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Vanterpool KB, Diallo K, Kim E, Van Pilsum Rasmussen SE, Johnson MA, Predmore Z, Brundage J, Barnaba B, Desai N, Levan ML, Sung HC, Kates O, Sugarman J, Durand CM. Patient Perspectives on Solid Organ Transplantation From Donors With Hepatitis C Viremia to Recipients Without Hepatitis C Viremia. Open Forum Infect Dis 2024; 11:ofae015. [PMID: 38434612 PMCID: PMC10906703 DOI: 10.1093/ofid/ofae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/08/2024] [Indexed: 03/05/2024] Open
Abstract
Background Organ transplantation from donors with hepatitis C viremia (HCV) to recipients without HCV (HCV D+/R-) has excellent medical outcomes. Less is known about the psychosocial impact and experiences of HCV D+/R- recipients, particularly outside of clinical trials. Methods We conducted in-depth, semistructured interviews with 24 HCV D+/R- recipients (kidney, n = 8; lung, n = 7; liver, n = 5; heart, n = 3; simultaneous heart and kidney, n = 1) who received transplants outside of clinical trials and were treated for HCV after transplant to assess their experiences and perspectives. We used thematic analysis to analyze the interviews. Results Interviewees' reasons for accepting an HCV D + organ were based on perceived benefits and confidence in the effectiveness of HCV treatment. The majority (62%) received HCV treatment within 1 month after transplant (range, 1 day-2 months). Most interviewees reported positive transplant outcomes, including reduced wait times and improved survival, health, physical activity, and quality of life. Overall, themes and experiences did not differ significantly between different organ transplant types. Generally, interviewees did not perceive stigma from those aware of the HCV D+ transplant; yet, disclosure was selective and a few recipients reported concerns from family members about posttransplant HCV transmission risk. Other common concerns included treatment costs and delays, which were not always anticipated by recipients. Conclusions Our findings suggest that HCV D+/R- kidney, liver, and heart and lung transplant recipients outside of clinical trials had overall positive experiences. However, HCV transmission risk, treatments costs, and treatment delays were a source of concern that might be mitigated with targeted pretransplant education.
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Affiliation(s)
- Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Kadiatou Diallo
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellie Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Morgan A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zachary Predmore
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Janetta Brundage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj Desai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Hannah C Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivia Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Jeremy Sugarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Aleyadeh W, Verna EC, Elbeshbeshy H, Sulkowski MS, Smith C, Darling J, Sterling RK, Muir A, Akushevich L, La D, Terrault N, Fried MW, Feld JJ. Outcomes of early vs late treatment initiation in solid organ transplantation from hepatitis C virus nucleic acid test-positive donors to hepatitis C virus-uninfected recipients: Results from the HCV-TARGET study. Am J Transplant 2024; 24:468-478. [PMID: 37871798 DOI: 10.1016/j.ajt.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/14/2023] [Accepted: 10/06/2023] [Indexed: 10/25/2023]
Abstract
Curative hepatitis C virus (HCV) therapy has increased transplantation from HCV-infected nucleic acid test-positive donors to HCV-uninfected recipients (D+/R-). We evaluated outcomes of early and late HCV treatment among D+/R- nonliver organ transplants. Patients received HCV regimens per local standard (n = 10 sites). Outcomes were compared between early and late treatments. Early treatment regimens (ETR) (n = 56) were initiated pretransplantation to day 7 posttransplant. Late treatment regimens (LTRs) (n = 102) began median 31 (range, 8-114) days posttransplant. There were 79 kidney, 50 lung, 23 heart, and 6 mixed transplants, similar between groups. HCV RNA was quantifiable in 98% of LTR versus 44.6% of ETR recipients (P < .001). Mean (range) days on treatment were 28 (7-93) ETR and 81 (51-111) LTR (P < .0001). There were no virological failures with ETR, but relapse (n = 3) and nonresponse (n = 2) in LTR (P = .16), including fibrosing cholestatic hepatitis postrelapse (n = 1). Sustained virological response was 100% (95% confidence interval, 93.4-100.0) in ETR (n = 54) and 94.9% (95% confidence interval, 88.5-98.3) in LTR (n = 98). Acute rejection occurred in 11 (19.6%) ETR and 25 (24.5%) LTR. In total, 11 HCV-unrelated deaths occurred: 8 ETR and 3 LTR. Organ transplantation from HCV-infected nucleic acid test-positive donors to HCV-uninfected recipients was safe. ETR led to fewer virological failures with shorter treatment duration, supporting recommendations to initiate treatment promptly posttransplant.
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Affiliation(s)
- Wesam Aleyadeh
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Elizabeth C Verna
- Transplant Hepatology, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Hany Elbeshbeshy
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Mark S Sulkowski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Coleman Smith
- Department of Transplant Hepatology, MedStar Georgetown University Transplant Institute, Washington, District of Columbia, USA
| | - Jama Darling
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, VCU Medical Center, Richmond, Virginia, USA
| | - Andrew Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lucy Akushevich
- Biometrics and Data Quality HCV-TARGET Data Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Danie La
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Norah Terrault
- Division of Gastroenterology and Liver Disease, Keck School of Medicine at University of Southern California, Los Angeles, California, USA
| | - Michael W Fried
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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3
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Binari LA, Thorne P, Rega SA, Feurer ID, Shawar S, Naik R, Birdwell KA, Helderman JH, Langone A, Sarrell BA, Schaefer H, DuBray BJ, Eid K, Hickman L, Shaffer D, Concepcion BP, Forbes RC. Twelve-month kidney and liver outcomes of kidney transplantation from Hepatitis C Viremic deceased donors to aviremic recipients. Transpl Infect Dis 2024; 26:e14213. [PMID: 38112078 PMCID: PMC10922352 DOI: 10.1111/tid.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Utilization of hepatitis C viremic (HCV+) deceased donor kidneys (DDKT) for aviremic recipients increases opportunities for transplantation with excellent short-term outcomes. Our primary aim was to understand longer-term outcomes, specifically assessing kidney and liver function in the first year posttransplant. METHODS This was a retrospective single-center study of adult DDKT recipients of HCV+ kidneys (cases) matched 1:1 to recipients of HCV- kidneys (comparators). Between-group outcomes were analyzed using comparisons of means and proportions, survival analysis methods, and multivariable mixed effects models. RESULTS Sixty-five cases and 65 comparators had statistically comparable demographic and clinical characteristics. There were no between-group differences in serum creatinine or estimated glomerular filtration rate at month 12 (p = .662) or in their trajectories over months 1-12 (p > .292). Within the first 60 days, rates of liver function values >3 times upper limit of normal among cases were comparable to comparators for aspartate aminotransferase (AST) (14% vs. 6%, p = .242) and higher for alanine transaminase (ALT) (23% vs. 6%, p = .011). AST declined during the first 8 weeks (p = .005) and stabilized for both groups (p = .406) during the following 10 months. ALT declined during the first 8 weeks (p < .001), continued to decline over months 3-12 (p = .016), and the trajectory was unrelated to antiviral therapy initiation among cases. CONCLUSIONS Aviremic recipients of HCV+ kidneys had comparable kidney outcomes to matched recipients of HCV- kidneys. Despite more HCV+ recipients having an elevation in ALT within the first 60 days, ALT values normalized with no identified liver complications attributed to HCV.
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Affiliation(s)
- Laura A Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter Thorne
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Saed Shawar
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ruchi Naik
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Harold Helderman
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Langone
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heidi Schaefer
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bernard John DuBray
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kareem Eid
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura Hickman
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Shaffer
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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4
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Gray M, Borges L, Conrath M, Marti K. Management of severe BK viremia in a patient receiving a kidney transplant from a hepatitis C virus-positive donor: A case report. Am J Health Syst Pharm 2024; 81:56-60. [PMID: 37793014 DOI: 10.1093/ajhp/zxad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Indexed: 10/06/2023] Open
Abstract
PURPOSE A case of BK nephropathy in a kidney transplant recipient who received an organ from a hepatitis C virus (HCV)-positive donor is reported. SUMMARY A 66-year-old male negative for HCV with chronic kidney disease secondary to diabetic glomerulosclerosis received a kidney transplant from an HCV-viremic donor. His initial postoperative course was uncomplicated, and HCV treatment with glecaprevir/pibrentasvir was initiated after discharge. On postoperative day (POD) 60, the patient developed BK viremia and his mycophenolate mofetil dose was decreased. Over the next few months, the BK viral load increased, with mycophenolate mofetil stopped and the tacrolimus goal lowered in response. On POD 130, the patient was admitted for a hypertensive crisis and found to have decreased renal function. During this hospitalization, the patient received a course of intravenous immune globulin (IVIG). Despite an initial response to the modification of immunosuppression therapy and several courses of IVIG over the following months, the patient's renal function continued to decline. At 18 months after transplantation, the patient was restarted on dialysis and taken off all immunosuppression. CONCLUSION Utilization of organs from HCV-positive donors in HCV-negative recipients allows for expansion of the donor pool and facilitates shorter times on the waitlist. Although initial data in HCV-discordant transplantation did not find an increased risk for opportunistic infections, more recent studies have shown that such risk may be present. This case report describes a patient who developed BK viremia and eventual allograft failure after an HCV-discordant transplantation.
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Affiliation(s)
- Megan Gray
- Pharmacy Department, UConn John Dempsey Hospital, Farmington, CT, USA
| | - Leanna Borges
- Transplant Department, Hartford HealthCare, Hartford, CT, USA
| | - Meagan Conrath
- Transplant Department, Hartford HealthCare, Hartford, CT, USA
| | - Kristen Marti
- Transplant Department, Hartford HealthCare, Hartford, CT, USA
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5
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Ventura S, Figueiredo C, Sousa C, Almeida M, Martins LS. Use of Hepatitis C Virus Antibody-Positive Donors in Kidney Transplantation. Cureus 2024; 16:e51849. [PMID: 38327969 PMCID: PMC10848599 DOI: 10.7759/cureus.51849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Background The use of kidney donors with hepatitis C virus (HCV) has been arising as a possibility to increase the donor pool. It encompasses both the use of donors with positive and negative viremia, particularly since the advent of direct antiviral agents that produce sustained virologic response. Methodology We conducted a retrospective observational study to describe the experience of our transplantation center in the use of HCV antibody-positive (HCV-Ab+) kidneys. Results We performed five transplants with HCV-Ab+ donors. The median age of kidney recipients was 63 (interquartile range (IQR) = 54-71) years, and 60% (n = 3) were males. Two recipients received a second transplant. The median dialysis vintage was 1,414 (IQR = 1,103-2,806) days. The induction immunosuppression protocol was basiliximab in most patients (60%, n = 3), and all received maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone. One of the recipients had a personal history of cured HCV infection. Seroconversion occurred in half of the remaining patients, which was sustained during the follow-up. None of the patients developed HCV viremia. At the end of follow-up, mean creatinine and proteinuria were 1.45 ± 1.12 mg/dL and 0.099 ± 0.045 g/g, respectively. We did not observe any rejection episodes, need for dialysis, or recipient's death. Conclusions Our work aligns with the current literature that advocates that the use of these donors is safe and cost-effective and can be an effective strategy for expanding the donor pool and augmenting the transplantation volume. Seroconversion is a known risk whose mechanisms are not entirely understood, although it does not appear to be related to a higher transmission risk.
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Affiliation(s)
- Sofia Ventura
- Nephrology, Hospital do Divino Espírito Santo, EPER, Ponta Delgada, PRT
| | | | - Círia Sousa
- Nephrology, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Manuela Almeida
- Nephrology, Centro Hospitalar Universitário do Porto, Porto, PRT
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6
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Desai NM, Leung SG, Motter JD, Segev DL, Warren D, Durand CM. Two-Week Direct-Acting Antiviral Prophylaxis for Kidney Transplantation From Donors With Hepatitis C Viremia to Recipients Without Hepatitis C Viremia: A Small Uncontrolled Trial. Ann Intern Med 2023; 176:1682-1684. [PMID: 38011702 DOI: 10.7326/m23-2682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sherry G Leung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer D Motter
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Dorry L Segev
- Department of Surgery and Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Daniel Warren
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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7
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Steinbrink JM, Byrns J, Berg C, Kappus M, King L, Ellis MJ, Sanoff S, Agarwal R, DeVore AD, Reynolds JM, Hartwig MG, Milano C, Sudan D, Maziarz EK, Saullo J, Alexander BD, Wolfe CR. Real-world Experiences in the Transplantation of Hepatitis C-NAAT-positive Organs. Transplant Direct 2023; 9:e1539. [PMID: 37829247 PMCID: PMC10567032 DOI: 10.1097/txd.0000000000001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 10/14/2023] Open
Abstract
Background Hepatitis C virus (HCV) nucleic acid amplification test (NAAT)-positive donors have increased the organ pool. Direct-acting antivirals (DAAs) have led to high rates of treatment success and sustained virologic response (SVR) in recipients with donor-derived HCV infection without significant adverse effects, although variability remains in the timing and duration of antivirals. Methods This retrospective study analyzed all adult HCV-NAAT-negative transplant recipients who received an organ from HCV-NAAT-positive donors from November 24, 2018, to March 31, 2022, at Duke University Medical Center with protocolized delay of DAA initiation until after hospital discharge, with at least 180-d follow-up on all patients. Transplant and HCV-related outcomes were analyzed. Results Two hundred eleven transplants (111 kidneys, 41 livers, 34 hearts, and 25 lungs) were performed from HCV-NAAT-positive donors to HCV-NAAT-negative recipients. Ninety percent of recipients became viremic within 7 d posttransplant. Ninety-nine percent of recipients were initiated on pangenotypic DAAs in the outpatient setting a median of 52 d posttransplant, most commonly with 12-wk courses of sofosbuvir-velpatasvir (lungs) and glecaprevir-pibrentasvir (heart, kidney, and liver). Ninety-seven percent of recipients had SVR after a first-line DAA; all ultimately achieved SVR at 12 wk after subsequent treatment courses. The median peak HCV RNA for all organ systems was 2 436 512 IU/mL; the median time from antiviral to undetectable RNA was 48 d, although differences were noted between organ groups. No patient deaths or graft losses were directly attributable to HCV infection. Conclusions One hundred percent of transplant recipients of HCV-NAAT-positive organs ultimately developed SVR without significant adverse effects when HCV antivirals were initiated in the outpatient setting after transplant hospitalization, suggesting that this real-world treatment pathway is a viable option.
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Affiliation(s)
- Julie M. Steinbrink
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | - Carl Berg
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC
| | - Matthew Kappus
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC
| | - Lindsay King
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC
| | - Matthew J. Ellis
- Division of Nephrology, Duke University School of Medicine, Durham, NC
| | - Scott Sanoff
- Division of Nephrology, Duke University School of Medicine, Durham, NC
| | - Richa Agarwal
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - John M. Reynolds
- Division of Pulmonary, Allergy and Critical Care, Duke University School of Medicine, Durham, NC
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Debra Sudan
- Division of Abdominal Transplant Surgery, Duke University School of Medicine, Durham, NC
| | - Eileen K. Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Jennifer Saullo
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | | | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
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8
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Jay JS, Patterson JA, Zhang Y, Ijioma SC, Carroll NV, Holdford DA, Sterling RK, Gupta G, Yakubu I. Cost minimization analysis of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants. J Am Pharm Assoc (2003) 2023; 63:1700-1705.e4. [PMID: 37414279 DOI: 10.1016/j.japh.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/09/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Trials describing 4-12 week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R-transplants), may be limited in application by costs and delayed access to expensive DAAs. A short prophylactic strategy may be safer and cost-effective. Here, we report a cost minimization analysis using the health system perspective to determine the least expensive DAA regimen, using available published strategies. OBJECTIVES To conduct cost-minimization analyses (CMAs) from the health system perspective of four DAA regimens to prevent and/or treat HCV transmission from D+/R-kidney transplants. METHODS CMAs comparing 4 strategies: 1) 7-day prophylaxis with generic sofosbuvir/velpatasvir (SOF/VEL), with 12-week branded glecaprevir/pibrentasvir (G/P) for those with transmission; 2) 8-day branded G/P prophylaxis, with 12-week branded SOF/VEL/voxilaprevir for those with transmission; 3) 4-week perioperative generic SOF/VEL prophylaxis, with 12-week branded G/P for those with transmission; and 4) 8-week branded G/P "transmit-and-treat." We included data from published literature to estimate the probability of viral transmission in patients who received DAA prophylaxis, and assumed a 100% transmission rate for those who received the "transmit-and-treat" approach. RESULTS In base-case analyses, strategies 1 (expected cost [EC]: $2326) and 2 (expected cost: $2646) were less expensive than strategies 3 (EC: $4859) and 4 (EC: $18,525). Threshold analyses for 7-day SOF/VEL versus 8-day G/P suggested that there were reasonable input levels at which the 8-day strategy may be least costly. The threshold values for the SOF/VEL prophylaxis strategies (7-day vs. 4- week) indicated that the 4-week strategy is unlikely to be less costly under any reasonable value of the input variables. CONCLUSIONS Short duration DAA prophylaxis using 7 days of SOF/VEL or 8 days of G/P has the potential to yield significant cost savings for D+/R- kidney transplants.
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9
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Toyoda H, Kikuchi K. Management of dialysis patients with hepatitis C virus in the era of direct-acting antiviral therapy. Ther Apher Dial 2023; 27:831-838. [PMID: 37217295 DOI: 10.1111/1744-9987.14003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/24/2023] [Accepted: 05/06/2023] [Indexed: 05/24/2023]
Abstract
The clinical use of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection has dramatically changed management of patients with HCV liver disease since 2014; this is also true for patients undergoing dialysis. Due to the high tolerability and antiviral efficacy of anti-HCV therapy, most dialysis patients with HCV infection should currently be candidates for this treatment. Many patients with HCV antibodies no longer have HCV infection, and it is difficult to identify patients with actual HCV infection based only on HCV antibody assays. Despite the high rate of successful HCV eradication, the risk of liver-related events such as hepatocellular carcinoma (HCC), the major complication of HCV infection, persists even after HCV cure, and patients at risk of HCC should undergo continuous HCC surveillance. Finally, the rarity of HCV reinfection and the survival benefit of HCV eradication in dialysis patients should be explored in further studies.
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Affiliation(s)
- Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kan Kikuchi
- Division of Nephrology, Shimoochiai Clinic, Tokyo, Japan
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10
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Gordon CE, Adam GP, Jadoul M, Martin P, Balk EM. Kidney Transplantation From Hepatitis C Virus-Infected Donors to Uninfected Recipients: A Systematic Review for the KDIGO 2022 Hepatitis C Clinical Practice Guideline Update. Am J Kidney Dis 2023; 82:410-418. [PMID: 37061019 DOI: 10.1053/j.ajkd.2022.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/31/2022] [Indexed: 04/17/2023]
Abstract
RATIONALE & OBJECTIVE Direct-acting antiviral (DAA) treatment of hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD) has made transplantation of kidneys from HCV-infected donors to uninfected recipients (D+/R-) feasible. To facilitate an update to the 2018 KDIGO guideline for patients with CKD and HCV, we conducted a systematic review of HCV D+/R-kidney transplantation coupled with DAA treatment. STUDY DESIGN Systematic review and meta-analysis. SETTING & STUDY POPULATIONS We included studies of HCV D+/R-kidney transplantations that used any DAA protocol. SELECTION CRITERIA FOR STUDIES Based on a search of PubMed, Embase, Cochrane, CINAHL, and ClinicalTrials.gov through February 1, 2022, conferences from 2019 to 2021, and the 2018 KDIGO HCV guideline we identified single-group (D+/R-) or comparative studies of D+/R-versus D-/R-kidney transplantation. DATA EXTRACTION Conducted in SRDR-Plus with review by a second researcher. ANALYTICAL APPROACH Maximum likelihood meta-analyses; the certainty of evidence was assessed per GRADE (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We identified 16 studies (N=557). A sustained viral response at 12 weeks after treatment (SVR12) was observed in 97.7% (95% CI, 96.3%-98.8%). Ultrashort duration treatment (≤8 days) resulted in viremia requiring standard-course DAA treatment in some patients, all of whom achieved SVR12 after 1 or rarely 2 DAA courses. Serious adverse events from DAA treatment were rare after D+/R-transplantation (0.4% [95% CI, 0.1%-2.8%]). At≥1 year after D+/R-transplantation, recipient death occurred in 2.1% (95% CI, 0.9-3.7) and allograft survival was 97.6% (95% CI, 95.7%-98.9%). Estimated glomerular filtration rate 1 year after transplantation ranged from 46 to 74mL/min/1.73m2. LIMITATIONS Analyses were generally based on low-certainty evidence. Uncertainty exists about the long-term safety and efficacy of D+/R-transplantation. Few studies investigated ultrashort treatment courses. CONCLUSIONS Kidney transplantation from HCV-infected donors to uninfected recipients followed by DAA treatment appears to be safe and associated with excellent 1-year clinical outcomes. PLAIN-LANGUAGE SUMMARY Due to the high efficacy of direct-acting antivirals (DAA), the use of kidneys from HCV-infected deceased donors may increase rates of kidney transplantation. We conducted a systematic review for the 2022 KDIGO Clinical Practice Guideline on Hepatitis C to evaluate the safety and efficacy of kidney transplantation from HCV-infected donors to uninfected recipients (D+/R-) followed by DAA therapy. Sixteen studies comprising 557 patients revealed high rates of sustained viral response, low rates of adverse events, and excellent patient and allograft survival 1 year after transplantation. Kidney transplantation from HCV-infected deceased donors to uninfected recipients treated with DAA appears safe and effective. Future studies should investigate shorter treatment durations, monitor safety, and obtain longer-term efficacy data.
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Affiliation(s)
- Craig E Gordon
- Division of Nephrology, Department of Medicine, School of Medicine, Tufts University, Boston, Massachusetts.
| | - Gaelen P Adam
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Michel Jadoul
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, School of Medicine, University of Miami, Miami, Florida
| | - Ethan M Balk
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island
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11
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Steinbrink JM, Narayanasamy S, Wolfe CR, Maziarz E, Byrns J, Kiser JJ, Naggie S. Antiviral Treatment Failures After Transplantation of Organs From Donors With Hepatitis C Infection: A Report of 4 Cases. Am J Kidney Dis 2023; 82:368-372. [PMID: 36740039 PMCID: PMC10400725 DOI: 10.1053/j.ajkd.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/10/2022] [Indexed: 02/05/2023]
Abstract
The transplantation of organs from donors with hepatitis C virus (HCV) infection into uninfected recipients has expanded the available organ donor pool. With the advancement of direct-acting antivirals (DAAs), high rates of cure among transplant recipients are possible. Although DAAs are highly effective, treatment failure can occur following an appropriate 12-week course of a pan-genotypic regimen. Here we describe 4 kidney transplant recipients of organs from donors with HCV infection (3 with genotype 3, 1 genotype 1a) in whom first-line DAA treatment with either glecaprevir-pibrentasvir or sofosbuvir-velpatasvir was unsuccessful, started 22-35 days after the day of transplantation. All ultimately achieved sustained virologic response with second- or third-line therapy. Post-treatment resistance-associated substitutions were tested and noted to be present in 2 cases. Additionally, antiviral levels were assessed in 2 cases and found to be therapeutic in each. This article explores possible reasons for treatment failure, including medication interactions, bariatric surgery, viral dynamics, and drug resistance.
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Affiliation(s)
- Julie M Steinbrink
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina.
| | - Shanti Narayanasamy
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Eileen Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Jennifer J Kiser
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Susanna Naggie
- Section of Infectious Diseases, Durham Veterans Affairs Health Care System, Durham, North Carolina
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12
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Franco A, Gosalvez C, Gimeno A, Trigueros M, Balibrea N, Perez Contreras FJ. Assessing Tissue Transmission of Hepatitis C Virus From Viremic Donor to Seronegative Kidney Transplant Recipients: A Case Series. Transpl Int 2023; 36:11110. [PMID: 37534060 PMCID: PMC10391827 DOI: 10.3389/ti.2023.11110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/15/2023] [Indexed: 08/04/2023]
Abstract
The transmission of hepatitis C virus from viremic donors to seronegative recipients of kidney transplantation is well documented. Pre-transplant administration of direct-acting antivirals prevents viremia, but the seroconversion rate is high. We studied the transmission of the virus through the transplanted tissue by determining viral RNA in 15 kidneys from 8 deceased viremic donors, 5 males and 3 females aged 52.3 ± 15 years. HIV positive donors and active intravenous drugs abusers were discarded to avoid possible window periods in the virus transmission. Recipients, 9 males and 6 females aged 52.7 ± 18 years, were treated with glecaprevir/pibrentasvir for 8 weeks and received immunosuppression with thymoglobulin, tacrolimus, sirolimus and prednisone. Hepatitis C Virus was detected in 9 of the 15 histological samples analyzed but viremia was detected in no recipient at day 1 and 7 post-transplantation and 12 weeks after the treatment. However, 13 of the 15 recipients had seroconverted within 1 month. In conclusion, Hepatitis C virus was detected in a significant proportion of tissue of kidney grafts from viremic donors, but treatment with direct-acting antivirals avoids the transmission of the virus from donor to recipient. Then Donor pools should be expanded.
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Affiliation(s)
- Antonio Franco
- Department of Nephrology, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - Carla Gosalvez
- Department of Microbiology, Hospital General Universitario Dr Balmis, Alicante, Spain
- Department of Pathology, Hospital General Universitario Dr Balmis, Alicante, Spain
| | - Adelina Gimeno
- Department of Microbiology, Hospital General Universitario Dr Balmis, Alicante, Spain
| | - Migul Trigueros
- Department of Pathology, Hospital General Universitario Dr Balmis, Alicante, Spain
| | - Noelia Balibrea
- Department of Nephrology, Hospital General Universitario Dr. Balmis, Alicante, Spain
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13
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Sharma P, Sawtell R, Wang Q, Sise ME. Management of Hepatitis C Virus and Hepatitis B Virus Infection in the Setting of Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:343-355. [PMID: 37657881 PMCID: PMC10479952 DOI: 10.1053/j.akdh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 09/03/2023]
Abstract
Treatment of chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection poses unique challenges in patients with kidney disease. Direct-acting antivirals have been a major breakthrough in eradicating HCV infection, and several pangenotypic regimens are available for patients with chronic kidney disease or end-stage kidney disease requiring dialysis with high cure rates and no need for dose adjustment. Direct-acting antiviral therapy alone can treat HCV-associated cryoglobulinemic glomerulonephritis; concurrent antiviral and immunosuppressive therapy is needed for cases of severe, organ-threatening manifestations of cryoglobulinemia. Immunosuppression may be needed for HBV-associated kidney disease (polyarteritis nodosa or membranous nephropathy) when there is evidence of severe immune-mediated injury while weighing the risk of potential viral activation. Most HBV antiviral agents need to be dose-adjusted in patients with chronic kidney disease or end-stage kidney disease requiring dialysis, and drug-drug interactions need to be carefully evaluated in patients with kidney transplants. Considerations for accepting HCV- and HBV-infected donors for kidney transplantation are discussed.
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Affiliation(s)
- Purva Sharma
- Department of Medicine, Division of Nephrology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Glomerular Disease Center at Northwell Health, Hempstead, NY
| | - Rani Sawtell
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Qiyu Wang
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA.
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14
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Salas J, Storm K, Durand CM. Organ Donors with Human Immunodeficiency Virus and Hepatitis C Virus: Expanding the Donor Pool. Infect Dis Clin North Am 2023:S0891-5520(23)00039-9. [PMID: 37258326 DOI: 10.1016/j.idc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Using organs from donors with treatable infections is a strategy to increase the quality and number of organs for transplantation. For HIV, pilot studies of kidney and liver transplantation from donors with HIV to recipients with HIV demonstrate excellent early outcomes. However, the number of donors and transplants per year remains lower than projected due to several barriers. For HCV, the use of organs from donors with HCV has expanded to recipients without HCV due to safe, effective direct-acting antivirals for HCV, which are well-tolerated in transplant recipients. Studies across organ types demonstrate good outcomes and shorter wait times.
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Affiliation(s)
- Jordan Salas
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA; Department of Medicine, Oregon Health & Science University School of Medicine, 3181 Southwest Sam Jackson Park Road, Portland, OR, USA
| | - Kaitlyn Storm
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA.
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15
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Kim MH, Sise ME, Xu M, Goldberg DS, Fontana RJ, Kort JJ, Alloway RR, Durand CM, Brown RS, Levitsky J, Gustafson JL, Reese PP, Chung RT. Early initiation of glecaprevir/pibrentasvir after transplantation of HCV-viremic kidneys into HCV-negative recipients is associated with normalization in the altered inflammatory milieu. Clin Transplant 2023; 37:e14926. [PMID: 36752566 PMCID: PMC10951469 DOI: 10.1111/ctr.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/04/2023] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
Our previous Multicenter Trial to Transplant HCV-infected Kidneys (MYTHIC) observed that 100% of hepatitis C virus (HCV)-uninfected patients who received a kidney from an HCV-infected deceased donor were cured of HCV with an 8-week regimen of glecaprevir and pibrentasvir (G/P) initiated 2-5 days after transplantation. Following acute and chronic infection with HCV, immune system perturbations have been reported to persist even after viral clearance. The aim of this study was to determine whether HCV viremic kidney recipients in the MYTHIC study experience sustained changes in the soluble inflammatory milieu associated with HCV infection. Among nine patients with HCV viremia at day 3 post-kidney transplant (post-KT D3), IP-10, IL-10, MIP-1β, and IL-8 were significantly elevated from baseline. However, over the subsequent visits, there was a rapid, dramatic reduction back to baseline levels. Among seven patients who were not HCV viremic at post-KT D3, the cytokine levels did not significantly change. HCV-uninfected patients who received a kidney from an HCV-viremic deceased donor and were treated with early G/P experienced only transient alterations in the soluble inflammatory milieu. These data provide reassuring evidence that there appear to be no persistent cytokine disturbances with transient HCV viremia accompanying HCV donor positive/recipient negative kidney transplant.
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Affiliation(s)
- Myung-Ho Kim
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan E. Sise
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Min Xu
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David S. Goldberg
- Division of Digestive Health & Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert J. Fontana
- Division of Gastroenterology & Hepatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jens J. Kort
- Global Medical Affairs Research & Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Rita R. Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert S. Brown
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jenna L. Gustafson
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter P. Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond T. Chung
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Merzkani M, Chang SH, Murad H, Lentine KL, Mattu M, Wang M, Hu V, Wang B, Al-Hosni Y, Alzahabi O, Alomar O, Wellen J, Alhamad T. The association of center volume with transplant outcomes in selected high-risk groups in kidney transplantation. BMC Nephrol 2023; 24:61. [PMID: 36941609 PMCID: PMC10029277 DOI: 10.1186/s12882-023-03099-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In context of increasing complexity and risk of deceased kidney donors and transplant recipients, the impact of center volume (CV) on the outcomes of high-risk kidney transplants(KT) has not been well determined. METHODS We examined the association of CV and outcomes among 285 U.S. transplant centers from 2000-2016. High-risk KT were defined as recipient age ≥ 70 years, body mass index (BMI) ≥ 35 kg/m2, receiving kidneys from donors with kidney donor profile index(KDPI) ≥ 85%, acute kidney injury(AKI), hepatitisC + . Average annual CV for the specific-high-risk KT categorized in tertiles. Death-Censored-Graft-Loss(DCGL) and death at 3 months, 1, 5, and 10 years were compared between CV tertiles using Cox-regression models. RESULTS Two hundred fifty thousand five hundred seventy-four KT were analyzed. Compared to high CV, recipients with BMI ≥ 35 kg/m2 had higher risk of DCGL in low CV(aHR = 1.11,95%CI = 1.03-1.19) at 10 years; recipients with age ≥ 70 years had higher risk of death in low CV(aHR = 1.07,95%CI = 1.01-14) at 10 years. There was no difference of DCGL or death in low CV for donors with KDPI ≥ 85%, hepatitisC + , or AKI. CONCLUSIONS Recipients of high-risk KT with BMI ≥ 35 kg/m2 have higher risk of DCGL and recipients age ≥ 70 years have higher risk of death in low CV, compared to high CV. Future studies should identify care practices associated with CV that support optimal outcomes after KT.
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Affiliation(s)
- Massini Merzkani
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Haris Murad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | - Munis Mattu
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Mei Wang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Vangie Hu
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Bolin Wang
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Yazen Al-Hosni
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Obadah Alzahabi
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Omar Alomar
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Jason Wellen
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA.
- Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO, USA.
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17
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Buchanan-Peart KA, Pagan J, Martin E, Turkeltaub J, Reese P, Goldberg DS. Temporal changes in the utilization of kidneys from hepatitis C virus-infected donors in the United States. Am J Transplant 2023:S1600-6135(23)00342-8. [PMID: 36893936 DOI: 10.1016/j.ajt.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023]
Abstract
Despite data demonstrating increased utilization of kidneys from hepatitis C virus (HCV)-infected donors, it is unknown whether this is due to an increase in the donor pool or improved organ utilization and whether data from early pilot trials were temporally associated with changes in organ utilization. We used data from the Organ Procurement and Transplantation Network on all kidney donors and recipients of kidney transplants from January 1, 2015, to March 31, 2022 to evaluate temporal changes using joinpoint regression. Our primary analyses compared donors on the basis of their HCV viremic status (HCV-infected vs HCV-negative). Kidney utilization changes were assessed by evaluating the kidney discard rate and kidneys transplanted per donor. A total of 81 833 kidney donors were included in the analysis. There was a statistically significant decrease in the discard rates of HCV-infected kidney donors from 40% to just over 20% over a 1-year period, with a concurrent increase in kidneys transplanted per donor. This increased utilization occurred in tandem with the publication of pilot trials involving HCV-infected kidney donors in HCV-negative recipients rather than an increase in the donor pool. Ongoing clinical trials may strengthen existing data, which could result in this practice becoming the accepted standard of care.
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Affiliation(s)
| | - Javier Pagan
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric Martin
- Division of Digestive Health and Liver Disease, University of Miami Miler School of Medicine, Miami, Florida, USA
| | - Joshua Turkeltaub
- Division of Digestive Health and Liver Disease, University of Miami Miler School of Medicine, Miami, Florida, USA
| | - Peter Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Disease, University of Miami Miler School of Medicine, Miami, Florida, USA.
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18
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Outcome of Kidney Transplants from Viremic and Non-Viremic Hepatitis C Virus Positive Donors into Negative Recipients: Results of the Spanish Registry. J Clin Med 2023; 12:jcm12051773. [PMID: 36902560 PMCID: PMC10002558 DOI: 10.3390/jcm12051773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Historically, donor infection with hepatitis-C virus (HCV) has been a barrier to kidney transplantation. However, in recent years, it has been reported that HCV positive kidney donors transplanted into HCV negative recipients offer acceptable mid-term results. However, acceptance of HCV donors, especially viremic, has not broadened in the clinical practice. This is an observational, multicenter, retrospective study including kidney transplants from HCV positive donors into negative recipients reported to the Spanish group from 2013 to 2021. Recipients from viremic donors received peri-transplant treatment with direct antiviral agents (DAA) for 8-12 weeks. We included 75 recipients from 44 HCV non-viremic donors and 41 from 25 HCV viremic donors. Primary non function, delayed graft function, acute rejection rate, renal function at the end of follow up, and patient and graft survival were not different between groups. Viral replication was not detected in recipients from non-viremic donors. Recipient treatment with DAA started pre-transplant avoids (n = 21) or attenuates (n = 5) viral replication but leads to non-different outcomes to post-transplant treatment with DAA (n = 15). HCV seroconversion was more frequent in recipients from viremic donors (73% vs. 16%, p < 0.001). One recipient of a viremic donor died due to hepatocellular carcinoma at 38 months. Donor HCV viremia seems not to be a risk factor for kidney transplant recipients receiving peri-transplant DAA, but continuous surveillance should be advised.
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19
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Lopez-Soler RI, Thorndyke A, Trotter C, Zingraf G, Sorenson J, Samra M. Kidney Transplantation in an Elderly Veteran Population With Hepatitis C Virus Nucleic Acid Test-Positive Donors Results in Improved Outcomes After Prophylactic Glecaprevir/Pibrentasvir Therapy. Transplant Proc 2023; 55:317-324. [PMID: 36801136 DOI: 10.1016/j.transproceed.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND The average age of waitlisted veterans is 64. Recent data has shown the safety and benefits of using kidneys from hepatitis C virus nucleic acid test (HCV NAT)-positive donors. However, these studies were limited to younger patients with initiation of therapy after transplant. The aim of this study was to determine the safety and efficacy of a preemptive treatment protocol in an elderly veteran population. METHODS This was a prospective, open-label trial with 21 deceased donor kidney transplantations (DDKTs) with HCV NAT-positive kidneys and 32 DDKTs with HCV NAT-negative transplanted between November 2020 and March 2022. The HCV NAT-positive recipients were treated with once-daily glecaprevir/pibrentasvir started preoperatively and continued for 8 weeks. Sustained virologic response (SVR)12 was determined by negative NAT Student's t test. Other endpoints included patient and graft survival as well as graft function. RESULTS There was no major difference between the cohorts other than the increased number of donation after circulatory death kidneys in the non-HCV recipients. Post-transplant graft and patient outcomes were equivalent between the groups. Eight of the 21 HCV NAT-positive recipients had detectable HCV viral loads 1 day after transplant, but all were undetectable by day 7 with 100% SVR12. Calculated estimated glomerular filtration rate was improved in the HCV NAT-positive cohort at week 8 (58.26 vs 47.16 mL/min; P < .05) and continued to be improved over non-HCV recipients 1 year after transplant (71.38 vs 42.15 mL/min; P < .05). Immunologic risk stratification was similar in both cohorts. CONCLUSION The HCV NAT-positive transplants with a preemptive treatment protocol results in improved graft function with minimal to no complications in an elderly veteran population.
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Affiliation(s)
- Reynold I Lopez-Soler
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois; Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois.
| | - Anne Thorndyke
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Christine Trotter
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Gerry Zingraf
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Jeffrey Sorenson
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Manpreet Samra
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois; Department of Medicine, Division of Transplant Nephrology, Stritch School of Medicine, Maywood, Illinois
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20
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Daloul R, Sureshkumar K, Schnelle K, Von Stein L, Logan A, Pesavento T. Kidney transplant from HCV viremic donors to HCV-negative recipients and risk for de novo donor specific antibodies and acute rejection. Clin Transplant 2023; 37:e14895. [PMID: 36580971 DOI: 10.1111/ctr.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Kidney transplantation from HCV-viremic donors into uninfected recipients is associated with excellent short-term outcomes. However, concerns regarding an increased risk for the development of de novo donor specific antibodies (DSA) and acute rejection have been raised in single center reports. METHODS A retrospective study of HCV-negative kidney-only transplant recipients between 2018 and 2020. Patients were grouped based on the donor HCV status into group 1; HCV-viremic donors, and group 2; HCV-negative donors. Inverse probability of treatment weighting (IPTW), with weights derived from the propensity score, were used to estimate the effect of donors' HCV-viremia on the recipients. The primary objective was to compare the 1-year incidence of de novo DSA. Secondary outcomes included group comparison of the incidence of biopsy proven acute rejection (BPAR), 1-year patient and allograft survival, and 1-year renal allograft function. RESULTS A total of 71 patients were included in the HCV NAT+ group, and 440 in the HCV- negative group. One-year incidence of de novo DSA was higher in the HCV NAT+ group in the IPTW weighted analysis (19% vs. 9%, p = .02). In the unweighted analysis, BPAR occurred in 7% of recipients in the HCV NAT+ group, compared to 3% in the control group (p = .06). However, due to the low event rate in the in the IPTW weighted groups, a statistical significance test could not be performed. Average estimated GFR was higher in the HCV-viremic group at 3 months (61 vs. 53 ml/min/1.73 m2 p = .002), but comparable at 6 (59 vs. 56 ml/min/1.73 m2 , p = .31) and 12 months (60 vs. 55 ml/min/1.73 m2 , p = .07). Patient and allograft survival were comparable between the two groups. CONCLUSION Kidney transplant from HCV-viremic donors was associated with an increased risk for the development of post-transplant de novo DSA in the first year after transplantation, but no difference in patient and graft survival.
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Affiliation(s)
- Reem Daloul
- Division of Nephrology, Department of Internal Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kalathil Sureshkumar
- Division of Nephrology, Department of Internal Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kendra Schnelle
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lauren Von Stein
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - April Logan
- Division of Transplantation, Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Todd Pesavento
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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21
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Steinbrink JM, Miller C, Myers RA, Sanoff S, Mazur A, Burke TW, Byrns J, Jackson AM, Luo X, McClain MT. Transcriptional responses define dysregulated immune activation in Hepatitis C (HCV)-naïve recipients of HCV-infected donor kidneys. PLoS One 2023; 18:e0280602. [PMID: 36701416 PMCID: PMC9879532 DOI: 10.1371/journal.pone.0280602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/03/2023] [Indexed: 01/27/2023] Open
Abstract
Renal transplantation from hepatitis C (HCV) nucleic acid amplification test-positive (NAAT-positive) donors to uninfected recipients has greatly increased the organ donation pool. However, there is concern for adverse outcomes in these recipients due to dysregulated immunologic activation secondary to active inflammation from acute viremia at the time of transplantation. This includes increased rates of cytomegalovirus (CMV) DNAemia and allograft rejection. In this study, we evaluate transcriptional responses in circulating leukocytes to define the character, timing, and resolution of this immune dysregulation and assess for biomarkers of adverse outcomes in transplant patients. We enrolled 67 renal transplant recipients (30 controls, 37 HCV recipients) and performed RNA sequencing on serial samples from one, 3-, and 6-months post-transplant. CMV DNAemia and allograft rejection outcomes were measured. Least absolute shrinkage and selection operator was utilized to develop gene expression classifiers predictive of clinical outcomes. Acute HCV incited a marked transcriptomic response in circulating leukocytes of renal transplant recipients in the acute post-transplant setting, despite the presence of immunosuppression, with 109 genes significantly differentially expressed compared to controls. These HCV infection-associated genes were reflective of antiviral immune pathways and generally resolved by the 3-month timepoint after sustained viral response (SVR) for HCV. Differential gene expression was also noted from patients who developed CMV DNAemia or allograft rejection compared to those who did not, although transcriptomic classifiers could not accurately predict these outcomes, likely due to sample size and variable time-to-event. Acute HCV infection incites evidence of immune activation and canonical antiviral responses in the human host even in the presence of systemic immunosuppression. After treatment of HCV with antiviral therapy and subsequent aviremia, this immune activation resolves. Changes in gene expression patterns in circulating leukocytes are associated with some clinical outcomes, although larger studies are needed to develop accurate predictive classifiers of these events.
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Affiliation(s)
- Julie M. Steinbrink
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
- * E-mail:
| | - Cameron Miller
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
| | - Rachel A. Myers
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
| | - Scott Sanoff
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Anna Mazur
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
| | - Thomas W. Burke
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Medical Center, Durham, NC, United States of America
| | - Annette M. Jackson
- Departments of Surgery and Immunology, Duke University, Durham, NC, United States of America
| | - Xunrong Luo
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Micah T. McClain
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, Durham, NC, United States of America
- Division of Infectious Diseases, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
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22
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Sawinski D, Rosenblatt RE, Morales JM. Renal transplantation using kidneys from hepatitis C-infected donors: A review of 30-years' experience. Nefrologia 2022:S2013-2514(22)00178-X. [PMID: 36564226 DOI: 10.1016/j.nefroe.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/18/2022] [Indexed: 06/17/2023] Open
Abstract
Kidney transplantation is the optimal therapy for end-stage kidney disease but limited by the available number of organs. Using HCV+ donors, both in HCV+ and HCV- recipients, is a rational response to the organ shortage. We review the historic experience using HCV+ donors in HCV+ recipients and assess long-term results. We also discuss contemporary practices, including the transplantation of HCV-viremic kidneys into HCV- recipients with different approaches to posttransplant HCV therapy.
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Affiliation(s)
- Deirdre Sawinski
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Russel E Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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23
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Azhar A, Tsujita M, Talwar M, Balaraman V, Bhalla A, Eason JD, Nouer SS, Sumida K, Remport A, Hall IE, Griffin R, Rofaiel G, Molnar MZ. CMV specific T cell immune response in hepatitis C negative kidney transplant recipients receiving transplant from hepatitis C viremic donors and hepatitis C aviremic donors. Ren Fail 2022; 44:831-841. [PMID: 35546431 PMCID: PMC9103398 DOI: 10.1080/0886022x.2022.2072744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/12/2022] [Accepted: 04/22/2022] [Indexed: 12/03/2022] Open
Abstract
Kidney transplants (KT) from hepatitis C (HCV) viremic donors to HCV negative recipients has shown promising renal outcomes, however, high incidence of cytomegalovirus (CMV) viremia were reported. We performed a prospective cohort study of 52 HCV negative KT recipients from Methodist University Hospital including 41 receiving transplants from HCV aviremic donors and 11 from HCV viremic donors. CMV specific CD4+ and CD8 + T cell immunity was measured by intracellular flow cytometry assay. Primary outcome was the development of positive CMV specific CD4+ and CD8 + T cell immune response in the entire cohort and each subgroup. The association between donor HCV status and CMV specific CD4+ and CD8 + T cell immune response was analyzed by Cox proportional hazard models. Mean recipient age was 48 ± 13 years, with 73% male and 82% African American. Positive CMV specific CD4+ and CD8 + T cell immune response was found in 53% and 47% of the cohort at 1 month, 65% and 70% at 2 months, 80% and 75% at 4 months, 89% and 87% at 6 months, and 94% and 94% at 9 months post-transplant, respectively. There was no significant difference in the incidence of positive CMV specific T cell immune response between recipients of transplants from HCV aviremic donors compared to HCV viremic donors in unadjusted (for CD8+: HR = 1.169, 95%CI: 0.521-2.623; for CD4+: HR = 1.208, 95%CI: 0.543-2.689) and adjusted (for CD8+: HR = 1.072, 95%CI: 0.458-2.507; for CD4+: HR = 1.210, 95%CI: 0.526-2.784) Cox regression analyses. HCV viremia in donors was not associated with impaired development of CMV specific T cell immunity in this cohort.
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Affiliation(s)
- Ambreen Azhar
- Department of Medicine, Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Simonne S. Nouer
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam Remport
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Isaac E. Hall
- Department of Medicine, Division of Nephrology & Hypertension, University of Utah, Salt Lake City, UT, USA
| | - Randi Griffin
- Office of Clinical Research, University of Tennessee Health Science Center, Memphis, TN, USA
| | - George Rofaiel
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, UT, USA
| | - Miklos Z. Molnar
- Department of Medicine, Division of Nephrology & Hypertension, University of Utah, Salt Lake City, UT, USA
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24
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Shadekejiang H, Zhu J, Wu X. Transplant of Kidneys From Hepatitis C Virus-Positive Donors To Hepatitis C Virus-Negative Recipients: A Retrospective Study and Systematic Review. EXP CLIN TRANSPLANT 2022; 20:1076-1084. [PMID: 36718006 DOI: 10.6002/ect.2022.0315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Kidneys from hepatitis C virus-positive donors were often discarded due to the lack of an effective treatment for hepatitis C virus. However, the advent of direct-acting antivirals has facilitated great progress for treatment of hepatitis C virus, providing additional opportunities for patients waiting for kidney transplant. We explored the feasibility and safety of kidney transplant from hepatitis C virus- positive donors to hepatitis C virus-negative recipients in combination with direct-acting antiviral therapy. MATERIALS AND METHODS This was a single-center retrospective study of 7 recipients of hepatitis C virus- positive kidneys from June 2018 to June 2021. All recipients were treated with sofosbuvir/velpatasvir for 12 weeks after kidney transplant. The primary recipients' outcome was achievement of sustained viral eradication at 12 weeks after treatment, and follow-up secondary outcomes were kidney function recovery, liver function, and adverse drug reactions. We reviewed previous studies, from 2017 to 2022, to analyze achievement of sustained viral eradication at 12 weeks after treatment, recipient and graft survival, and adverse event of kidney transplant from a hepatitis C virus-positive donor to a hepatitis C virus-negative recipient. RESULTS Median follow-up time was 71 weeks (range, 56-183 weeks). All recipients achieved sustained viral eradication at 12 weeks after treatment, and their kidney function recovered without severe liver damage or adverse drug reactions. Previous studies suggested that transplant of hepatitis C virus-positive donor kidneys is safe and feasible when combined with direct-acting antiviral therapy. However, details regarding optimal duration of treatment and directacting antiviral regimen remain undetermined, so prospective randomized studies are warranted. CONCLUSIONS Our study further confirms that kidney transplant from hepatitis C virus-positive donors to hepatitis C virus-negative recipients is safe and feasible with direct-acting antiviral treatment. Grafts from hepatitis C virus-infected donors may be effective to resolve the problem of kidney shortage.
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Affiliation(s)
- Halinuer Shadekejiang
- From the Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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25
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Jadoul M, Awan A, Berenguer M, Bruchfeld A, Fabrizi F, Goldberg D, Jia J, Kamar N, Mohamed R, Pessôa M, Pol S, Sise M, Martin P. KDIGO 2022 Clinical Practice Guideline FOR the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease. Kidney Int 2022; 102:S129-S205. [PMID: 36410841 DOI: 10.1016/j.kint.2022.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/19/2022]
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26
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Lushniak SA, Durand CM. Donors with human immunodeficiency virus and hepatitis C virus for solid organ transplantation: what's new. Curr Opin Infect Dis 2022; 35:321-329. [PMID: 35849522 PMCID: PMC9718437 DOI: 10.1097/qco.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF THE REVIEW Passage of the HOPE Act and the advent of direct-acting antiviral (DAA) therapies have allowed for expansion of the donor organ pool to include donors with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), thus providing new opportunities for waitlist candidates. This article provides updates on recent studies in solid organ transplantation (SOT) utilizing donors with HIV and HCV. RECENT FINDINGS The first pilot studies of kidney and liver transplantation from donors-with-HIV to recipients-with-HIV (HIV D+/R+) show robust patient survival, comparable graft survival to transplantation from donors without HIV (HIV D-/R+) and no increased rates of HIV breakthrough. The number of HIV D+ organs utilized has been lower than initial estimates due to several potential factors. With high numbers of overdose deaths from the opioid epidemic, there have been more HCV D+ organs available, leading to transplantation in recipients without HCV (HCV D+/R-) in combination with DAAs. Outcomes in both abdominal and thoracic HCV D+/R transplantation are excellent. SUMMARY With recent findings of good outcomes in both HIV D+/R+ and HCV D+/R- SOT, we feel the evidence supports both practices as standard clinical care options to mitigate organ shortage and reduce waitlist mortality.
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Affiliation(s)
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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27
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Daloul R, Schnelle K, Von Stein L, Logan A, Singh P, Yenebere P, Pesavento T, Washburn K. Kidney transplant from hepatitis C viremic donors into aviremic recipients and risk for post-transplant BK and CMV infection. Transpl Infect Dis 2022; 24:e13887. [PMID: 35752929 DOI: 10.1111/tid.13887] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/06/2022] [Accepted: 04/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND kidney transplantation from HCV-viremic donors to uninfected recipients is associated with excellent short-term outcomes. However, HCV viremia might be associated with an increased risk for post-transplant viral complications. METHODS We designed a retrospective study of HCV-negative kidney-only transplant recipients between 2018 and 2020. Recipients were grouped into group 1; HCV-negative donors, and group 2; HCV-viremic donors. Patients were matched 1:1 using propensity score. Primary objectives were to compare the incidence of CMV viremia ≥ 200 ml/IU, and BK viremia ≥1000 copies/ml between the groups. Secondary outcomes included group comparison of CMV disease, BK viremia ≥10,000 copies/ml, and one year patient and allograft survival. RESULTS The study included 634 patients in group 1, and 71 patients in group 2. 65 pairs of patients were matched. Incidence of CMV viremia (33.3% vs 40.0%, p = 0.4675), and BK viremia (15.9% vs 27.7%, P = 0.1353) did not differ significantly between groups in the matched cohort. Incidence of CMV disease (81.0% Vs 76.9%; p = 1.000), and BK viremia ≥10,000 copies/ml (9.5% vs 16.9%, p = 0.2987) were comparable between groups. There was no difference in the one-year patient or allograft survival between groups. CONCLUSION kidney transplant from HCV-viremic donors is not associated with increased risk for BK or CMV viremia. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Reem Daloul
- Division of Nephrology, Kidney and Pancreas Transplant Program, Allegheny General Hospital
| | - Kendra Schnelle
- Department of Pharmacy, The Ohio State University Wexner Medical Center
| | - Lauren Von Stein
- Department of Pharmacy, The Ohio State University Wexner Medical Center
| | - April Logan
- Division of Transplantation, Department of Surgery, The Ohio State University College of Medicine
| | - Priyamvada Singh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine
| | - Priya Yenebere
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine
| | - Todd Pesavento
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine
| | - Kenneth Washburn
- Division of Transplantation, Department of Surgery, The Ohio State University College of Medicine
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28
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Barnes E, Cooke GS, Lauer GM, Chung RT. Implementation of a controlled human infection model for evaluation of HCV vaccine candidates. Hepatology 2022; 77:1757-1772. [PMID: 35736236 DOI: 10.1002/hep.32632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 12/08/2022]
Abstract
Hepatitis C virus (HCV) remains a major global health concern. Directly acting antiviral (DAA) drugs have transformed the treatment of HCV. However, it has become clear that, without an effective HCV vaccine, it will not be possible to meet the World Health Organization targets of HCV viral elimination. Promising new vaccine technologies that generate high magnitude antiviral T and B cell immune responses and significant new funding have recently become available, stimulating the HCV vaccine pipeline. In the absence of an immune competent animal model for HCV, the major block in evaluating new HCV vaccine candidates will be the assessment of vaccine efficacy in humans. The development of a controlled human infection model (CHIM) for HCV could overcome this block, enabling the head-to-head assessment of vaccine candidates. The availability of highly effective DAA means that a CHIM for HCV is possible for the first time. In this review, we highlight the challenges and issues with currently available strategies to assess HCV vaccine efficacy including HCV "at-risk" cohorts and animal models. We describe the development of CHIM in other infections that are increasingly utilized by trialists and explore the ethical and safety concerns specific for an HCV CHIM. Finally, we propose an HCV CHIM study design including the selection of volunteers, the development of an infectious inoculum, the evaluation of host immune and viral parameters, and the definition of study end points for use in an HCV CHIM. Importantly, the study design (including number of volunteers required, cost, duration of study, and risk to volunteers) varies significantly depending on the proposed mechanism of action (sterilizing/rapid viral clearance vs. delayed viral clearance) of the vaccine under evaluation. We conclude that an HCV CHIM is now realistic, that safety and ethical concerns can be addressed with the right study design, and that, without an HCV CHIM, it is difficult to envisage how the development of an HCV vaccine will be possible.
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Affiliation(s)
- Eleanor Barnes
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Graham S Cooke
- Department of Infectious Disease, Imperial College London, Oxford, UK
| | - Georg M Lauer
- Liver Center, GI Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center, GI Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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29
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Survival Benefit in Older Patients Transplanted With Viremic Hepatitis C Positive Kidneys When Compared With High KDPI Kidneys. Transplantation 2022; 106:2217-2223. [PMID: 35675439 DOI: 10.1097/tp.0000000000004179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Because of the continued demand in kidney transplantation, organs from donors with risk criteria for blood-borne viruses, high Kidney Donor Profile Index (KDPI) kidneys, and hepatitis C virus (HCV)-positive kidneys are being considered. There continues to be reluctance on the part of the providers and the candidates to accept HCV-positive kidneys. METHODS We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adult (≥18 y old) recipients undergoing kidney transplant from May 10, 2013, to June 30, 2021. We compared patient and graft survival in candidates who received HCV-positive kidneys versus non-hepatitis C (Hep C) high KDPI kidneys by estimated posttransplant survival (EPTS) groups. RESULTS HCV-viremic kidneys were transplanted in 5.6% of patients in the EPTS >61% group compared with 5.1% of patients in the 21%-60% EPTS group and 1.9% of 0%-20% EPTS group (P < 0.001). Of all transplants performed in the EPTS 61%-100% group, 11.9% were KDPI >85% compared with 5.2% in the EPTS 21%-60%, and 0.5% in the EPTS 0%-20%. Patient survival was significantly longer at 1, 3, and 5 y in the EPTS >61% group who received Hep C-viremic or -nonviremic allografts compared with non-Hep C kidneys with KDPI >85%. When it comes to listing, only 25% of candidates in the EPTS >61% group were listed for Hep C nucleic acid testing-positive kidneys in 2021. CONCLUSIONS Our findings could be used for counseling candidates on the types of kidneys they should consider for transplantation. Also, listing practices for viremic Hep C kidneys need continued re-evaluation.
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30
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Liver Outcome in Renal Transplant Recipients Who Acquired Hepatitis C Infection From an Infected Graft: Study Based on Liver Biopsy Findings. Transplant Direct 2022; 8:e1342. [PMID: 35651584 PMCID: PMC9148688 DOI: 10.1097/txd.0000000000001342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022] Open
Abstract
Long-term liver outcome in hepatitis C virus (HCV)-negative kidney recipients who acquired HCV infection from viremic donors is of intense interest in the transplant community. We evaluated the incidence of fibrosis in liver biopsy specimens of recipients who were transplanted with HCV-infected grafts.
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31
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Doherty DT, Athwal V, Moinuddin Z, Augustine T, Prince M, van Dellen D, Khambalia HA. Kidney Transplantation From Hepatitis-C Viraemic Donors:Considerations for Practice in the United Kingdom. Transpl Int 2022; 35:10277. [PMID: 35592447 PMCID: PMC9110637 DOI: 10.3389/ti.2022.10277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/11/2022] [Indexed: 12/01/2022]
Abstract
Background: Donor hepatitis-C (HCV) infection has historically represented a barrier to kidney transplantation (KT). However, direct-acting antiviral (DAA) medications have revolutionised treatment of chronic HCV infection. Recent American studies have demonstrated that DAA regimes can be used safely peri-operatively in KT to mitigate HCV transmission risk. Methods: To formulate this narrative review, a comprehensive literature search was performed to analyse results of existing clinical trials examining KT from HCV-positive donors to HCV-negative recipients with peri-operative DAA regimes. Results: 13 studies were reviewed (11 single centre, four retrospective). Outcomes for 315 recipients were available across these studies. A sustained virological response at 12 weeks (SVR12) of 100% was achieved in 11 studies. One study employed an ultra-short DAA regime and achieved an SVR12 of 98%, while another achieved SVR12 of 96% due to treatment of a missed mixed genotype. Conclusion: HCV+ KT is safe and may allow increased utilisation of organs for transplantation from HCV+ donors, who often have other favourable characteristics for successful donation. Findings from US clinical trials can be applied to the United Kingdom transplant framework to improve organ utilisation as suggested by the NHSBT vision strategy "Organ Donation and Transplantation 2030: meeting the need".
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Affiliation(s)
- Daniel T. Doherty
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Varinder Athwal
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Hepatology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Zia Moinuddin
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Titus Augustine
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Martin Prince
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Hepatology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David van Dellen
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Hussein A. Khambalia
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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32
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Kuntzen C, Bagha Z. The Use of Hepatitis C Virus-Positive Organs in Hepatitis C Virus-Negative Recipients. Clin Liver Dis 2022; 26:291-312. [PMID: 35487612 DOI: 10.1016/j.cld.2022.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The use of hepatitis C virus (HCV) -positive organs in HCV-negative recipients with posttransplant antiviral treatment has increasingly been studied since the introduction of new direct-acting antivirals. This article reviews existing experience in liver and kidney transplant. Fifteen studies with 218 HCV D+/R- liver transplants, with 182 from viremic donors, show a sustained viral response for 12 weeks (SVR12) rate of 99.5%. Nine studies involving 204 HCV donor-positive recipient-negative kidney transplant recipients had an SVR12 rate of 99.5%. Complications are infrequent. Preemptive treatment in kidney transplant of for only 4 weeks or even 4 days showed surprising success rates.
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Affiliation(s)
- Christian Kuntzen
- Hofstra University at Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Zohaib Bagha
- Hofstra University at Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA
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Sawinski D, Rosenblatt RE, Morales JM. Renal transplantation using kidneys from hepatitis C-infected donors: A review of 30-years’ experience. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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34
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Gupta G, Devarakonda T, Sharma A, Miles M, Yakubu I, Khan A, Sterling RK. Ultrashort Duration Prophylaxis for Hepatitis C Donor Positive to Recipient Negative Simultaneous Kidney/Pancreas Transplants. Transplantation 2022; 106:e234-e235. [PMID: 35333848 DOI: 10.1097/tp.0000000000004022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Aadi Sharma
- Virginia Commonwealth University, Richmond, VA
| | | | | | - Aamir Khan
- Virginia Commonwealth University, Richmond, VA
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Czarnecka P, Czarnecka K, Tronina O, Baczkowska T, Durlik M. Utilization of HCV viremic donors in kidney transplantation: a chance or a threat? Ren Fail 2022; 44:434-449. [PMID: 35260039 PMCID: PMC8920354 DOI: 10.1080/0886022x.2022.2047069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Kidney transplantation is the treatment of choice in end-stage renal disease. The main issue which does not allow to utilize it fully is the number of organs available for transplant. Introduction of highly effective oral direct-acting antivirals (DAAs) to the treatment of chronic hepatitis C virus infection (HCV) enabled transplantation of HCV viremic organs to naive recipients. Despite an increasing number of reports on the satisfying effects of using HCV viremic organs, including kidneys, they are more often rejected than those from HCV negative donors. The main reason is the presence of HCV viremia and not the quality of the organ. The current state of knowledge points to the fact that a kidney transplant from an HCV nucleic acid testing positive (NAT+) donor to naive recipients is an effective and safe solution to the problem of the insufficient number of organs available for transplantation. It does not, however, allow to draw conclusions as to the long-term consequence of such an approach. This review analyzes the possibilities and limitations of the usage of HCV NAT + donor organs. Abbreviations: DAA: direct-acting antivirals; HCV: hepatitis C virus; NAT: nucleic acid testing; OPTN: Organ Procurement and Transplantation Network; KDIGO: Kidney Disease: Improving Global Outcomes; Ab: antigen; eGFR: estimated glomerular filtration rate; D: donor; R: recipient; CMV: cytomegalovirus; HBV: hepatitis B virus; UNOS: United Network for Organ Sharing; PHS: Public Health Service; EBR/GZR: elbasvir/grazoprevir; SVR: sustained virologic response; RAS: resistance-associated substitutions; SOF: soforbuvir; GLE/PIB: glecaprevir/pibrentasvir; ACR: acute cellular rejection; AR: acute rejection; DSA: donor-specific antibodies; KTR: kidney transplant recipients; AASLD: American Association for the Study of Liver Disease; IDSA: Infectious Diseases Society of America; PPI: proton pump inhibitors; CKD: chronic kidney disease; GN: glomerulonephritis; KAS: The Kidney Allocation system.
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Affiliation(s)
- Paulina Czarnecka
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Kinga Czarnecka
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Olga Tronina
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Teresa Baczkowska
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Molnar MZ, Potluri VS, Schaubel DE, Sise ME, Concepcion BP, Forbes RC, Blumberg E, Bloom RD, Shaffer D, Chung RT, Strohbehn IA, Elias N, Azhar A, Shah M, Sawinski D, Binari LA, Talwar M, Balaraman V, Bhalla A, Eason JD, Besharatian B, Trofe-Clark J, Goldberg DS, Reese PP. Association of donor hepatitis C virus infection status and risk of BK polyomavirus viremia after kidney transplantation. Am J Transplant 2022; 22:599-609. [PMID: 34613666 PMCID: PMC8968853 DOI: 10.1111/ajt.16834] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/01/2021] [Accepted: 09/03/2021] [Indexed: 02/03/2023]
Abstract
Kidney transplantation (KT) from deceased donors with hepatitis C virus (HCV) into HCV-negative recipients has become more common. However, the risk of complications such as BK polyomavirus (BKPyV) remains unknown. We assembled a retrospective cohort at four centers. We matched recipients of HCV-viremic kidneys to highly similar recipients of HCV-aviremic kidneys on established risk factors for BKPyV. To limit bias, matches were within the same center. The primary outcome was BKPyV viremia ≥1000 copies/ml or biopsy-proven BKPyV nephropathy; a secondary outcome was BKPyV viremia ≥10 000 copies/ml or nephropathy. Outcomes were analyzed using weighted and stratified Cox regression. The median days to peak BKPyV viremia level was 119 (IQR 87-182). HCV-viremic KT was not associated with increased risk of the primary BKPyV outcome (HR 1.26, p = .22), but was significantly associated with the secondary outcome of BKPyV ≥10 000 copies/ml (HR 1.69, p = .03). One-year eGFR was similar between the matched groups. Only one HCV-viremic kidney recipient had primary graft loss. In summary, HCV-viremic KT was not significantly associated with the primary outcome of BKPyV viremia, but the data suggested that donor HCV might elevate the risk of more severe BKPyV viremia ≥10 000 copies/ml. Nonetheless, one-year graft function for HCV-viremic recipients was reassuring.
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Affiliation(s)
- Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vishnu S. Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, Philadelphia, PA
| | - Meghan E. Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Beatrice P. Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Rachel C. Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Emily Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Roy D. Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Raymond T. Chung
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
| | - Ian A. Strohbehn
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Nahel Elias
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Boston MA
| | - Ambreen Azhar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mital Shah
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Deirdre Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Laura A. Binari
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Behdad Besharatian
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | | | - David S. Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, FL
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
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Richter BI, Parent B, Lonze BE. The Moral Necessity to Increase Access to HCV+ Transplants With Early Treatment for HCV-naive Patients. Transplantation 2022; 106:236-238. [PMID: 34342960 DOI: 10.1097/tp.0000000000003898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Benjamin I Richter
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY
| | - Brendan Parent
- Division of Medical Ethics, Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Bonnie E Lonze
- Transplant Institute, New York University Langone Health, New York, NY
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38
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Sise ME, Goldberg DS, Schaubel DE, Fontana RJ, Kort JJ, Alloway RR, Durand CM, Blumberg EA, Woodle ES, Sherman KE, Brown RS, Friedewald JJ, Desai NM, Sultan ST, Levitsky J, Lee MD, Strohbehn IA, Landis JR, Fernando M, Gustafson JL, Chung RT, Reese PP. One-Year Outcomes of the Multi-Center StudY to Transplant Hepatitis C-InfeCted kidneys (MYTHIC) Trial. Kidney Int Rep 2022; 7:241-250. [PMID: 35155863 PMCID: PMC8820987 DOI: 10.1016/j.ekir.2021.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Transplanting kidneys from hepatitis C virus (HCV) viremic donors into HCV-negative patients (HCV D-RNA-positive/R-negative) has evolved from experimental to “standard-of-care” at many centers. Nevertheless, most data derive from single centers and provide only short-term follow-up. Methods The Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC) study was a multicenter (7 sites) trial of HCV D-RNA-positive/R-negative kidney transplantation (KT) followed by 8 weeks of glecaprevir/pibrentasvir (G/P) initiated 2 to 5 days post-KT. Prespecified outcomes included probability of KT (vs. matched waitlist comparators) and 1-year safety outcomes, allograft function, and survival. Results Among 63 enrolled patients, 1-year cumulative incidence of KT was approximately 3.5-fold greater for the MYTHIC cohort versus 2055 matched United Network for Organ Sharing (UNOS) comparators who did not opt-in to receive a kidney from an HCV-viremic donor (68% vs. 19%, P < 0.0001). Of 30 HCV D-RNA-positive/R-negative KT recipients, all achieved HCV cure. None developed clinically significant liver disease or HCV-related kidney injury. Furthermore, 1-year survival was 93% and 1-year graft function was excellent (median creatinine 1.17; interquartile range [IQR]: 1.02–1.38 mg/dl). There were 4 cases of cytomegalovirus (CMV) disease among 10 CMV-negative patients transplanted with a kidney from an HCV-viremic/CMV-positive donor. Conclusion The 1-year findings from this multicenter trial suggest that opting-in for HCV-viremic KT offers can increase probability of KT with excellent 1-year outcomes. Trial Registration: NCT03781726
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El Helou G, Jay C, Nunez M. Hepatitis C virus and kidney transplantation: Recent trends and paradigm shifts. Transplant Rev (Orlando) 2022; 36:100677. [DOI: 10.1016/j.trre.2021.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/28/2021] [Accepted: 12/31/2021] [Indexed: 12/09/2022]
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40
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Kim M, Stern J, Robalino R, Weldon EP, Ali N, Mehta SA, Stewart ZA, Lonze BE. Caregiver exposure to hepatitis C virus following transplantation with hepatitis C viremic donor organs: A case series. Transpl Infect Dis 2021; 24:e13775. [PMID: 34910839 DOI: 10.1111/tid.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Direct acting antiviral (DAA) therapeutics have ushered in an era in which transplanting organs from donors infected with hepatitis C virus (HCV+) into recipients without (HCV-) is an increasingly common practice. Rare but potentially life-threatening events have been reported in recipients of HCV+ organs. METHODS Since 2018 at our institution, 182 HCV- patients have received HCV+ donor organs. Here, we retrospectively reviewed cases in which recipients' family member caregivers reported sustaining needlestick exposures at home following discharge of the transplant recipient from the hospital. RESULTS Caregiver needlestick exposures were passively reported in three cases of HCV+ into HCV- transplants (1.64% of such cases at our center). In all instances, the exposed individuals were aiding in diabetic management and the exposure occurred via lancets or insulin needles. In one case, the recipient viral load was undetectable at the time of the exposure but in the other two, recipients were viremic, putting their family members at risk to contract HCV infection. Surveillance for the exposed individuals was undertaken and no transmissions occurred. DISCUSSION For centers performing HCV+ into HCV- transplants, it is important that informed consent includes discussion of potential secondary risks to family members and caregivers. Further, protocols for post-exposure surveillance and for the acquisition of DAA treatment in the event of a secondary transmission should be in place. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michelle Kim
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Jeffrey Stern
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Ryan Robalino
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Elaina P Weldon
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - NicoleM Ali
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Sapna A Mehta
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Zoe A Stewart
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Bonnie E Lonze
- Transplant Institute, New York University Langone Health, New York, NY, USA
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Kreitman KR, Kothadia JP, Nair SP, Maliakkal BJ. Unexpected hepatitis B virus transmission after liver transplant from nucleic acid testing- and serology-negative liver donors who are hepatitis C viremic. Hepatol Res 2021; 51:1242-1246. [PMID: 34114715 DOI: 10.1111/hepr.13680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 01/15/2023]
Abstract
The opioid epidemic has led to increased availability of organs for liver transplantation. The success of direct-acting antiviral therapy for hepatitis C (HCV) has led to the acceptance of HCV viremic donor organs. Nucleic acid testing (NAT) has led to increased detection of HCV and hepatitis B (HBV) in potential donors. A total of 36 patients underwent liver transplantation from donation after brain death donors who were HCV NAT-positive, and three of them were diagnosed with HBV several months after. All three recipients received livers from HCV viremic donors who were negative for HBV by serology and NAT. Soon after liver transplantation, HCV was treated, and all achieved sustained virologic response. They became HBV DNA-positive shortly thereafter. To date, there have been no reported cases of unexpected HBV transmission since universal donor NAT was implemented in 2013. We postulate that the inhibitory effect of HCV viremia on HBV may have prolonged the "NAT window period" in these donors beyond the 20-22 days quoted for solitary HBV infection. These cases highlight the need for more intensive and prolonged screening for HBV in recipients of livers from HCV viremic donors.
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Affiliation(s)
- Kyle R Kreitman
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Jiten P Kothadia
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Satheesh P Nair
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Benedict J Maliakkal
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Fruh K, Duman EK. Offering more without offering compensation: non-compensating benefits for living kidney donors. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:711-719. [PMID: 34165674 DOI: 10.1007/s11019-021-10034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 06/13/2023]
Abstract
While different positions on the permissibility of organ markets enjoy support, there is widespread agreement that some benefits to living organ donors are acceptable and do not raise the same moral concerns associated with organ markets, such as exploitation and commodification. We argue on the basis of two distinctions that some benefit packages offered to donors can defensibly surpass conventional reimbursement while stopping short of controversial cash payouts. The first distinction is between benefits that defray the costs of donating an organ and benefits that incentivize donation by offering something in excess of defraying. The second distinction is between benefits that compensate donors and benefits that are non-compensating. We argue that non-compensating benefits are innocent of moral concerns typically associated with controversial cash payouts, and thus may be a morally promising avenue for increasing rates of kidney donation to address the tragic results of undersupply.
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Affiliation(s)
- Kyle Fruh
- Duke Kunshan University, Kunshan, China.
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43
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Gupta G, Yakubu I, Zhang Y, Kimball P, Kang L, Mitchell K, Ijioma S, Carroll N, Patterson J, Shinbashi M, Kumar D, Moinuddin I, Kamal L, King A, Bhati C, Levy M, Cotterell A, Khan A, Sharma A, Sterling R. Outcomes of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants. Am J Transplant 2021; 21:3734-3742. [PMID: 34212479 DOI: 10.1111/ajt.16747] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 01/25/2023]
Abstract
Trials describing 4- to 12-week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R- transplants) may be limited in "real-world" application by costs and delayed access to DAAs. We previously reported HCV transmission of 13% among D+/R- transplants with 2- to 4-day pangenotypic sofosbuvir/velpatasvir (SOF/VEL) perioperative prophylaxis, where one patient with HCV transmission was a nonresponder to first-line full-course DAA. Here, we report new data with a 7-day prophylaxis protocol (N = 50), as well as cumulative treatment and outcome data on all HCV D+/R- transplants (N = 102). Overall, nine patients (9/102; 9%; 95% CI: 5%-16%) developed HCV transmission, with a significant decline noted in the 7-day group (2/50; 4%; 95% CI: 0%-13%) compared with 2- to 4-day prophylaxis (7/52; 13%; 95% CI: 5%-25%). All patients with HCV transmission achieved sustained virologic response post full-course therapy (including one nonresponder from initial trial). A 1:1 matched analysis (N = 102) with contemporary HCV D-/R- transplants (controls) showed that although the pretransplant wait time was significantly shorter for D+/R- compared with D-/R- (mean: 1.8 vs. 4.4 years; p < .001), there were no differences in infections, rejection, development of de novo donor-specific antibody, or transplant outcomes up to 6 months of transplant.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Idris Yakubu
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Yiran Zhang
- Global Health Economics & Outcomes Research, Indivior Inc., Richmond, Virginia, USA
| | - Pamela Kimball
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kimberly Mitchell
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Stephen Ijioma
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Norman Carroll
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Julie Patterson
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Meagan Shinbashi
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Irfan Moinuddin
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Anne King
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Chandra Bhati
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Marlon Levy
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Adrian Cotterell
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Aamir Khan
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Amit Sharma
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Richard Sterling
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Section of Hepatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Franco A, Moreso F, Sancho A, Esforzado N, Paul J, Llorente S, Crespo M, Guirado L, Melilli E, Roncero FG. Protocol for Optimizing the Use of Kidneys From Donors With Seropositivity for Hepatitis C Virus in Seronegative Recipients. Transplant Proc 2021; 53:2655-2658. [PMID: 34657711 DOI: 10.1016/j.transproceed.2021.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The rapid identification of the viral load from hepatitis C virus (HCV) in seropositive donors enables the determination of their infection capacity and the subsequent design of a strategy to optimize the use of direct-action antivirals (DAA) in seronegative recipients. In 2017, we designed an optimization protocol; this study aims to assess its efficacy and safety. METHODS This is a prospective, multicenter observational study that complies with the Declarations of Helsinki and Istanbul. Donors were HCV seropositive. The HCV and human immunodeficiency virus loads were immediately determined in the donors. For viremic donors, recipients were treated with DAA for 8 weeks. For nonviremic donors, DAA was started if a viral load was detected during the follow-up period. The minimum follow-up period was 6 months posttransplant. RESULTS This study recruited 28 donors. Just over half of the donors (n = 15; 53.5%) had a nonactive history of injection drug use. Eight (22.4%) donors were viremic, and 20 (87.6%) were nonviremic; 13 (65%) had been treated previously. Nine grafts were ineligible for the protocol. We performed a total of 47 transplants. Procedure I (viremic donors) was performed in 13 recipients (27.7%). Posttransplant viremia was observed in 6 participants. Posttransplant viremia was low (<100 IU/mL) in 4 participants but high (36,000 and 138,000 IU/mL) in 2 participants who had initiated DAA after the transplant; all these patients had a sustained viral response. Seroconversion was observed in 11 of 13 (84.6%) patients. Procedure II (nonviremic donors) was undertaken in 34 (82.3%) patients. No positive viral loads were observed. Seroconversion occurred in 7 of 34 (20.5%) recipients. All recipients maintained kidney function at 6 months posttransplant, except 1 patient with a graft that had never been functional and another patient who died of pancreatitis. Both patients had received kidneys from nonviremic donors. CONCLUSIONS Our experience supports the efficacy and safety of this protocol.
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Affiliation(s)
- Antonio Franco
- Department of Nephrology, Hospital General Universitario, Alicante, Spain.
| | - Francesc Moreso
- Department of Nephrology, Hospital Valld´Hebron, Barcelona, Spain; Department of Nephrology, Hospital Doctor Peset, Valencia, Spain
| | - Asuncion Sancho
- Department of Nephrology, Hospital Doctor Peset, Valencia, Spain
| | | | - Javier Paul
- Department of Nephrology, Hospital Miguel Servet, Zaragoza, Spain
| | - Santiago Llorente
- Department of Nephrology, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Luis Guirado
- Department of Nephrology, Hospital Puigvert, Barcelona, Spain
| | - Eduardo Melilli
- Department of Nephrology, Hospital Belvitge, Barcelona, Spain
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Azhar A, Binari LA, Joglekar K, Tsujita M, Talwar M, Balaraman V, Bhalla A, Eason JD, Hall IE, Rofaiel G, Forbes RC, Shaffer D, Concepcion BP, Molnar MZ. Association between ezetimibe usage and hepatitis C RNA levels in uninfected kidney transplant recipients who received hepatitis C infected kidneys. Clin Transplant 2021; 35:e14485. [PMID: 34523744 DOI: 10.1111/ctr.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/24/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022]
Abstract
Kidney transplantation (KT) from hepatitis C virus infected (HCV+) donors to HCV negative recipients achieve excellent graft function but have relatively higher rates of post-KT co-infections presumably due to prolonged HCV viremia in transmission-and-treat approach. Ezetimibe acts as an antagonist of Niemann-Pick C1-Like 1 receptor required for HCV entry and theoretically can reduce HCV viremia. However, no data is available to examine the role of ezetimibe as a bridge therapy between KT surgery and direct acting antiviral (DAA) initiation. A retrospective cohort study including 70 HCV+ to HCV negative KT recipients from Methodist University Hospital and Vanderbilt University Medical Center was performed to determine the association between ezetimibe usage and HCV viremia. Twenty patients received ezetimibe daily while 50 patients did not. Primary outcome of study was mean HCV RNA level at 1-2 weeks post-KT and before initiation of DAA. Median (IQR) viral load (VL) in log copies/ml was one log lower in ezetimibe group versus non-ezetimibe group (4.1 [3.7-5.3] vs. 5.1 [4.4-5.5], P = .01), and highest VL was also lower in ezetimibe group (4.2 [3.7-5.4] vs. 5.4 [4.7-5.9], P = .006). We concluded that ezetimibe bridge therapy might be associated with reduction in HCV VL while waiting for DAA initiation in HCV+ to HCV negative KT recipients.
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Affiliation(s)
- Ambreen Azhar
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Laura A Binari
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kiran Joglekar
- Division of Gastroenterology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - George Rofaiel
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
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Clinical and Financial Implications of 2 Treatment Strategies for Donor-derived Hepatitis C Infections. Transplant Direct 2021; 7:e762. [PMID: 34514117 PMCID: PMC8425828 DOI: 10.1097/txd.0000000000001222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022] Open
Abstract
Transplanting hepatitis C viremic donor organs into hepatitis C virus (HCV)-negative recipients is becoming increasingly common; however, practices for posttransplant direct-acting antiviral (DAA) treatment vary widely. Protracted insurance authorization processes for DAA therapy often lead to treatment delays.
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Edmonds C, Carver A, DeClercq J, Choi L, Peter M, Schlendorf K, Perri R, Forbes RC, Concepcion BP. Access to hepatitis C direct-acting antiviral therapy in hepatitis C-positive donor to hepatitis C-negative recipient solid-organ transplantation in a real-world setting. Am J Surg 2021; 223:975-982. [PMID: 34548142 DOI: 10.1016/j.amjsurg.2021.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Emerging data supports expanding the solid organ donor pool with transplantation from hepatitis C virus (HCV)-positive donors into HCV-negative recipients. However, concerns exist regarding the ability to access direct-acting antivirals (DAAs) post-transplant in a real-world setting. METHODS This single-center, retrospective study evaluated DAA access rates, time to first dose, and patient cost in donor-derived HCV solid-organ transplant recipients utilizing an integrated specialty pharmacy process. RESULTS Among 91 patients, all accessed DAAs through prescription insurance (97%) or patient assistance programs (3%). Of those who received DAAs through insurance, only 65% received approval on initial insurance submission. Median time from transplant to first dose was 45d [IQR 34-66]. The on-site specialty pharmacy was used by 69% of patients. Copay assistance programs reduced the median monthly patient cost from $1914 [range $7-7536] to $0 [range $0-5]. CONCLUSION Our findings indicate that access to DAAs in donor-derived HCV post-transplant is achievable and affordable; however, significant added administrative efforts may be required for insurance approval as well as obtaining copay assistance, which is a limited resource.
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Affiliation(s)
- Cori Edmonds
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Alicia Carver
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Megan Peter
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kelly Schlendorf
- Section of Heart Failure and Cardiac Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Roman Perri
- Department of Medicine, Division of Hepatology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.
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Kidney Transplantation From Hepatitis C Viremic Deceased Donors to Aviremic Recipients in a Real-world Setting. Transplant Direct 2021; 7:e761. [PMID: 34514116 PMCID: PMC8425827 DOI: 10.1097/txd.0000000000001217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background. Transplantation of hepatitis C viremic (HCV+) deceased donor kidney transplants (DDKT) into aviremic (HCV–) recipients is a strategy to increase organ utilization. However, there are concerns around inferior recipient outcomes due to delayed initiation of direct-acting antiviral (DAA) therapy and sustained HCV replication when implemented outside of a research setting. Methods. This was a retrospective single-center matched cohort study of DDKT recipients of HCV+ donors (cases) who were matched 1:1 to recipients of HCV– donors (comparators) by age, gender, race, presence of diabetes, kidney donor profile index, and calculated panel-reactive antibody. Data were analyzed using summary statistics, t-tests, and chi-square tests for between-group comparisons, and linear mixed-effects models for longitudinal data. Results. Each group consisted of 50 recipients with no significant differences in baseline characteristics. The 6-mo longitudinal trajectory of serum creatinine and estimated glomerular filtration rate did not differ between groups. All recipients had similar rates of acute rejection and readmissions (all P > 0.05). One case lost the allograft 151 d posttransplant because of acute rejection, and 1 comparator died on postoperative day 7 from cardiac arrest. HCV+ recipients initiated DAA on average 29 ± 11 d posttransplant. Ninety-eight percent achieved sustained virologic response at 4 and 12 wks with the first course of therapy; 1 patient had persistent HCV infection and was cured with a second course of DAA. Conclusions. Aviremic recipients of HCV+ DDKT with delayed DAA initiation posttransplant had similar short-term outcomes compared with matched recipient comparators of HCV– donors.
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Raasikh T, Jamali T, Flores A, Cotton RT, Ramanathan V, Tan HP, Hernaez R. Systematic review: hepatitis C viraemic allografts to hepatitis C-negative recipients in solid organ transplantation. Aliment Pharmacol Ther 2021; 54:571-582. [PMID: 34265111 DOI: 10.1111/apt.16508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/14/2021] [Accepted: 06/16/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Given the success of direct-acting antivirals (DAAs) in treating hepatitis C (HCV), interest is growing in utilizing solid organs from allografts with active HCV to expand donor availability. AIM To review post-transplant outcomes and patient survival in HCV-negative recipients receiving solid organ transplants (SOT) from viraemic, that is, HCV+/NAT+ (nucleic acid testing) allografts. METHODS A literature search was conducted on PubMed and EMBASE from 01/01/2007 to 4/17/2021 for articles matching eligibility criteria. Two authors independently screened titles and abstracts. Disagreements were solved by a third independent reviewer. Methodological quality assessment was done using a modified Newcastle-Ottawa scale (NOS). Data synthesis was done qualitatively using median, ranges and percentages. RESULTS Thirty-five studies were included (or 852 SOTs): 343 kidney, 233 heart, 204 liver, and 72 lung transplants from viraemic allografts. Of the recipients eligible for sustained virological response at 12 weeks (SVR12) calculation, 100% achieved cure from HCV. No deaths/graft failures were reported to be related to HCV transmission. Seven SOT recipients had viral relapse, with all seven patients treated successfully. Four patients developed fibrosing cholestatic hepatitis with complete resolution post-treatment. CONCLUSIONS Transplanting viraemic organs into uninfected individuals can become the standard of care for patients who do not have contraindications to DAAs.
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Affiliation(s)
- Taaj Raasikh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Taher Jamali
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Avegail Flores
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Venkat Ramanathan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Henkie P Tan
- Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, VA Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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50
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Strohbehn IA, Seethapathy R, Lee M, Sise ME. Curative Therapies for Hepatitis C Virus Infection in Patients with Kidney Disease. KIDNEY360 2021; 2:1316-1325. [PMID: 35369667 PMCID: PMC8676392 DOI: 10.34067/kid.0001812021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/21/2021] [Indexed: 02/04/2023]
Abstract
Through the discovery of direct-acting antiviral therapies over the last decade, hepatitis C virus (HCV) has been transformed from a highly morbid and potentially fatal chronic viral infection to a curable illness. HCV is common in patients with kidney disease, is a risk factor for progression of CKD, is associated with higher morbidity and mortality in patients receiving dialysis, and leads to worse allograft and patient outcomes in recipients of kidney transplants. Clinical trial and real-world data of direct-acting antivirals in patients with kidney disease demonstrate extremely high cure rates and favorable adverse event profiles. This review covers the transformative effects of curative HCV therapies on patients with kidney disease, including patients with CKD, ESKD, and those who have received a kidney transplant.
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Affiliation(s)
- Ian A Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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