Transplanting Hepatitis C-infected kidneys is cost-effective and safe

Transplanting hepatitis C virus (HCV)-infected kidneys into patients infected with the virus is cost–effective and these kidneys can be safely transplanted into uninfected recipients, according to the results of two new studies.

In one study, transplanting HCV-infected kidneys increased quality-adjusted life expectancy and reduced costs compared with transplanting HCV-uninfected kidneys into HCV-infected patients. In the second study, donor HCV-positivity did not meaningfully harm the quality of transplanted kidneys.

Direct-acting antiviral combinations are approved for chronic HCV infection in patients with end-stage renal disease (ESRD). Some patients are willing to accept kidneys from HCV-positive deceased donors in order to shorten their wait times. Many kidneys from HCV-infected donors are discarded in part because they are thought to be of lower quality.

To examine whether it is more cost-effective to transplant HCV-infected or HCV-uninfected kidneys into HCV-infected patients, researchers at the University of Cincinnati, led by Mark H. Eckman, MD, developed a decision analytic model to estimate the comparative effectiveness and cost-effectiveness of the two options.

The results show that transplantation of an HCV-infected kidney followed by HCV treatment was more effective and less costly than transplantation of an HCV-uninfected kidney preceded by HCV treatment, largely because of longer wait times for uninfected kidneys. A typical 57.8-year-old patient receiving hemodialysis would gain an average of 0.50 quality-adjusted life-years at a lifetime cost savings of $41,591.

“In an era of increasing success for kidney transplants and demand that far outstrips supply, deferring antiviral therapy until after transplant of HCV-infected kidneys, when available, should be both cost-saving and effective,” the researchers wrote.

The researchers published their results on August 21, 2018, in the Annals of Internal Medicine.

The second study examined 12-month outcomes after transplantation of HCV–infected kidneys into uninfected recipients. The open-label, non-randomized trial included 20 HCV-negative transplant candidates with a mean age 56.3 years. The researchers from the Perelman School of Medicine, University of Pennsylvania, led by Peter Reese, MD, evaluated HCV treatment outcomes, estimated glomerular filtration rate (GFR), and quality of life. The participants underwent transplantation with kidneys infected with genotype 1 HCV and received direct-acting antiviral therapy on post-transplant day 3. All 20 participants achieved HCV cure. All of the participants achieved sustained virologic response at 12 weeks with their initial course of treatment. The first 10 participants have remained HCV-negative 12 months after transplant.
No patients experienced allograft rejection. Some developed weakly positive donor-specific antibodies.

Estimated GFRs at 6 and 12 months post-transplant were significantly better than for comparable patients who received HCV-negative kidneys. Quality-of-life physical scores declined at 4 weeks, but then increased to above pre-transplant levels. Mental scores decreased at four weeks and returned to baseline by 12 months.

The researchers concluded that “kidneys from HCV-infected donors may be a valuable transplant resource.” They would like both Medicare and other insurance companies to create payment pathways for HCV medications after transplant to bring transplants to more kidney disease patients.