Hepatitis C virus–infected kidney waitlist patients: Treat now or treat later?

Abstract

Currently many but not all centers transplant hepatitis C virus (HCV) viremic positive (+) donor kidneys into HCV+ recipients. Directed donation of HCV+ organs reduces the wait time to transplantation for HCV+ patients. Direct-acting antiviral (DAA) therapy can cure HCV in virtually all who are infected. Some have suggested that treatment of HCV+ waitlisted patients be deferred with the hope that earlier transplantation will provide better outcomes than early DAA therapy. However, there are not enough organs to guarantee prompt transplantation for the current waitlist of infected candidates. A Markov medical decision analysis model was created to compare the overall outcomes of delayed DAA therapy (Option 1) to immediate DAA therapy (Option 2) in waitlisted HCV+ patients. Option 1 patients were modeled to be transplanted 1 year earlier, with a higher cumulative transplant incidence (54% at 5 years post-listing vs 45% for Option 2). Despite this, Option 2 provided 0.43 (95% confidence interval [CI] 0.38-0.49) more life years than Option 1. However, Option 1 was preferred for regions with much greater access to HCV+ organs or in patients with very low HCV+-associated mortality. The best option from an individual patient's perspective will differ by region and candidate.

Population level outcomes and cost-effectiveness of hepatitis C treatment pre- vs postkidney transplantation

“…Our findings are somewhat in contrast to a recent Markov decision analysis by Kiberd et al, which found that pretransplant treatment of HCV was preferred, as it afforded patients more life‐years, except in cases of patients with “low” HCV‐related mortality or with access to HCV‐infected organs. There are several essential methodologic differences in our studies that may account for the variation in findings: (1) Kiberd et al used general dialysis and wait‐list mortality estimates, rather than rates specific to wait‐listed HCV+ candidates; (2) they did not model liver disease by fibrosis stage, despite marked increase in patient mortality with advancing fibrosis stage; (3) they did not account for relative differences in transplantation rates at the OPO level; and (4) they assumed that all patients were cured, which does not accurately reflect real‐world experience .…”

Center-level trends in utilization of HCV-exposed donors for HCV-uninfected kidney and liver transplant recipients in the United States

“…16,17,19,30 HCV Ab+ donors who do have risk factors for recent HCV or HIV infection, however, should be evaluated similar to IRDs. 1,5,17,31,32 Our findings extend the work of recent publications that discuss weighing treatment for HCV-infected kidney transplant candidates and recipients, [33][34][35] transmission risk of HCV Ab+ kidney donors for HCV-recipients, 16 cost-effectiveness of using HCV Ab+ kidney donors for HCV-recipients and treatment, 36 Our study has limitations that merit consideration. Although we found that HCV D+/R− transplantation increased over time,…”

Hepatitis C Infection May Be a Blessing for Patients in Need of a Transplant

“…“That could mean there may be 700 infected kidneys available each year. If all were used,…about 5 to 15% of [patients] with HCV infection currently on the list could be transplanted within the year with a median wait time of less than 1 year.” Dr. Kiberd's recent analysis determined that such a strategy would be most beneficial for patients in regions with greater access to HCV‐positive organs and/or those with very low anticipated HCV‐positive–associated mortality . He adds that “The landscape is changing and the best approach is not the same everywhere.”…”