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Changes in Utilization and Discard of HCV Antibody-Positive Deceased Donor Kidneys in the Era of Direct-Acting Antiviral Therapy

Bowring, Mary G.1; Kucirka, Lauren M., MD, PhD1,2; Massie, Allan B., PhD1,2; Ishaque, Tanveen1; Bae, Sunjae1; Shaffer, Ashton A.1,2; Garonzik Wang, Jacqueline, MD, PhD1; Sulkowski, Mark, MD3; Desai, Niraj, MD3; Segev, Dorry L., MD, PhD1,2,4; Durand, Christine M., MD3

doi: 10.1097/TP.0000000000002323
Original Clinical Science—General

Background The availability of direct-acting antiviral (DAA) therapy might have impacted use of hepatitis C virus (HCV)-infected (HCV+) deceased donor kidneys for transplantation.

Methods We used 2005 to 2018 Scientific Registry of Transplant Recipients data to identify 18 936 candidates willing to accept HCV+ kidneys and 3348 HCV+ recipients of HCV+ kidneys. We compared willingness to accept, utilization, discard, and posttransplant outcomes associated with HCV+ kidneys between 2 treatment eras (interferon [IFN] era, January 1, 2005 to December 5, 2013 vs DAA era, December 6, 2013 to August 2, 2018). Models were adjusted for candidate, recipient, and donor factors where appropriate.

Results In the DAA era, candidates were 2.2 times more likely to list as willing to accept HCV+ kidneys (adjusted odds ratio, 2.072.232.41; P < 0.001), and HCV+ recipients were 1.95 times more likely to have received an HCV+ kidney (adjusted odds ratio, 1.761.952.16; P < 0.001). Median Kidney Donor Profile Index of HCV+ kidneys decreased from 77 (interquartile range [IQR], 59-90) in 2005 to 53 (IQR, 40-67) in 2017. Kidney Donor Profile Index of HCV− kidneys remained unchanged from 45 (IQR, 21-74) to 47 (IQR, 24-73). After adjustment, HCV+ kidneys were 3.7 times more likely to be discarded than HCV− kidneys in the DAA era (adjusted relative rate, 3.363.674.02; P < 0.001); an increase from the IFN era (adjusted relative rate, 2.783.023.27; P < 0.001). HCV+ kidney use was concentrated within a subset of centers; 22.5% of centers performed 75% of all HCV+ kidney transplants in the DAA era. Mortality risk associated with HCV+ kidneys remained unchanged (aHR, 1.071.191.32 in both eras).

Conclusions Given the elevated risk of death on dialysis facing HCV+ candidates, improving quality of HCV+ kidneys, and DAA availability, broader utilization of HCV+ kidneys is warranted to improve access in this era of organ shortage.

The authors compare the willingness of listed patients to accept an HCV+ kidney, and the current use and discard rates of such kidneys, during 2 time periods, before the use of HCV direct antiviral therapy and since then. Willingness to accept and current acceptance increased, but surprisingly the discard rate of HCV+ kidneys also increased which leaves some hope for improvement.

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

3 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

4 Scientific Registry of Transplant Recipients, Minneapolis, MN.

Received 31 January 2018. Revision received 22 May 2018.

Accepted 6 June 2018.

C.M.D. is supported by grant K23CA177321-01A1 from the National Cancer Institute. M.S. is supported by National Institute of Allergy and Infectious Disease by grant K24DA034621. D.L.S, L.M.K., A.A.S., and A.B.M. are supported by the National Institute of Diabetes and Digestive and Kidney Diseases by grants K24DK101828 (Segev), F30DK095545 (Kucirka), F30DK116658 (Shaffer) and K23DK101677 (Massie), respectively.

C.M.D has received research grants from Gilead Sciences and Bristol Meyers Squibb, served as a scientific advisor for Gilead Sciences, Bristol Meyers Squibb, and Merck Pharmaceuticals, and served as a speaker for Roche Diagnostics. C.M.D. also received funds from Gilead for grant review. M.S. served as scientific advisor for AbbVie, Gilead Sciences, Cocrystal, Janssen, Merck Pharmaceuticals, and Trek. M.S. also received research grants from AbbVie, Gilead Sciences, and Merck Pharmaceuticals. The remaining authors declare no conflicts of interest.

M.G.B. participated in research design, statistical analysis, and writing and revising the article. L.M.K. and A.B.M participated in research design, statistical analysis, and revising the article. T.I. and S.B. participated in independent statistical analysis and results replication. A.A.S., J.G.W., M.S., and N.D. participated in research design and revising the article. D.L.S. and C.M.D. participated in research design, analytical support, and writing and revising the article.

Correspondence: Christine M. Durand, MD, Department of Medicine, Johns Hopkins School of Medicine, Room 450D, 1830 East Monument S, Baltimore, MD 21087. (cdurand2@jhmi.edu).

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