Race, Risk, and Willingness of End-Stage Renal Disease Patients Without Hepatitis C Virus to Accept an HCV-Infected Kidney Transplant

Pilot studies suggest that transplanting hepatitis C virus (HCV)-positive donor (D+) kidneys into HCV-negative renal transplant (RT) recipients (R-), then treating HCV with direct-acting antivirals (DAA) is clinically feasible. To determine whether this is a cost-effective approach, a decision tree model was developed to analyze costs and effectiveness over a 5-year time frame between 2 choices: RT using a D+/R- strategy compared to continuing dialysis and waiting for a HCV-negative donor (D-/R-). The strategy of accepting a HCV+ organ then treating HCV was slightly more effective and substantially less expensive and resulted in an expected 4.8 years of life (YOL) with a cost of ≈$138 000 compared to an expected 4.7 YOL with a cost of ≈$329 000 for the D-/R- strategy. The D+/R- strategy remained dominant after sensitivity analyses including the difference in RT death probabilities or acute rejection probabilities between using D+ vs D- kidney; time that D-/R- patients waited for RT; dialysis death probabilities while waitlisted for RT in the D-/R- strategy; DAA therapy expected cure rate; costs of transplant, immunosuppressives, DAA therapy, dialysis, or acute rejection. The D+/R- strategy followed by treatment with DAA is less costly and slightly more effective compared to the D-/R- strategy.

Section: Discussionmentioning

confidence: 82%

Cost-effectiveness of hepatitis C–positive donor kidney transplantation for hepatitis C–negative recipients with concomitant direct-acting antiviral therapy

Gupta

Zhang

Carroll

et al. 2018

“…Transplant programs and candidates, willing to accept the long‐term uncertainties, could consider expanding the utilization of these organs as a potential strategy to increase the number of transplants and decrease costs . Furthermore, a survey revealed that 82% of transplant candidates would consider an HCV positive organ in some situations . Transplants from HCV viremic to uninfected recipients should be performed in the context of scientific institutional review board approved protocols as recommended by the American Society of Transplantation consensus conference on the use of hepatitis C viremic donors in solid organ transplantation …”

Section: Discussionmentioning

confidence: 99%

Short-term outcomes of deceased donor renal transplants of HCV uninfected recipients from HCV seropositive nonviremic donors and viremic donors in the era of direct-acting antivirals

Hoz

Sandikçi

Ariyamuthu

et al. 2019

The United States opioid use epidemic over the past decade has coincided with an increase in hepatitis C virus (HCV) positive donors. Using propensity score matching, and the Organ Procurement Transplant Network data files from January 2015 to June 2019, we analyzed the short-term outcomes of adult deceased donor kidney transplants of HCV uninfected recipients with two distinct groups of HCV positive donors (HCV seropositive, nonviremic n = 352 and viremic n = 196) compared to those performed using HCV uninfected donors (n = 36 934). Compared to the reference group, the transplants performed using HCV seropositive, nonviremic and viremic donors experienced a lower proportion of delayed graft function (35.2 vs 18.9%; P < .001 [HCV seropositive, nonviremic donors] and 36.2 vs 16.8%; P < .001 [HCV viremic donors]). The recipients of HCV viremic donors had better allograft function at 6 months posttransplant (eGFR [54.1 vs 68.3 mL/min/1.73 m2; P = .004]. Furthermore, there was no statistical difference in the overall graft failure risk at 12 months posttransplant by propensity score matched multivariable Cox proportional analysis (HR = 0.60, 95% CI 0.23 to 1.29 [HCV seropositive, nonviremic donors] and HR = 0.85, 95% CI 0.25 to 2.96 [HCV viremic donors]). Further studies are required to determine the long-term outcomes of these transplants and address unanswered questions regarding the use of HCV viremic donors. K E Y W O R D S clinical research/practice, infection and infectious agents -viral: hepatitis C, infectious disease, kidney (allograft) function/dysfunction, kidney transplantation/nephrology 1 | INTRODUC TI ON Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD). It extends life, improves quality of life, and reduces cost compared to maintenance dialysis. 1,2 Although mortality in patients on the renal transplant waitlist has decreased, it remains unacceptably high (up to 12.7 per 100 patients-year) in certain regions of the United States (US). 3 Data in 2016 from the Scientific Registry of Transplant Recipients (SRTR) revealed that more than 25% of the 33 291 adult patients removed from the kidney transplant waitlist were withdrawn due to death or deteriorating medical condition. This withdrawal rate reflects the excessive wait times | 3059 LA HOZ et AL.

“…In addition, we assumed only HCV+ candidates had access to HCV‐infected organs. Should research protocols providing HCV‐infected organs to HCV− recipients gain wider acceptance, opening the pool of HCV‐infected donors to HCV− recipients, there would no longer be a wait‐time advantage in delaying therapy and treating pretransplant would drive care. Although we modeled elbasvir/grazoprevir as salvage therapy, treatment guidelines do not offer specific recommendations for treatment failure in patients with ESRD; inferences were consistent when we considered sofosbuvir/velpatasvir/voxilaprevir as a salvage regimen instead.…”

Section: Discussionmentioning

confidence: 99%

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

Shelton

Sawinski

Linas

et al. 2018

Self Cite

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.