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

Abstract

Direct‐acting antivirals approved for use in patients with end‐stage renal disease (ESRD) now exist. HCV‐positive (HCV+) ESRD patients have the opportunity to decrease the waiting times for transplantation by accepting HCV‐infected kidneys. The optimal timing for HCV treatment (pre‐ vs posttransplant) among kidney transplant candidates is unknown. Monte Carlo microsimulation of 100 000 candidates was used to examine the cost‐effectiveness of HCV treatment pretransplant vs posttransplant by liver fibrosis stage and waiting time over a lifetime time horizon using 2 regimens approved for ESRD patients. Treatment pretransplant yielded higher quality‐adjusted life years (QALYs) compared with posttransplant treatment in all subgroups except those with Meta‐analysis of Histological Data in Viral Hepatitis stage F0 (pretransplant: 5.7 QALYs vs posttransplant: 5.8 QALYs). However, treatment posttransplant was cost‐saving due to decreased dialysis duration with the use of HCV‐infected kidneys (pretransplant: $735 700 vs posttransplant: $682 400). Using a willingness‐to‐pay threshold of $100 000, treatment pretransplant was not cost‐effective except for those with Meta‐analysis of Histological Data in Viral Hepatitis stage F3 whose fibrosis progression was halted. If HCV+ candidates had access to HCV‐infected donors and were transplanted ≥9 months sooner than HCV‐negative candidates, treatment pretransplant was no longer cost‐effective (incremental cost‐effectiveness ratio [ICER]: $107 100). In conclusion, optimal timing of treatment depends on fibrosis stage and access to HCV+ kidneys but generally favors posttransplant HCV eradication.

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,…”

Successful Kidney Transplantation in a Recipient Coinfected with Hepatitis C Genotype 2 and HIV from a Donor Infected with Hepatitis C Genotype 1 in the Direct-Acting Antiviral Era

“…is was confirmed in our case, despite kidney, not liver, transplantation, and therefore, substantially lower donor genotype 1a, compared to recipient genotype 2, viral load burden. e optimal timing of DAA treatment in HCV-positive transplant candidates, including HIV coinfected patients, remains in a state of flux, with limited real-world data [7,9,10]. e risk of treatment delay and progression of liver disease, which can be accelerated by immunosuppression, should be weighed against the benefit of shorter wait time for HCV-infected organs.…”

“…Based on sophisticated modelling, it has been suggested that for HCV-monoinfected patients with minimal liver fibrosis, treatment post-transplantation with an HCV-positive organ is beneficial. Nevertheless, in patients with advanced fibrosis, treatment prior to transplant may be preferred, unless the wait time benefit is >9 months [10]. For HCV/HIV coinfected patients, treatment posttransplant was consistently cost-saving as compared to treatment pretransplant and associated with higher life months and quality-adjusted life months with wait times >18 months [7].…”

“…Contemporary cohorts of HIV-infected transplant recipients have demonstrated excellent patient and graft survival [1][2][3][4][5][6][7]. Similarly, for patients with hepatitis C virus (HCV) infection, kidney transplantation offers a survival benefit and can be more cost-effective than remaining on the waitlist [8][9][10]. However, compared to their HCVuninfected counterparts, these patients experience higher rates of post-transplant glomerulonephritis, malignancy, and progression of liver disease [11,12].…”

“…e introduction of direct-acting antivirals (DAA) allows for safe treatment of HCV-infected transplant recipients, and therefore, transplantation of HCV-infected organs to both HCV-infected and uninfected patients [9,[14][15][16][17][18][19]. e optimal timing for treatment of HCV-infected transplant candidates (pre-vs. post-transplant with HCV-infected or HCV-uninfected organ donation, respectively) remains controversial, as the risk of treatment delay must be balanced by the benefit of shorter wait time for HCV-infected organs [7,10,13]. DAA prophylaxis for uninfected recipients of HCV-infected organs, including shorter courses [17], has also been proposed as an effective way to expand the organ pool [16][17][18].…”