Published online Feb 18, 2023. doi: 10.5500/wjt.v13.i2.44
Peer-review started: September 21, 2022
First decision: October 24, 2022
Revised: November 7, 2022
Accepted: December 21, 2022
Article in press: December 21, 2022
Published online: February 18, 2023
While Hepatitis C virus infection (HCV+) kidneys have traditionally been discarded rather than transplanted into HCV- recipients, the introduction of direct-acting antivirals (DAAs) in 2013 revolutionized HCV treatment by consistently achieving sustained virologic responses, opening the door for transplantation of HCV+ organs.
As HCV+ rates in kidney donors and transplant recipients rise, the introduction of DAA may effect transplant outcomes.
To analyze the effects of HCV+ in donors, recipients, or both, on deceased-donor (DD) kidney transplantation (KT) outcomes, and the impact of DAAs on those effects.
The Organ Procurement and Transplantation Network data of adult first solitary DD-KT recipients 1994-2019 were allocated into four groups by donor and recipient HCV+ status. We performed patient survival (PS) and death-censored graft survival (DCGS) pairwise comparisons after propensity score matching to assess the effects of HCV+ in donors and/or recipients, stratifying our study by DAA era to evaluate potential effect modification.
Pre-DAA, for HCV+ recipients, receiving an HCV+ kidney was associated with 1.28-fold higher mortality (HR 1.151.281.42) and 1.22-fold higher death-censored graft failure (HR 1.081.221.39) compared to receiving an HCV- kidney and the absolute risk difference was 3.3% (95%CI: 1.8%-4.7%) for PS and 3.1% (95%CI: 1.2%-5%) for DCGS at 3 years. The HCV dual-infection (donor plus recipient) group had worse PS (0.56-fold) and DCGS (0.71-fold) than the dual-uninfected. Donor HCV+ derived worse post-transplant outcomes than recipient HCV+ (PS 0.36-fold, DCGS 0.34-fold). In the DAA era, the risk associated with HCV+ in donors and/or recipients was no longer statistically significant, except for impaired PS in the dual-infected vs dual-uninfected (0.43-fold).
Prior to DAA introduction, donor HCV+ negatively influenced kidney transplant outcomes in all recipients, while recipient infection only relatively impaired outcomes for uninfected donors. These adverse effects disappeared with the introduction of DAA.
Given comparable outcomes across all four patient cohorts in the DAA era, a new allocation algorithm, eliminating HCV+ kidneys’ negative influence on the KDRI, is urgently needed to improve utilization and allocation of this under-utilized resource.