Why hepatitis C-positive kidney transplants are giving ailing veterans hope

IOWA CITY - Three months after receiving his kidney transplant, Jack Jones Jr. returned to the Veterans Affairs Hospital in Iowa City for his checkup.

Jones, a U.S. Navy veteran, still isn't able to fish, which is a favorite pastime for the 61-year-old from Asheville, N.C. But despite that, the pep in Jones's step wasn't gone during his appointment in late June.

Lab results from his checkup showed Jones was negative for hepatitis C, a viral infection that causes inflammation of the liver.

Not only is that good news for Jones as a patient, but it presents a potential shift in the transplant program at the Iowa City VA Health Care System.

Earlier this year, a medical team at the VA introduced a new option for patients waiting for kidney transplants - kidneys that tested positive for hepatitis C.

Organs with hepatitis C traditionally have not been used in transplant procedures across the country. But recent research has shown the medical staff in the Iowa City-based hospital that the procedure is a safe option for patients - and one that could allow waiting recipients to get the organs they need faster.

'What if I told you we did that, we could get you a kidney three years faster than being on dialysis for three more years? Because we can treat the hepatitis C and cure it,” said Dr. M. Lee Sanders, a nephrologist on the VA transplant team.

In March, the team placed hepatitis C-positive kidneys into four veterans and immediately began treatment for the viral infection - making the Iowa City VA one of only a half-dozen facilities nationwide that has offered the procedure.

In June, those four patients - including Jones, the first to receive a kidney, on March 8 - returned to the Iowa City VA for their three month post-transplant checkup. All were negative for hepatitis C infection.

VA doctors are hopeful this could open the doors for patients on the organ transplant list, but challenges with insurance may prevent this option from going beyond the VA Health System.

'Even though it's been shown to be safe and effective, it's not getting adopted widely in the private sector because there's a disconnect between the dialysis world and the transplant world,” said Dr. Daniel Katz, transplant surgery director for the Iowa City VA.

OPENING THE DOOR

For awaiting kidney transplant candidates, the risk associated with kidney failure is greater than the risk associated with hepatitis C, the VA transplant team said.

'It's known that people who qualify for transplant have a better quality of life and they have less mortality,” Sanders said.

Hepatitis C is the most common chronic blood borne infection in the United States, and causes inflammation of the liver, according to the Centers for Disease Control and Prevention. The CDC estimates 2.4 million Americans are living with the viral infection.

The concept of using hepatitis C positive organs in transplant surgeries has been around for some time, but was limited to patients that already had the infection.

Before 2014, there was no effective treatment for hepatitis C. Treatments that did exist had harsh side effects and were not always effective, said Dr. Randhir Jesudoss, a gastroenterologist on the transplant team.

The introduction of better treatment options for the infection in 2014 changed the discussion. Oral medication therapy taken over an 8-12 week period offered a cure for many, Jesudoss said. According to the CDC, more than 90 percent of infected people can be cured with these medications.

'That opened up the door for taking hepatitis C-positive kidneys and putting them into hepatitis C-negative patients,” Katz said.

One study conducted by the University of Pennsylvania - and published in the New England Journal of Medicine - helped confirmed that possibility. Researchers found that of 10 patients that received infected kidneys and were treated for hepatitis C, all were cured.

After transplanting infected kidneys into the four veterans, the Iowa City VA team opted to treat recipients immediately for hepatitis C after the surgery, instead of waiting to see if the patient is infected.

'We think that we've kind of built a little bit better mousetrap where we've improved upon the treatment algorithm, in my opinion,” Katz said. ' ...

We think that we're erring really on the safety side by designing it the way we have.”

The transplant team started their initiative with recipients who already had been cured of hepatitis C. Jones was cleared of the infection - which doctors believe he received sometime during his service - about two years ago.

Jones volunteered for the procedure without any hesitation because he wanted that kidney 'in a bad way.”

'I love to 'coon hunt, I love to hunt deer, I love to fish,” he said. 'I couldn't do all of that on dialysis.”

Jones's wife Martha Jones, 60, said she's noticed a significant improvement in her husband since his surgery.

'He's got something to live for now. He's ready to get out there and live his life,” she said.

'Before for so long, he was not there. He was getting a little depressed. I tried to get him out of it every time, but I could tell he was a little depressed.”

‘THERE'S A COST SAVINGS'

This procedure also can ease the shortage of available organs.

As of July 1, more than 500 candidates in Iowa are awaiting a kidney transplant, according to the Organ Procurement and Transplantation Network.

Waiting times for kidney transplants exceed three to five years in many parts of the United States, 'yet more than 500 high-quality kidneys” from deceased donors with hepatitis C are discarded annually, according to a 2017 article in the New England Journal of Medicine.

More organs have become available in recent years, experts say, in part caused by the nation's opioid epidemic, experts say. The CDC estimates opioids were involved in 47,600 overdose deaths in 2017.

Some heroin users share needles, leading to a 400 percent increase from 2004 to 2014 in acute hepatitis C among 18- to 29-year-olds, according to the CDC.

Other VA transplant centers in Wisconsin, Virginia, Oregon, Tennessee and Pennsylvania also offer hepatitis C positive donor organs to uninfected recipients.

But the Iowa City transplant teams says they don't expect many transplant centers outside VA hospitals nationwide to take on this procedure.

Oftentimes, insurance companies do not cover the high cost of the medications to treat hepatitis C. Insurers, however, will cover the cost of dialysis - the treatment for declining kidney function.

As a single-payer system, the VA finds covering the cost of a transplant and hepatitis C treatment is more cost effective than covering dialysis over a long period of time, Katz said.

'What happens when you transplant somebody relatively soon and get them off dialysis, there's a cost savings,” Katz said. 'Even though the transplant is sort of expensive, it's not as expensive as keeping somebody on dialysis.”

According to the University of California, San Francisco, Medicare pays on average $90,000 per patient annually for dialysis treatment. The average cost of a kidney transplant is $32,000 for the surgery and $25,000 post-surgery care.

'If the insurance company doesn't pay for it, then these patients are stuck with the virus,” Jesudoss said. 'The beauty of the VA system is that we have all these medicines here and we're able to give it to them.”

By the numbers

Here are the number of hepatitis C-positive organs that have been procured and transplanted into patients since 2015, according to data from Organ Procurement and Transplantation Network. The data does not specify whether the patient also was infected by the hepatitis C virus.

2015

' All organs: 495

' Kidneys: 266

' Livers: 225

2016

' All organs: 731

' Kidneys: 382

' Livers: 339

2017

' All organs: 821

' Kidneys: 359

' Livers: 363

2018

' All organs: 1,204

' Kidneys: 542

' Livers: 402

2019 (as of May 31)

' All organs: 292

' Kidneys: 147

' Livers: 79

' Comments: (319) 368-8536; michaela.ramm@thegazette.com