Hepatitis C (HCV) is a worldwide health problem. Effective therapies for HCV infection, coupled with an increase in deceased donors due to the opioid epidemic has led to broader availability and use of HCV infected donor organs, including HCV nucleic acid test positive (NAT+) donors in HCV negative recipients. In this review we discuss the prevalence of HCV infection, trends in the use of HCV infected donors and outcomes for those who receive HCV seropositive or HCV NAT+ donor organs. We discuss management considerations such as Hepatitis B reactivation, selection of the optimal direct acting antiviral regimen and potential complications. We also present a framework for the rational use of HCV infected donor organs in the future.