This is an open-label, pilot trial to test the safety and efficacy of transplantation of livers from Hepatitis C seropositive non-viremic (HCV Ab+/NAT-) and HCV seropositive viremic (HCV Ab+/NAT+) donors to HCV seronegative recipients on the liver transplant waitlist. Treatment and prophylaxis will be administered, using a transmission-triggered approach for the first scenario (HCV Ab+/NAT- donors, arm 1) and a prophylaxis approach for the later scenario (HCV Ab+/NAT+ donors, arm 2).

This is a prospective, single center, pilot, open-label study of transplantation of livers of HCVAb+ donors to HCVAb- recipients with subsequent therapy with sofosbuvir/velpatasvir (Epclusa®). Recipients of a liver from HCVAb+/NAT- donors will be in arm 1 (the transmission-triggered arm) of the study. In this arm, the study will monitor transmission of HCV by measuring HCV RNA in liver transplant recipients. If HCV RNA is detected, indicating transmission of HCV, recipients will be treated with sofosbuvir/velpatasvir (Epclusa®) for 12 weeks. Virological response will be assessed at 4 weeks, end of treatment and 12 weeks after completion of therapy.

Recipients of a liver from HCVAb+/NAT+ donors will be in arm 2 (the prophylaxis arm) of the study. In this arm, patients will be started on a 12-week course of sofosbuvir/velpatasvir (Epclusa®) immediately post-operatively and will undergo close monitoring of HCV RNA for evidence of transmission.

To be eligible for the study, subjects need to be listed for liver transplantation, be not infected with HCV, HBV or HIV, and sign informed consent.

Inclusion criteria (recipients):

1. Patients with end-stage liver disease listed for liver transplantation at UPMC.
2. Age ≥ 18
3. No available living liver donor
4. Listed for an isolated liver transplant at UPMC
5. Have panel reactive antibody level of <98%
6. Able to travel to UPMC for routine post-transplant visits and study visits for a minimum of 12 months after transplantation
7. Able to provide informed consent
8. Be willing to use a contraceptive method for a year after transplant

Exclusion criteria (recipients):

1. HIV positive
2. HCVAb or HCV RNA positive
3. Presence of behavioral risk factors for contracting HCV. These behavioral risk factors are current injection drug use, current intranasal illicit drug use, current percutaneous/parenteral exposures in an unregulated setting.
4. Hepatitis B surface antigen positive
5. History of atrial fibrillation requiring the use of amiodarone over the past 12m
6. Receipt of prior organ transplant
7. Waitlisted for a multi-organ transplant
8. Pregnant women
9. Known allergy to sofosbuvir/velpatasvir
10. Any condition, psychiatric or physical, that in the opinion of the investigator would make it unsafe to proceed with transplantation or interfere with the ability of the subject to participate in the study

Inclusion criteria (donors):

1. HCV antibody positive
2. HCV NAT negative or positive

Exclusion criteria (donors):

1. Confirmed HIV positive (positive HIV-1 antibody, positive HIV-2 antibody, positive p24 antigen and/or positive HIV NAT)
2. Confirmed HBV positive (positive hepatitis B surface antigen and/or HBV NAT)
3. Known ongoing therapy for HCV

We do not plan to share individual patient data outside of our investigative team. Aggregate data will be shared in publications as appropriate.

From transplant until end of follow-up, up to 5 years.

For this study, AEs are recorded and reportable only if study related or unexpected. Study endpoints (detection of HCV RNA, rejection, graft loss, mortality) and certain pre-specified expected events commonly seen in this population will not be reported as serious adverse events even if they meet the serious event criteria.

The limited sample sizes (n=1 and n=4) preclude valid statistical inference; accordingly, analyses are restricted to descriptive reporting.