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Last gasps of the hepatitis C virus dragon: Direct acting antiviral failures and hepatitis C virus–positive donors

1. Transplantation of hepatitis C virus (HCV)donors to HCV-positive recipients appears well tolerated and effective, but is underutilized. 2. The use of highly effective and very well-tolerated direct antiviral agents against HCV in the setting of liver transplantation (LT) has many potential implications, such as improving graft and patient survival, reducing the need for LT in a proportion of patients, and allowing a broader use of antiHCV-positive organs, possibly including also their use in uninfected HCV-negative recipients. 3. The use of anti-HCV–positive organs into uninfected HCV recipients will need to be balanced against (i) HCV treatment costs; (ii) risk of HCV treatment failure after transplant; and (iii) risk of death on the waiting list. 4. HCV treatment failure with new oral combinations rarely occurs in the general population and mostly concentrates in the subset of patients at need for LT due to advanced liver disease with portal hypertension and prior antiviral exposure. 5. Strategies to approach treatment failure before and after LT include the use of newer combinations, switching the class of direct antiviral agents, the use of continuous sofosbuvir therapy to the time of transplantation, and the use of interferon and sofosbuvir-based therapy.