HCV-Positive Kidney Allograft Survival Just as Good at 5 Years

Transplantation of kidneys positive for hepatitis C virus (HCV) resulted in outcomes that were statistically no different than with uninfected kidney transplants, a retrospective U.S.-based cohort study indicated.

No significant differences in 5-year allograft survival were observed between recipients of HCV-positive versus HCV-negative donor kidneys (72% vs 69%, respectively, P=0.47), reported Peter Reese, MD, PhD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.

Mean allograft survival was 4.30 years for the HCV-positive subset and 4.27 years for the HCV-negative subset, the group detailed in their JAMA research letter.

“These findings may provide a rationale for the transplant community to reexamine the Kidney Donor Profile Index (KDPI) penalty,” the team wrote.

“Clinicians should be cautious in extrapolating results to HCV-RNA-positive kidneys that get discarded,” the group cautioned, while noting that “patients on the transplant waiting list should weigh the option of transplant with an HCV-RNA-positive donor kidney.”

“Comparing as closely as we could, adjusting for many covariates, we did not see a difference based on 5-year survival,” co-author Douglas Schaubel, PhD, also of the Perelman School of Medicine, told MedPage Today.

The team explained that before 2016, most HCV-positive kidneys were transplanted only to individuals who already had HCV. Starting in that year, however, the availability of direct-acting antiviral therapy enabled transplant trials of HCV-infected kidneys into HCV-uninfected recipients, “with most trials reporting 100% HCV cure rates and excellent short-term allograft function.”

Uptake has been slow, however, and HCV-positive kidneys still get rejected, Reese told MedPage Today. “Follow-up study has been limited because the numbers are small,” he explained, noting that there are several studies with just 1 year of follow-up. “It took a while for the numbers to go up enough for us to see what 5 years look like.”

Researchers followed up on 45,827 deceased donor kidneys and compared outcomes with HCV-positive (n-2,551) or HCV-negative (n=43,276) kidneys in a cohort of 75,905 kidney recipients from 217 transplant centers. Multiorgan recipients were excluded, along with recipients of repeat transplants and HCV-antibody-positive or HCV-RNA-negative kidney recipients.

When evaluating the characteristics of the HCV-positive donor kidneys, the researchers found that overall that group was younger (median 35 vs 39 years, P<0.001), had better KDPI scores (median 32% vs 47%, P<0.001), and were less likely to be hypertensive, have diabetes, or have died from stroke (P<0.001).

For recipients, those receiving HCV-positive kidneys were older (median age 60 vs 56, P<0.001), weighed more (median 85 vs 81 kg [about 187 vs 179 lbs], P<0.001), and were more likely to have diabetes (P<0.001).

Investigators adjusted for age, race, ethnicity, sex, height, weight, time undergoing dialysis before placement on the waiting list and transplant, malignancy, HCV seropositivity, blood type, calendar year, and transplant center. “If you don’t adjust carefully you can be deceived into thinking that you have better outcomes with hepatitis C-positive donors,” Schaubel noted.

Reese said that HCV-infected kidneys are currently penalized with lower KDPI scores. As a result, kidneys are sometimes discarded, and others are rejected based on stigma. Some health centers are nervous about transplanting an infected organ, and others don’t want the hassle and delays involved in filling out insurance paperwork, he explained.

Despite the availability of antiretrovirals to treat HCV, patients often feel reluctant to receive an HCV-positive kidney — often, it’s because many infected kidneys come from a donor who died of a drug overdose, Reese said, noting that some people have a low threshold for risk in the transplant setting. They might say, “‘I don’t know, doc — sounds experimental to me,'” he said.

There are some cases, however, where an HCV-positive kidney may not be advisable, Reese said — for example, in a patient with fatty liver disease. But, he said, the current study shows there is no added risk of allograft failure associated with HCV transplant, and it’s important to talk to patients about the possibility that there may be a kidney with HCV when their name comes up on the waiting list.

“You need to address this while they are on the waiting list so they have some preparation when the donor comes,” Reese said.