ones that really understand this disease. And it’s certain complexities in our excellent infectious disease team. We have one of the best ID teams specifically for transplant in the country who have already developed paradigms for follow up of patients accepting high-risk donors. So we had all that in place in terms of follow up in the staffing etc. Then the protocol was put together by the team and they initiated it.
12 patients so far that have received circulating Hep C have lived and survived the programs. Is that right?
Dr. Reyes: Five hearts and seven livers, a total of 12. All of them received organs from patients from donor patients that had circulating virus. Viruses are highly specialized, being of sorts and perfectly designed to infect and replicate. So the understanding how it does that, that’s in the structure of it. And that leading to the ability to detect a virus is kind of like detecting a needle in a stack of needles. It was fascinating actually. You’re a Hep C positive, you develop an antibody, and you have the circulating virus by the PCR that will infect. It’s there to infect, that’s its job. It’s circulating it’s ready to infect. But these donors for some reason have lived in this symbiosis of circulating virus. Their immune system is kind of like sort of taking it and keeping them at bay. And then they have this devastating trauma or what have you become donors. So yes, they have twelve patients certainly in virus transplanted, infected that then undergo planned treatment. So we know they’re gonna get infected, they will be treated as soon as feasible. You know they’re recovering from surgery, starting the treatment, and most of them are cured. Some are still have ongoing treatment, and there was one patient that had complications, your standard transplant complications that was not able to undergo treatment.
So he wasn’t able to undergo treatment. So he still has Hep C?
Dr. Reyes: That patient did not survive.
It’s kind of amazing especially in a world where there aren’t enough organs to donate.
Dr. Reyes: It’s amazing because of that. You know when I was growing back in the late 80s, most donors were younger than 45 years old. A donor older than forty five was expanded criteria. That’s an old donor. So things have changed a lot because you know the list has grown. Success has generated more indications for transplant and disease or epidemiology of lifestyles, particularly young adults have resulted in more disease. Then now we have this epidemic of drug abuse and substance abuse, high-risk social behaviors that result in exposure to these infections. And as early as ten years ago nobody would be looking at donors from this patient population just based on their social behavior because there was such high risk for potentially transmitting disease. But this is where the testing for viruses came about where in order to be able to explore this we need to be able to say that these patients do not have circulating virus.
What do your surviving patients from the program say about having this? Were they hesitant going in or just grateful to have an option?
Dr. Reyes: That’s a good question. In my experience with liver patients, at first you get this negative reaction. And then you explain their situation and the situation of organ donation in general, and their likelihood of getting transplanted or not. You know whenever we start talking about transplantation with any patient. Today for example I had a conversation about a patient that was being evaluated for transplant. And my first question to him… Aside from hi how are you? My name is Dr. Reyes. I’ve gone through all your history and I have one question for you to begin with which is, do you think you need a live transplant? At first a patient might respond well you’re the doctor. You tell me. No, you’ve seen many doctors already and you know we’re here to discuss an already advanced part of this process. But I need to know from what you feel; do you want a liver transplant? Do you understand the risks? And are you willing to undergo those risks. The use of Hepatitis C organs is an added risk, you kind of prepare the discussion prepare their mindset of if I don’t get a transplant, I will die of liver disease. If I do get a transplant I have in our program a ninety five percent plus chance of doing very well, surviving the transplant and doing well. You know in the balance of things I’d rather have the transplant. Then we go into the conversation of organ availability and then the need to get them sooner than later depending on the patient and their disease. And again gradually becoming a team with where my job is to get them an organ. That’s my job; transplant surgeon – my job is to get them an organ put it in effectively and get then get them home. And the Hep C question is again risk benefit, now the excitement of all this is that I can say that with our team is that we can cure it. I just need to put in a healthy liver to get them out of this bad situation that they have with their liver. So they understand and I have not had anybody say I don’t want to have Hepatitis C.
You’ve been running this program for over a year?
Dr. Reyes: A little over, I always think of well when we actually started talking about it, the many meetings that the teams went on in times, a little bit more than a year. The start time was a year. Preparation and then talking to our administrative leaders, financial concerns, insurance companies. What do you want to do? You want to do what? And you know is it ethical, things like that. All these questions. So our ethics teams. What do you think?
Do you see expanding the work or can it be expanded?
Dr. Reyes: Absolutely. I think that if we have a donor who has Hepatitis C positive and with healthy organs all those organs should be used. All of them. Again we’re using these organs in patients who are what we call Hepatitis C naïve, so they are Hep C negative. They have never been exposed to Hepatitis C, but their risk of dying of their liver disease or their heart disease etcetera is very high. So they’re willing to take that risk.
What you were talking earlier about risky behavior and drug use. Is this a spinoff of the opioid crisis or not really?
Dr. Reyes: Yes and no. We’ve been dealing with these situations since the Vietnam era. You know war is a terrible thing but we send our men out there to different countries etcetera. And they get wounded, but they also acquire disease and bring back disease. In the days when I would start doing transplants and they need blood transfusions we could detect Hepatitis B and Hepatitis A; we had a test. But there were clearly liver diseases or diseases that were hepatitis, it looked and acted like a viral induced Hepatitis but we didn’t know what it was. We used to call it None A and None B and eventually ended up with Hepatitis C, very unique and very aggressive. But even in those days, Vietnam era, culture is changing differently after World War 2 and the drug abuse, alcohol abuse, etc. were at a different height of epidemic proportions where it is a serious problem. There are more and more donors, regardless of being Hepatitis C or A or B positive, there are more donors that are becoming donors because of this problem.
What else haven’t I asked you about the program. The Hep C donors that we should get the story that I haven’t asked yet?
Dr. Reyes: I deal with pediatric transplants as well and we have a hard time finding organs for children. And yet we are using expanded criteria donors in children as well because there is that. You ask me how patients respond, it’s a very interesting question. Even though I tried to make it a general response that they were okay with it, it is different. But it’s always very positive. It’s difficult for us who are for now healthy, it’s difficult for us to see how they would jump into something like this. It’s like what? And I’ll give you an example. We had a conference this year, earlier this year, the American transplant conference. And I was giving a talk about a certain type of expanded criteria donor in children. It wasn’t Hep C but it was something else. And after our lectures we asked the attendees, which were pediatric nephrologists and pediatric hematologists what they thought. And there was a lot of no no no, they need the best organs etc. etc. Well they do, but how long do you wait for the best organs? One nephrologist, she’s a very good nephrologist, I’ve known her for years, she said you know I’ve been against this for a long time. But recently we had a donor that our pediatric patient, an adolescent came up for. And I explained to them that this was not an ideal donor I would understand perfectly if they declined the offer. And their response was what time do you want us to be here? They had no questions. They just wanted to know when should they be there. So in the end organ disease is really a horrible situation for our patients. And you think dialysis, well there’s dialysis but being on dialysis is really hard. It really is hard. Then you have these patients, those heart patients that are on these mechanical hearts and bowel bags and stuff like that. Just watching them is very, very hard.
What’s the next step with the donor program?
Dr. Reyes: There are teams in the country that are using in the kidney. Our team has not started that yet. But for example if we have a patient that’s waiting for a liver and a kidney we would use a Hep C positive donor. But if it’s for the isolated kidneys, that we have not started yet. Our wait time for kidneys is very short compared to the rest of the country. So our team is waiting for analysis of more results because we know that patients with Hepatitis C that have liver disease, there is an impact on the kidneys, there is an effect. There is pathology of the Hepatitis C virus in the kidney. So they just need a little more information for them to see what the outcomes are in other centers that are doing it for the kidney to then proceed.
But the biggest thing is that Hep C is now curable.
Dr. Reyes: Right.
Is the only reason the donors are positive in Hep C is they don’t know they have it, otherwise they’d be cured of it?
Dr. Reyes: Yes.
So these recipients are not living with Hep C their whole life after, they’re cured of it. And the donors would have been cured if they knew they had it in the first place.
Dr. Reyes: Right. So with our protocol and the experience we have in these 12 patients, we have cured all of our patients. There are only a couple that are in treatment still. They just started treatment but all the patients that have completed treatment are cured of Hepatitis C.
END OF INTERVIEW
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