Together, the long waiting times for solid organ transplants, high rates of discard of organs from deceased donors with hepatitis C virus (HCV), and advent of directacting antiviral (DAA) agents have created a dialogue about the use of organs from HCV-positive donors for HCV-negative recipients. 1 In this issue, Trotter et al2 examined this topic in 3 parts: first, how many potential donors in the United Kingdom are ruled out due to HCV-positive or injection drug use status? Second, what were the trends in utilization versus discard of recovered HCV-positive deceased donor organs in the United Kingdom? And third, what is the cost-effectiveness of transplanting kidneys from HCV-positive deceased donors into HCV-negative recipients? To quantify the potential increase in transplants if HCV-positive donors were not ruled out because of the HCV status, Trotter et al2 studied the UK Potential Donor Audit, a registry of all individuals younger than 80 years who die in critical care units in the United Kingdom. They found that 120 individuals in the Potential Donor Audit between 2009 and 2016 were not considered as potential donors solely due to injection drug use or HCV-positive status. A limitation in this step was the lack of laboratory testing to identify HCV antibody versus RNA status of potential donors. Trotter et al2 then examined 244 HCV-positive deceased donors in the UK Transplant Registry between 2000 and 2015, of whom only 31% proceeded to donation. The quality of declined organs did not differ from the quality of transplanted organs, and the reason given for declining was positive HCV status in 69% of offers. Patient and graft survival were no different for recipients of kidneys and livers from HCV-positive donors compared to HCV-negative donors. Finally, to examine the cost-effectiveness of treating transmitted HCV in recipients of kidneys from HCV-positive donors, cost of sofosbuvir and ledipasvir along with costs of renal transplantation were compared with the cost of hemodialysis. Transplantation with use of DAAs was cost-neutral with continued hemodialysis after 5 years. Importantly, this cost analysis examined 1 approved DAA regimen (sofosbuvir and ledipasvir for 12 weeks) in the United Kingdom; however, other approved DAA regimens and pricing in other countries may lead to a faster “break even” point. 2 Furthermore, Trotter et al did not consider the mortality difference between hemodialysis and transplantation, and thus certainly underestimated the benefit in increased years of life after transplantation. In the United States, these questions must be considered in the context of recent consensus guidelines from the American Society of Transplantation, which include projections of availability of HCV-positive donors. 1 These donors are anticipated to be from 2 broad groups: baby boomers with chronic HCV and younger people who inject drugs. 1 In the setting of the opioid epidemic in the United States, 3 current estimates of 300 to 500 additional HCV-positive donors per year might be expected to increase over time. 4 Although it is an accepted practice to transplant livers and kidneys from HCV-positive donors to HCV-positive recipients as a way to decrease waiting time and adverse waitlist outcomes substantially, 1 less is known about transplantation to HCV-negative recipients5 and transplantation of other organs from HCV-positive donors. 6, 7 To assess the safety and efficacy of DAA treatment in HCV-negative recipients of kidneys from HCV-positive donors, there is ongoing study by 2 groups in the United States. 8, 9

At the University of Pennsylvania, Goldberg et al8 conducted a pilot trial (Transplanting Hepatitis C Kidneys into …