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Sutcliffe S, Ji M, Chang SH, Stewart D, Axelrod DA, Lentine KL, Wellen J, Alrata L, Gupta G, Alhamad T. The association of donor hepatitis C virus infection with 3-year kidney transplant outcomes in the era of direct-acting antiviral medications. Am J Transplant 2023; 23:629-635. [PMID: 37130619 DOI: 10.1016/j.ajt.2022.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 01/14/2023]
Abstract
To determine the effect of donor hepatitis C virus (HCV) infection on kidney transplant (KT) outcomes in the era of direct-acting antiviral (DAA) medications, we examined 68,087 HCV-negative KT recipients from a deceased donor between March 2015 and May 2021. A Cox regression analysis was used to estimate adjusted hazard ratios (aHRs) of KT failure, incorporating inverse probability of treatment weighting to control for patient selection to receive an HCV-positive kidney (either nucleic acid amplification test positive [NAT+, n = 2331] or antibody positive (Ab+)/NAT- [n = 1826]) based on recipient characteristics. Compared with kidney from HCV-negative donors, those from Ab+/NAT- (aHR = 0.91; 95% confidence interval [CI], 0.75-1.10) and HCV NAT+ (aHR = 0.89; 95% CI, 0.73-1.08) donors were not associated with an increased risk of KT failure over 3 years after transplant. Moreover, HCV NAT+ kidneys were associated with a higher 1-year estimated glomerular filtration (63.0 vs 61.0 mL/min/1.73 m2, P = .007) and lower risk of delayed graft function (aOR = 0.76; 95% CI, 0.68-0.84) compared with HCV-negative kidneys. Our findings suggest that donor HCV positivity is not associated with an elevated risk of graft failure. The inclusion of donor HCV status in the Kidney Donor Risk Index may no longer be appropriate in contemporary practice.
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Affiliation(s)
- Siobhan Sutcliffe
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA
| | - Mengmeng Ji
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA; Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Washington University in St Louis, St Louis, Missouri, USA
| | - Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Krista L Lentine
- Division of Nephrology, Saint Louis University, St Louis, Missouri, USA
| | - Jason Wellen
- Division of Transplant Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Louai Alrata
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri, USA.
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Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.
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Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
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3
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Yuan Q, Hong S, Leya G, Roth E, Tsoulfas G, Williams WW, Madsen JC, Elias N. Analysis of the effects of donor and recipient hepatitis C infection on kidney transplant outcomes in the United States. World J Transplant 2023; 13:44-57. [PMID: 36908306 PMCID: PMC9993188 DOI: 10.5500/wjt.v13.i2.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 12/21/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND As Hepatitis C virus infection (HCV+) rates in kidney donors and transplant recipients rise, direct-acting antivirals (DAA) may affect outcomes.
AIM To analyze the effects of HCV+ in donors, recipients, or both, on deceased-donor (DD) kidney transplantation (KT) outcomes, and the impact of DAAs on those effects.
METHODS The Organ Procurement and Transplantation Network data of adult first solitary DD-KT recipients 1994-2019 were allocated into four groups by donor and recipient HCV+ status. We performed patient survival (PS) and death-censored graft survival (DCGS) pairwise comparisons after propensity score matching to assess the effects of HCV+ in donors and/or recipients, stratifying our study by DAA era to evaluate potential effect modification.
RESULTS Pre-DAA, for HCV+ recipients, receiving an HCV+ kidney was associated with 1.28-fold higher mortality (HR 1.151.281.42) and 1.22-fold higher death-censored graft failure (HR 1.081.221.39) compared to receiving an HCV- kidney and the absolute risk difference was 3.3% (95%CI: 1.8%-4.7%) for PS and 3.1% (95%CI: 1.2%-5%) for DCGS at 3 years. The HCV dual-infection (donor plus recipient) group had worse PS (0.56-fold) and DCGS (0.71-fold) than the dual-uninfected. Donor HCV+ derived worse post-transplant outcomes than recipient HCV+ (PS 0.36-fold, DCGS 0.34-fold). In the DAA era, the risk associated with HCV+ in donors and/or recipients was no longer statistically significant, except for impaired PS in the dual-infected vs dual-uninfected (0.43-fold).
CONCLUSION Prior to DAA introduction, donor HCV+ negatively influenced kidney transplant outcomes in all recipients, while recipient infection only relatively impaired outcomes for uninfected donors. These adverse effects disappeared with the introduction of DAA.
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Affiliation(s)
- Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing 100853, China
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Shanjuan Hong
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Gregory Leya
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Eve Roth
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Georgios Tsoulfas
- Department of Surgery, Aristototle University of Thessaloniki, Thessaloniki 541 24, Greece
| | - WW Williams
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Joren C Madsen
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Nahel Elias
- Transplant Center and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, United States
- Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
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4
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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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Utilization of HCV Viremic Kidneys with Genotyping/Subtyping-Free Sofosbuvir/Velpatasvir Treatment Strategy: Experience from China. BIOMED RESEARCH INTERNATIONAL 2022; 2022:3758744. [PMID: 35941983 PMCID: PMC9356870 DOI: 10.1155/2022/3758744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/26/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
Background. Owing to the advent of pangenotypic direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) treatment, utilization of HCV-infected deceased donor kidneys with simplified genotyping/subtyping-free sofosbuvir/velpatasvir (SOF/VEL) treatment strategy is now becoming a promising strategy for expanding the organ donor pool. Methods. This retrospective, comparative, single-center study included HCV viremic donor kidneys that were transplanted to 9 HCV-positive (HCV Ab-positive) recipients (D+/R+ group) and 14 HCV-negative recipients (D+/R- group) from May 2018 to January 2021. Both groups received prophylaxis with SOF/VEL treatment within 1-week posttransplant devoid of HCV genotyping/subtyping. The primary outcomes were sustained virologic response 12 weeks after completion of therapy (SVR12) and graft survival at 1-year posttransplant. Results. Baseline characteristics were similar between the HCV D+/R- and D+/R+ groups. The mean age of all recipients was
(SD) years, and 73.9% were male. A total of 92.9% (13 out of 14) recipients had pretreatment HCV viremia in the D+/R- group. The pretreatment HCV viral load in the D+/R+ group (5.98, log 10 IU/mL; IQR, 5.28-6.53) was significantly higher than that in the D+/R- group (3.61, log 10 IU/mL; IQR, 2.57-4.57). After SOF/VEL treatment, SVR12 was achieved in all recipients, with a 100% 1-year patient and graft survival rates. The D+/R+ group had a higher incidence of abnormal liver function (44.4% vs. 7.1%). No significant difference was observed between the two groups in terms of DGF, acute rejection, ALT, serum creatinine, and eGFR within 1-year posttransplant. No severe adverse events associated with either HCV viremia or SOF/VEL were observed. Conclusions. Using a simplified genotyping/subtyping-free SOF/VEL treatment strategy, kidneys from hepatitis C viremic donors for both infected and uninfected recipients presented with safe, excellent, and comparable 1-year outcomes, which can safely expand the donor pool. HCV-positive donor kidneys should be utilized regularly, regardless of the recipient’s HCV status.
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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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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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8
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Chaudhry D, Chaudhry A, Peracha J, Sharif A. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ 2022; 376:e068769. [PMID: 35232772 PMCID: PMC8886447 DOI: 10.1136/bmj-2021-068769] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To investigate the survival benefit of transplantation versus dialysis for waitlisted kidney failure patients with a priori stratification. DESIGN Systematic review and meta-analysis. DATA SOURCES Online databases MEDLINE, Ovid Embase, Web of Science, Cochrane Collection, and ClinicalTrials.gov were searched between database inception and 1 March 2021. INCLUSION CRITERIA All comparative studies that assessed all cause mortality for transplantation versus dialysis in patients with kidney failure waitlisted for transplant surgery were included. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Meta-analysis was done using the DerSimonian-Laird random effects model, with heterogeneity investigated by subgroup analyses, sensitivity analyses, and meta-regression. RESULTS The search identified 48 observational studies with no randomised controlled trials (n=1 245 850 patients). In total, 92% (n=44/48) of studies reported a long term (at least one year) survival benefit associated with transplantation compared with dialysis. However, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. In 18 studies suitable for meta-analysis, kidney transplantation showed a survival benefit (hazard ratio 0.45, 95% confidence interval 0.39 to 0.54; P<0.001), with significant heterogeneity even after subgroup/sensitivity analyses or meta-regression analysis. CONCLUSION Kidney transplantation remains the superior treatment modality for most patients with kidney failure to reduce all cause mortality, but some subgroups may lack a survival benefit. Given the continued scarcity of donor organs, further evidence is needed to better inform decision making for patients with kidney failure. STUDY REGISTRATION PROSPERO CRD42021247247.
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Affiliation(s)
- Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abdullah Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Javeria Peracha
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Liver and Kidney Recipient Selection of Hepatitis C Virus Viremic Donors: Meeting Consensus Report From the 2019 Controversies in Transplantation. Transplantation 2020; 104:476-481. [PMID: 31634329 DOI: 10.1097/tp.0000000000003014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The development of multiple highly effective and safe direct-acting antivirals to treat hepatitis C virus (HCV) has resulted in greater ease and confidence in managing HCV infection in transplant recipients that in turn has impacted the solid organ transplant community as well. In the United States, the opioid epidemic has increased the number of overdose deaths with a concomitant increase in younger HCV viremic donors after brain death being identified. At the same time, a decrease in HCV viremic transplant candidates has led to a growing interest in exploring the use of HCV viremic liver and kidney donor allografts in HCV-negative recipients. To date, experience with the use of HCV viremic liver and kidney allografts in HCV-negative recipients is limited to a few small prospective research trials, case series, and case reports. There are also limited data on recipient and donor selection for HCV viremic liver and kidney allografts. In response to this rapidly changing landscape in the United States, experts in the field of viral hepatitis and liver and kidney transplantation convened a meeting to review current data on liver and kidney recipient selection and developed consensus opinions related specifically to recipient and donor selection of HCV viremic liver and kidney allografts.
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10
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Morales JM, Sawinski D. New insights into the rational use of HCV+ organs worldwide. Clin Transplant 2019; 33:e13739. [PMID: 31648391 DOI: 10.1111/ctr.13739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 01/06/2023]
Abstract
Hepatitis C (HCV) is a worldwide health problem. Effective therapies for HCV infection, coupled with an increase in deceased donors due to the opioid epidemic, have led to the broader availability and the use of HCV-infected donor organs, including HCV nucleic acid test-positive (NAT+) donors in HCV-negative recipients. In this review, we discuss the prevalence of HCV infection, trends in the use of HCV-infected donors, and outcomes for those who receive HCV-seropositive or HCV NAT+ donor organs. We discuss management considerations such as hepatitis B reactivation, selection of the optimal direct-acting antiviral regimen, and potential complications. We also present a framework for the rational use of HCV-infected donor organs in the future.
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Affiliation(s)
- Jose M Morales
- Research Institute, Hospital 12 de Octubre, Complutense University, Madrid, Spain
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Changes in Utilization and Discard of HCV Antibody-Positive Deceased Donor Kidneys in the Era of Direct-Acting Antiviral Therapy. Transplantation 2019; 102:2088-2095. [PMID: 29912046 DOI: 10.1097/tp.0000000000002323] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The availability of direct-acting antiviral (DAA) therapy might have impacted use of hepatitis C virus (HCV)-infected (HCV+) deceased donor kidneys for transplantation. METHODS We used 2005 to 2018 Scientific Registry of Transplant Recipients data to identify 18 936 candidates willing to accept HCV+ kidneys and 3348 HCV+ recipients of HCV+ kidneys. We compared willingness to accept, utilization, discard, and posttransplant outcomes associated with HCV+ kidneys between 2 treatment eras (interferon [IFN] era, January 1, 2005 to December 5, 2013 vs DAA era, December 6, 2013 to August 2, 2018). Models were adjusted for candidate, recipient, and donor factors where appropriate. RESULTS In the DAA era, candidates were 2.2 times more likely to list as willing to accept HCV+ kidneys (adjusted odds ratio, 2.072.232.41; P < 0.001), and HCV+ recipients were 1.95 times more likely to have received an HCV+ kidney (adjusted odds ratio, 1.761.952.16; P < 0.001). Median Kidney Donor Profile Index of HCV+ kidneys decreased from 77 (interquartile range [IQR], 59-90) in 2005 to 53 (IQR, 40-67) in 2017. Kidney Donor Profile Index of HCV- kidneys remained unchanged from 45 (IQR, 21-74) to 47 (IQR, 24-73). After adjustment, HCV+ kidneys were 3.7 times more likely to be discarded than HCV- kidneys in the DAA era (adjusted relative rate, 3.363.674.02; P < 0.001); an increase from the IFN era (adjusted relative rate, 2.783.023.27; P < 0.001). HCV+ kidney use was concentrated within a subset of centers; 22.5% of centers performed 75% of all HCV+ kidney transplants in the DAA era. Mortality risk associated with HCV+ kidneys remained unchanged (aHR, 1.071.191.32 in both eras). CONCLUSIONS Given the elevated risk of death on dialysis facing HCV+ candidates, improving quality of HCV+ kidneys, and DAA availability, broader utilization of HCV+ kidneys is warranted to improve access in this era of organ shortage.
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12
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Esforzado N, Morales JM. Hepatitis C and kidney transplant: The eradication time of the virus has arrived. Nefrologia 2019; 39:458-472. [PMID: 30905391 DOI: 10.1016/j.nefro.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/07/2019] [Accepted: 01/13/2019] [Indexed: 12/11/2022] Open
Abstract
Hepatitis C virus (HCV) infection is a factor that reduces the survival of the patient and the graft in renal transplant (RT). The availability of directly acting antivirals agents (DAAs), very effective and with an excellent safety profile, it allows eradicate HCV from patients with kidney disease, and this is a revolutionary radical change in the natural evolution of this infection, until now without effective and safe treatment for the contraindication use of interferon in kidney transplant patients. The efficiency of some DAAs for all genotypes, even in patients with renal insufficiency constitutes a huge contribution to eradicate HCV in the RT population independently the genotype, severity of kidney failure, progression of liver disease and previous anti HCV therapy. All this is raising, although with controversies, the possibility of use kidneys from infected HCV+ donors for transplant in uninfected receptors and can be treated successfully in the early post-TR, thus increasing the total "pool" of kidneys for RT.
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13
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Sawinski D, Forde KA, Lo Re V, Goldberg DS, Cohen JB, Locke JE, Bloom RD, Brensinger C, Weldon J, Shults J, Reese PP. Mortality and Kidney Transplantation Outcomes Among Hepatitis C Virus-Seropositive Maintenance Dialysis Patients: A Retrospective Cohort Study. Am J Kidney Dis 2019; 73:815-826. [PMID: 30704882 DOI: 10.1053/j.ajkd.2018.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/20/2018] [Indexed: 12/25/2022]
Abstract
RATIONALE & OBJECTIVE Hepatitis C virus (HCV) infection is common among maintenance dialysis patients. Few studies have examined both dialysis survival and transplantation outcomes for HCV-seropositive patients because registry data sets lack information for HCV serostatus. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult long-term dialysis patients treated by a US national dialysis provider between January 1, 2004, and December 31, 2014. EXPOSURE HCV antibody serostatus obtained as part of clinical data from a national dialysis provider. OUTCOMES Mortality on dialysis therapy, entry onto the kidney transplant waiting list, kidney transplantation, and estimated survival benefit from kidney transplantation versus remaining on the waitlist. ANALYTICAL APPROACH After linking clinical data with data from the Organ Procurement and Transplantation Network, Cox and cause-specific hazards regression were implemented to estimate the associations between HCV seropositivity and mortality, as well as entry onto the kidney transplant waitlist. Cox regression was also used to estimate the survival benefit from transplantation versus dialysis among HCV-seropositive individuals. RESULTS Among 442,171 dialysis patients, 31,624 (7.2%) were HCV seropositive. HCV seropositivity was associated with a small elevation in the rate of death (adjusted HR [aHR], 1.09; 95% CI, 1.07-1.11) and a substantially lower rate of entry onto the kidney transplant waitlist (subdistribution HR [sHR], 0.67; 95% CI, 0.61-0.74). Once wait-listed, the kidney transplantation rate was not different for HCV-seropositive (sHR 1.10; 95% CI, 0.96-1.27) versus HCV-seronegative patients. HCV-seropositive patients lived longer with transplantation (aHR at 3 years, 0.42; 95% CI, 0.27-0.63). Receiving an HCV-seropositive donor kidney provided a survival advantage at the 2-year posttransplantation time point compared to remaining on dialysis therapy waiting for an HCV-negative kidney. LIMITATIONS No data for HCV viral load or liver biopsy. CONCLUSIONS HCV-seropositive patients experience reduced access to the kidney transplantation waitlist despite deriving a substantial survival benefit from transplantation. HCV-seropositive patients should consider foregoing HCV treatment while accepting kidneys from HCV-infected donors to facilitate transplantation and prolong survival.
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Affiliation(s)
- Deirdre Sawinski
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly A Forde
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vincent Lo Re
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S Goldberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jordana B Cohen
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Roy D Bloom
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Colleen Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joe Weldon
- DaVita Clinical Research, Minneapolis, MN; Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; DaVita Clinical Research, Minneapolis, MN; Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter P Reese
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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14
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Avery RK, Yen-Lieberman B. Viral Diagnostics. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7115029 DOI: 10.1007/978-1-4939-9034-4_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This chapter discusses recent developments in diagnostics for cytomegalovirus (CMV), Epstein-Barr virus (EBV), BK virus (BKV), community respiratory viruses (CRVs), parvovirus, hepatitis viruses, HIV, and other viral agents of importance in solid organ and hematopoietic stem cell transplantation.
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15
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KDIGO 2018 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease. Kidney Int Suppl (2011) 2018; 8:91-165. [PMID: 30675443 PMCID: PMC6336217 DOI: 10.1016/j.kisu.2018.06.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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Shelton BA, Sawinski D, Linas BP, Reese PP, Mustian M, Hungerpiller M, Reed RD, MacLennan PA, Locke JE. Population level outcomes and cost-effectiveness of hepatitis C treatment pre- vs postkidney transplantation. Am J Transplant 2018; 18:2483-2495. [PMID: 30058218 PMCID: PMC6206868 DOI: 10.1111/ajt.15040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 01/25/2023]
Abstract
Direct-acting antivirals approved for use in patients with end-stage renal disease (ESRD) now exist. HCV-positive (HCV+) ESRD patients have the opportunity to decrease the waiting times for transplantation by accepting HCV-infected kidneys. The optimal timing for HCV treatment (pre- vs posttransplant) among kidney transplant candidates is unknown. Monte Carlo microsimulation of 100 000 candidates was used to examine the cost-effectiveness of HCV treatment pretransplant vs posttransplant by liver fibrosis stage and waiting time over a lifetime time horizon using 2 regimens approved for ESRD patients. Treatment pretransplant yielded higher quality-adjusted life years (QALYs) compared with posttransplant treatment in all subgroups except those with Meta-analysis of Histological Data in Viral Hepatitis stage F0 (pretransplant: 5.7 QALYs vs posttransplant: 5.8 QALYs). However, treatment posttransplant was cost-saving due to decreased dialysis duration with the use of HCV-infected kidneys (pretransplant: $735 700 vs posttransplant: $682 400). Using a willingness-to-pay threshold of $100 000, treatment pretransplant was not cost-effective except for those with Meta-analysis of Histological Data in Viral Hepatitis stage F3 whose fibrosis progression was halted. If HCV+ candidates had access to HCV-infected donors and were transplanted ≥9 months sooner than HCV-negative candidates, treatment pretransplant was no longer cost-effective (incremental cost-effectiveness ratio [ICER]: $107 100). In conclusion, optimal timing of treatment depends on fibrosis stage and access to HCV+ kidneys but generally favors posttransplant HCV eradication.
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Affiliation(s)
- Brittany A. Shelton
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Deirdre Sawinski
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Peter P. Reese
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaux Mustian
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Mitch Hungerpiller
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Rhiannon D. Reed
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Paul A. MacLennan
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Jayme E. Locke
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
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17
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Chascsa DM, Mousa OY, Pungpapong S, Zhang N, Chervenak A, Nidamanuri S, Rodriguez E, Franco D, Ryland K, Keaveny AP, Huskey JL, Smith M, Reddy KS, Taner CB, Vargas HE, Aqel BA. Clinical outcomes of hepatitis C treatment before and after kidney transplantation and its impact on time to transplant: A multicenter study. Am J Transplant 2018; 18:2559-2565. [PMID: 29758123 DOI: 10.1111/ajt.14931] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 05/04/2018] [Accepted: 05/06/2018] [Indexed: 01/25/2023]
Abstract
Waitlist time for kidney transplantation is long but may be shortened with the utilization of hepatitis C positive allografts. We retrospectively reviewed the course of 36 hepatitis C positive patients awaiting kidney transplantation at 2 large centers within the same health system, with near-identical care delivery models with the exception of timing of hepatitis C treatment, to determine the impact of timing of hepatitis C treatment on access to transplant, waitlist time, and treatment efficacy and tolerability. The majority of patients had hepatitis C genotype 1a or 1b, and all received direct acting antiviral therapy with 100% treatment response. One patient underwent transplantation in the pretransplant treatment group. The 1-year transplantation rate was 12.5% vs 67.9% (P = .0013) in those treated posttransplantation. The median waitlist time in the posttransplant group was 122 (interquartile range [IQR] 21.5, 531.0) days, which was significantly shorter than the center's regional and national wait time. Pathologic review revealed no difference in allograft quality. Overall treatment related adverse events were not different between the 2 groups. A strategy of posttransplant hepatitis C treatment increased access to transplant and reduced waitlist time. Delaying treatment until after transplant did not appear to adversely affect recipients' kidney allograft or overall survival.
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Affiliation(s)
- D M Chascsa
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - O Y Mousa
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - S Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Transplant Center, Mayo Clinic, Jacksonville, FL, USA
| | - N Zhang
- Department of Biostatistics, Mayo Clinic, Phoenix, AZ, USA
| | - A Chervenak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - S Nidamanuri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - E Rodriguez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - D Franco
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - K Ryland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - A P Keaveny
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Transplant Center, Mayo Clinic, Jacksonville, FL, USA
| | - J L Huskey
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Department of Nephrology, Mayo Clinic, Phoenix, AZ, USA
| | - M Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - K S Reddy
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Department of Transplantation Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - C B Taner
- Transplant Center, Mayo Clinic, Jacksonville, FL, USA.,Department of Transplantation Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - H E Vargas
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - B A Aqel
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
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18
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Sageshima J, Troppmann C, McVicar JP, Santhanakrishnan C, de Mattos AM, Perez RV. Impact of Willingness to Accept Hepatitis C Seropositive Kidneys Among Hepatitis C RNA-Positive Waitlisted Patients. Transplantation 2018; 102:1179-1187. [PMID: 29953423 PMCID: PMC7228641 DOI: 10.1097/tp.0000000000002096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/14/2017] [Accepted: 11/28/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Kidney transplantation from hepatitis C seropositive (HCV+) donors may benefit hepatitis C RNA-positive (RNA+) candidates, but it is unclear how the willingness to be listed for and accept such kidneys affects waitlist and transplant outcomes. METHODS In a single-center retrospective analysis, HCV+ transplant candidates (N = 169) listed from March 2004 to February 2015 were evaluated. All RNA+ candidates were offered the option to be listed for HCV+ donors. RNA- candidates were listed only for HCV- donors. RESULTS Fifty-seven patients (51% of all RNA+ transplant candidates) willing to accept HCV+ donors were listed for both HCV+ and HCV- donor kidneys. During 6-year follow up, 43 (75%) of 57 patients accepting HCV+ versus 19 (35%) of 55 patients not accepting HCV+ received a deceased donor kidney transplant (P < 0.0001). Multivariable analysis demonstrated that willingness to be listed for and accept HCV+ kidneys was associated with receiving deceased donor kidney transplant (P = 0.0016). Fewer patients accepting HCV+ donors (7 [12%] vs 16 [29%]) were removed from the list due to death or deteriorated medical condition (P = 0.0117). Posttransplant patient and graft survival rates were not significantly different. Overall patient survival since the listing (combined waitlist and posttransplant survival) was similar among the groups. CONCLUSIONS HCV RNA+ candidates had better access to transplantation and similar overall survival before the era of widespread use of direct-acting anti-HCV agents.
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Affiliation(s)
| | | | - John P McVicar
- Department of Surgery, University of California Davis, Sacramento, CA
| | | | - Angelo M de Mattos
- Department of Internal Medicine, University of California Davis, Sacramento, CA
| | - Richard V Perez
- Department of Surgery, University of California Davis, Sacramento, CA
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19
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Pliszczyński J, Jasztal K, Jóźwik A, Kosieradzki M, Danielewicz R, Małkowski P, Czerwiński J. Results of Renal Transplant From Deceased Anti-hepatitis C Virus Donors, Poland 1998-2012. Transplant Proc 2018; 50:1691-1696. [PMID: 30056883 DOI: 10.1016/j.transproceed.2018.02.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 11/25/2022]
Abstract
Kidney transplant (KTx) is the best method of renal insufficiency treatment. In dialyzed patients, mortality rises with the time on dialysis. There is a continuing shortage of organs for transplantation, hence a propensity to expand the donor pool with expanded-criteria donors, anti-hepatitis C virus-positive included. In the above case a transmission of hepatitis C virus (HCV) genotype to recipient is present. It has been proven that contamination with more than 1 HCV genotype did not worsen KTx outcomes. There are 2.6% anti-HCV(+) donors in Poland. Use is only possible in cases of anti-HCV(+) and anti-HCV RNA(+) recipients. METHODS Retrospective analysis covered 8675 deceased donors (1998-2012 Polish data from Poltransplant). The early (after 12 months) and late (after 60 months) graft and patient survival was assessed in KTx recipients, with documented recipient and donor data spanning at least 1 year after KTx. In comprehensive analysis, 7016 KTx recipients with known anti-HCV status were included according to anti-HCV profile of recipient and donor. The results are in absolute and percentage values and P < .05 assessed with χ2 test. RESULTS Twelve-month survival: recipient (R) (95%), graft (G) (89%), total; R (95% vs 89%, P < .001), G (88 vs 79, P < .001) in HCV(-) to HCV(+/-) vs HCV(+) to HCV(+); R (95 vs 94, P = .2), G (88 vs 83, P < .001), HCV(-) to HCV(-) vs HCV(-) to HCV(+); R (93 vs 95, P = .004), G (82 vs 89, P < .001) in HCV(+/-) to HCV(+) vs HCV(-) to HCV(-); R (95 vs 89, P < .001), G (88 vs 79, P < .001) in HCV(-) to HCV(-) vs HCV(+) vs HCV (+). Sixty-month survival: R (86%), G (75%), total; R (84 vs 88, P = .01), G (63 vs 71, P = .001) in HCV(+/-) to HCV(+) vs HCV(-) to HCV(-); R (88 vs 80, P = .003) in HCV(-) to HCV(-) vs HCV(+) to HCV(+). CONCLUSIONS The worst anti-HCV serological profile was HCV(+) to HCV(+), although transplanting HCV(+) to HCV(+) did not worsen outcomes in that group. Worse KTx outcomes of HCV(+) over HCV(-) donors can be attributed to HCV(+) status of the recipient.
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Affiliation(s)
- J Pliszczyński
- Department of General and Transplantation Surgery, Warsaw Medical University, Warsaw, Poland.
| | - K Jasztal
- Department of Surgical and Transplant Nursing, Warsaw Medical University, Warsaw, Poland
| | - A Jóźwik
- Department of General and Transplantation Surgery, Warsaw Medical University, Warsaw, Poland
| | - M Kosieradzki
- Department of General and Transplantation Surgery, Warsaw Medical University, Warsaw, Poland
| | - R Danielewicz
- Department of Surgical and Transplant Nursing, Warsaw Medical University, Warsaw, Poland
| | - P Małkowski
- Department of Surgical and Transplant Nursing, Warsaw Medical University, Warsaw, Poland
| | - J Czerwiński
- Department of Emergency Medicine, Warsaw Medical University, Warsaw, Poland
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20
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Shelton BA, Sawinski D, Mehta S, Reed RD, MacLennan PA, Locke JE. Kidney transplantation and waitlist mortality rates among candidates registered as willing to accept a hepatitis C infected kidney. Transpl Infect Dis 2018; 20:e12829. [DOI: 10.1111/tid.12829] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/12/2017] [Accepted: 11/19/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Brittany A. Shelton
- Comprehensive Transplant Institute; University of Alabama at Birmingham; Birmingham AL USA
| | - Deirdre Sawinski
- Comprehensive Transplant Center; University of Pennsylvania; Philadelphia PA USA
| | - Shikha Mehta
- Comprehensive Transplant Institute; University of Alabama at Birmingham; Birmingham AL USA
| | - Rhiannon D. Reed
- Comprehensive Transplant Institute; University of Alabama at Birmingham; Birmingham AL USA
| | - Paul A. MacLennan
- Comprehensive Transplant Institute; University of Alabama at Birmingham; Birmingham AL USA
| | - Jayme E. Locke
- Comprehensive Transplant Institute; University of Alabama at Birmingham; Birmingham AL USA
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21
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Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PKT, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101:S1-S109. [PMID: 28742762 PMCID: PMC5540357 DOI: 10.1097/tp.0000000000001769] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.
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Affiliation(s)
| | | | | | | | - Josefina Alberú
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | - Dorry L. Segev
- Johns Hopkins University, School of Medicine, Baltimore, MD
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22
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Joglekar K, Eason JD, Molnar MZ. Do we really need more evidence to use hepatitis C positive donor kidney more liberally? Clin Kidney J 2017; 10:560-563. [PMID: 28835817 PMCID: PMC5561329 DOI: 10.1093/ckj/sfx067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 01/15/2023] Open
Abstract
The number of patients listed active for kidney transplantation has continued to rise over the last 10 years, leading to significantly increased wait-list time for patients awaiting kidney transplantation in the USA. This increased demand has led to a supply–demand mismatch and should prompt clinicians to seek timely solutions to improve access to available organs. Hepatitis C virus positive [HCV(+)] kidneys continue to be discarded without clear evidence that they lead to poor outcomes in the current era of highly efficacious HCV treatment with direct-acting antiviral agents (DAAs). Increased utilization of HCV(+) donor kidneys will decrease wait-list time and improve availability of donor organs. Emerging data suggests that HCV can be successfully treated with DAAs after kidney transplantation with 100% sustained virologic response rates and no significant changes from baseline kidney function. Utilization of HCV(+) donor kidneys should be considered more liberally in the era of highly effective HCV treatment. Further studies are warranted to assess the long-term effect of HCV(+) donor kidneys in transplant recipients in the new era of DAAs.
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Affiliation(s)
- Kiran Joglekar
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - James D Eason
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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23
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Cohen JB, Eddinger KC, Shelton B, Locke JE, Forde KA, Sawinski D. Effect of kidney donor hepatitis C virus serostatus on renal transplant recipient and allograft outcomes. Clin Kidney J 2017; 10:564-572. [PMID: 28852496 PMCID: PMC5569958 DOI: 10.1093/ckj/sfx048] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
Background Hepatitis C virus (HCV) infection is common in dialysis patients and renal transplant recipients and has been associated with diminished patient and allograft survival. HCV-positive (HCV+) kidneys have been used in HCV-positive (HCV+) recipients as a means of facilitating transplantation and expanding the organ donor pool; however, the effect of donor HCV serostatus in the modern era is unknown. Methods Using national transplant registry data, we created a propensity score–matched cohort of HCV+ recipients who received HCV-positive donor kidneys compared to those transplanted with HCV-negative kidneys. Results Transplantation with an HCV+ kidney was associated with an increased risk of death {hazard ratio [HR] 1.43 [95% confidence interval (CI) 1.18–1.76]; P < 0.001} and allograft loss [HR 1.39 (95% CI 1.16–1.67); P < 0.001] compared with their propensity score–matched counterparts. However, HCV+ kidneys were not associated with an increased risk of acute rejection [odds ratio 1.16 (95% CI 0.84–1.61); P = 0.35]. Conclusions While use of HCV+ donor kidneys can shorten the wait for renal transplantation and maximize organ utility for all candidates on the waiting list, potential recipients should be counseled about the increased risks associated with HCV+ kidney.
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Affiliation(s)
- Jordana B Cohen
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin C Eddinger
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany Shelton
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kimberly A Forde
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deirdre Sawinski
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
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24
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Westphal GA, Garcia VD, de Souza RL, Franke CA, Vieira KD, Birckholz VRZ, Machado MC, de Almeida ERB, Machado FO, Sardinha LADC, Wanzuita R, Silvado CES, Costa G, Braatz V, Caldeira Filho M, Furtado R, Tannous LA, de Albuquerque AGN, Abdala E, Gonçalves ARR, Pacheco-Moreira LF, Dias FS, Fernandes R, Giovanni FD, de Carvalho FB, Fiorelli A, Teixeira C, Feijó C, Camargo SM, de Oliveira NE, David AI, Prinz RAD, Herranz LB, de Andrade J. Guidelines for the assessment and acceptance of potential brain-dead organ donors. Rev Bras Ter Intensiva 2017; 28:220-255. [PMID: 27737418 PMCID: PMC5051181 DOI: 10.5935/0103-507x.20160049] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Corresponding author: Glauco Adrieno Westphal, Centro
Hospitalar Unimed, Rua Orestes Guimarães, 905, Zip code: 89204-060 -
Joinville (SC), Brazil. E-mail:
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25
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Equal 3-Year Outcomes for Kidney Transplantation Alone in HCV-Positive Patients With Cirrhosis. Int Surg 2016; 100:142-54. [PMID: 25594655 DOI: 10.9738/intsurg-d-13-00231.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Kidney transplantation alone in clinically compensated patients with cirrhosis is not well documented. Current guidelines list cirrhosis as a contraindication for kidney transplantation alone. This is an Institutional Review Board-approved retrospective study. We report our experience with a retrospective comparison between transplants in hepatitis C virus-positive (HCV(+)) patients without cirrhosis and HCV(+) patients with cirrhosis. All of the patients were followed for at least a full 3-year period. All of the deaths and graft losses were recorded and analyzed using Kaplan-Meier methodology. One- and three-year cumulative patient survival rates for noncirrhotic patients were 91% and 82%, respectively. For cirrhotic patients, one- and three-year cumulative patient survival rates were 100% and 83%, respectively (P = NS). One- and three-year cumulative graft survival rates censored for death were 94% and 81%, and 95% and 82% for the noncirrhosis and cirrhosis groups, respectively (P = NS). Comparable patient and allograft survival rates were observed when standard kidney allograft recipients were analyzed separately. This study is the longest follow-up document in the literature showing that HCV(+) clinically ompensated patients with cirrhosis may undergo kidney transplantation alone as a safe and viable practice.
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26
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Nowak KM, Witzke O, Sotiropoulos GC, Benkö T, Fiedler M, Timm J, Kribben A, Wilde B, Saner F, Paul A, Treckmann J. Transplantation of Renal Allografts From Organ Donors Reactive for HCV Antibodies to HCV-Negative Recipients: Safety and Clinical Outcome. Kidney Int Rep 2016; 2:53-59. [PMID: 29142940 PMCID: PMC5678640 DOI: 10.1016/j.ekir.2016.09.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/01/2016] [Accepted: 09/23/2016] [Indexed: 01/17/2023] Open
Abstract
Introduction Because of the shortage of available organs for renal transplantation, strategies enabling the safe use of organs from donors with potential chronic infections such as hepatitis C are necessary. The aim of this study was to analyze the outcome of renal transplant donation from hepatitis C virus (HCV)-positive donors. Methods Between September 2002 and May 2007, 51 kidneys (34 donors) reactive for HCV antibodies were further evaluated. Six kidneys (5 donors) were transplanted to 6 recipients with known chronic HCV infection. The remaining 29 donors underwent extended virological testing. Nine donors were HCV RNA positive and thus not suitable for HCV-negative patients. Twenty donors (21 kidneys) did not have detectable HCV RNA copies and were transplanted into 21 HCV-negative recipients. Clinical outcomes focusing on safety, allograft function, and de novo HCV infection in the recipient were collected. Results There were no de novo HCV infections detected in recipients who were HCV negative before transplantation. The extended virological donor screening did not have an impact on median cold ischemia time. Five-year graft survival was 75%. Discussion Organs from anti-HCV-reactive, nonviremic donors can be transplanted safely to HCV-negative recipients.
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Affiliation(s)
- Knut Michael Nowak
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Oliver Witzke
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany.,Department of Infectious Diseases, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Georgios C Sotiropoulos
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Tamas Benkö
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Melanie Fiedler
- Institute of Virology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Jörg Timm
- Institute of Virology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Jürgen Treckmann
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
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Belga S, Doucette KE. Hepatitis C in non-hepatic solid organ transplant candidates and recipients: A new horizon. World J Gastroenterol 2016; 22:1650-63. [PMID: 26819530 PMCID: PMC4721996 DOI: 10.3748/wjg.v22.i4.1650] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/20/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection is estimated to affect 130-150 million people globally which corresponds to 2%-3% of the total world population. It remains the leading indication for liver transplant worldwide and has been demonstrated to negatively impact both patient and graft survival following non-hepatic organ transplantation. In the era of interferon-based therapy, although treatment and cure of HCV prior to non-hepatic transplant improved survival, tolerability and low cure rates substantially limited therapy. Interferon (IFN)-based therapy following non-hepatic solid organ transplant, due to the risk of allograft rejection, is generally contraindicated. Rapid advances in IFN-free therapy with direct acting antivirals (DAAs) in the last few years have completely changed the paradigm of hepatitis C therapy. Compared to IFN-based regimens, DAAs have less frequent and less severe adverse effects, shorter durations of therapy, and higher cure rates that are minimally impacted by historically negative predictors of response such as cirrhosis, ethnicity, and post-transplant state. Recent studies have shown that liver transplant (LT) recipients can be safely and effectively treated with DAA combination therapies; although data are limited, many of the principles of therapy in LT may be extrapolated to non-hepatic solid organ transplant recipients. Here we review the data on DAA combination therapies in transplantation, discuss the advantages and disadvantages of pre- vs post-transplant HCV therapy and future directions.
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Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Morales JM, Martinez-Flores JA, Serrano M, Serrano A, Dominguez-Gil B. What are the management issues for hepatitis C in dialysis patients?: renal transplantation from hepatitis C-positive donors. Semin Dial 2015; 27:459-62. [PMID: 25204880 DOI: 10.1111/sdi.12293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Jose M Morales
- Instituto de Investigacion Hospital 12 de Octubre, Madrid, Spain
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30
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Azmi AN, Tan SS, Mohamed R. Hepatitis C and kidney disease: An overview and approach to management. World J Hepatol 2015; 7:78-92. [PMID: 25624999 PMCID: PMC4295197 DOI: 10.4254/wjh.v7.i1.78] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/13/2014] [Accepted: 11/10/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C infection and chronic kidney disease are major health burden worldwide. Hepatitis C infection is associated with a wide range of extra-hepatic manifestations in various organs including the kidneys. A strong association between hepatitis C and chronic kidney disease has come to light. Hemodialysis in supporting the end stage renal disease patients unfortunately carries a risk for hepatitis C infection. Despite much improvement in the care of this group of patients, the prevalence of hepatitis C infection in hemodialysis patients is still higher than the general population. Hepatitis C infection has a negative effect on the survival of hemodialysis and renal transplant patients. Treatment of hepatitis C in end stage renal disease patients using conventional or pegylated interferon with or without ribavirin remains a clinical challenge with low response rate, high dropout rate due to poor tolerability and many unmet needs. The approval of new direct acting antiviral agents for hepatitis C may dramatically change the treatment approach in hepatitis C infected patients with mild to moderate renal impairment. However it remains to be confirmed if the newer Hepatitis C therapies are safe in individuals with severe renal impairment. This review article discusses the relationship between hepatitis C and chronic kidney disease, describe the various types of renal diseases associated with hepatitis C and the newer as well as the existing treatments for hepatitis C in the context of this subpopulation of hepatitis C patients.
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Gunderson A, Said A. Liver disease in kidney transplant recipients. Transplant Rev (Orlando) 2015; 29:1-7. [DOI: 10.1016/j.trre.2014.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 07/18/2014] [Accepted: 08/22/2014] [Indexed: 12/17/2022]
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Laftavi MR, Sharma R, Feng L, Said M, Pankewycz O. Induction Therapy in Renal Transplant Recipients: A Review. Immunol Invest 2014; 43:790-806. [DOI: 10.3109/08820139.2014.914326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Baid-Agrawal S, Pascual M, Moradpour D, Somasundaram R, Muche M. Hepatitis C virus infection and kidney transplantation in 2014: what's new? Am J Transplant 2014; 14:2206-20. [PMID: 25091274 DOI: 10.1111/ajt.12835] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/15/2014] [Accepted: 05/16/2014] [Indexed: 01/25/2023]
Abstract
Chronic hepatitis C virus (HCV) infection remains an important health problem, which is associated with deleterious consequences in kidney transplant recipients. Besides hepatic complications, several extrahepatic complications contribute to reduced patient and allograft survival in HCV-infected kidney recipients. However, HCV infection should not be considered as a contraindication for kidney transplantation because patient survival is better with transplantation than on dialysis. Treatment of HCV infection is currently interferon-alpha (IFN-α) based, which has been associated with higher renal allograft rejection rates. Therefore, antiviral treatment before transplantation is preferable. As in the nontransplant setting, IFN-free treatment regimens, because of their greater efficacy and reduced toxicity, currently represent promising and attractive therapeutic options after kidney transplantation as well. However, clinical trials will be required to closely evaluate these regimens in kidney recipients. There is also a need for prospective controlled studies to determine the optimal immunosuppressive regimens after transplantation in HCV-infected recipients. Combined kidney and liver transplantation is required in patients with advanced liver cirrhosis. However, in patients with cleared HCV infection and early cirrhosis without portal hypertension, kidney transplantation alone may be considered. There is some agreement about the use of HCV-positive donors in HCV-infected recipients, although data regarding posttransplant survival rates are controversial.
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Affiliation(s)
- S Baid-Agrawal
- Department of Nephrology and Medical Intensive Care, Campus Virchow-Klinikum, Charité Universitaetsmedizin Berlin, Berlin, Germany
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Xia Y, Friedmann P, Yaffe H, Phair J, Gupta A, Kayler LK. Effect of HCV, HIV and coinfection in kidney transplant recipients: mate kidney analyses. Am J Transplant 2014; 14:2037-47. [PMID: 25098499 DOI: 10.1111/ajt.12847] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 03/21/2014] [Accepted: 03/27/2014] [Indexed: 01/25/2023]
Abstract
Reports of kidney transplantation (KTX) in recipients with hepatitis C virus (HCV+), human immunodeficiency virus (HIV+) or coinfection often do not provide adequate adjustment for donor risk factors. We evaluated paired deceased-donor kidneys (derived from the same donor transplanted to different recipients) in which one kidney was transplanted into a patient with viral infection (HCV+, n = 1700; HIV+, n = 243) and the other transplanted into a recipient without infection (HCV- n = 1700; HIV- n = 243) using Scientific Registry of Transplant Recipients data between 2000 and 2013. On multivariable analysis (adjusted for recipient risk factors), HCV+ conferred increased risks of death-censored graft survival (DCGS) (adjusted hazard ratio [aHR] 1.24, 95% confidence interval [CI] 1.04-1.47) and patient survival (aHR 1.24, 95% CI 1.06-1.45) compared with HCV-. HIV+ conferred similar DCGS (aHR 0.85, 95% CI 0.48-1.51) and patient survival (aHR 0.80, 95% CI 0.39-1.64) compared with HIV-. HCV coinfection was a significant independent risk factor for DCGS (aHR 2.33; 95% CI 1.06, 5.12) and patient survival (aHR 2.88; 95% CI 1.35, 6.12). On multivariable analysis, 1-year acute rejection was not associated with HCV+, HIV+ or coinfection. Whereas KTX in HIV+ recipients were associated with similar outcomes relative to noninfected recipients, HCV monoinfection and, to a greater extent, coinfection were associated with poor patient and graft survival.
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Affiliation(s)
- Y Xia
- Department of Surgery, Montefiore Medical Center, Bronx, NY; Department of Surgery, Albert Einstein College of Medicine, Bronx, NY
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Althaf MM, Abdelsalam MS, Rashwan M, Nadri Q. Acute hepatitis C infection in a renal transplant recipient: primacy of the liver or kidney? BMJ Case Rep 2014; 2014:bcr-2014-203643. [PMID: 24907214 DOI: 10.1136/bcr-2014-203643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
We present a case where a renal transplant recipient contracted chronic hepatitis C virus (HCV) infection post-transplantation. The disease progressed and deteriorated leading to fibrosing cholestatic hepatitis that mandated treatment. Treatment with pegylated interferon α-2a and ribavirin was successful in salvaging the liver and eradicating the virus but as a consequence lead to treatment-resistant acute rejection and loss of the renal allograft.
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Affiliation(s)
- Mohammed Mahdi Althaf
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Ar-Riyadh, Saudi Arabia
| | - Mohamed Said Abdelsalam
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Ar-Riyadh, Saudi Arabia Internal Medicine Department, Alexandria University, Faculty of Medicine, Alexandria, Egypt
| | - Mohamed Rashwan
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Ar-Riyadh, Saudi Arabia
| | - Quaid Nadri
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Ar-Riyadh, Saudi Arabia
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Pipili C, Cholongitas E. Μanagement of patients with hepatitis B and C before and after liver and kidney transplantation. World J Hepatol 2014; 6:315-25. [PMID: 24868325 PMCID: PMC4033289 DOI: 10.4254/wjh.v6.i5.315] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/10/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
New nucleos(t)ide analogues (NAs) with high genetic barrier to hepatitis B virus (HBV) resistance (such as entecavir, tenofovir) have improved the prognosis of patients with HBV decompensated cirrhosis and have prevented HBV recurrence after liver transplantation (LT). NAs are considered the most proper approach for HBV infection in patients under renal replacement therapy but their doses should be adjusted according to the patient's creatinine clearance. In addition, physicians should be aware of the potential nephrotoxicity. However, patients with chronic hepatitis C and decompensated cirrhosis can receive only one therapeutic option before LT, as well as for Hepatitis C virus (HCV) recurrence after LT, which is the combination of subcutaneous Peg-IFN and ribavirin. Generally, therapy for HCV after renal transplantation should be avoided. Although the optimal antiviral therapy for HCV infection has not been established, attention has turned to a new, oral direct acting antiviral treatment which marks a promising strategy in prognosis and in amelioration of these diseases.
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Affiliation(s)
- Chrysoula Pipili
- Chrysoula Pipili, Department of Nephrology, Laiki Merimna, 17343 Athens, Greece
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38
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Veroux M, Corona D, Sinagra N, Giaquinta A, Zerbo D, Ekser B, Giuffrida G, Caglià P, Gula R, Ardita V, Veroux P. Kidney transplantation from donors with hepatitis C infection. World J Gastroenterol 2014; 20:2801-2809. [PMID: 24659873 PMCID: PMC3961963 DOI: 10.3748/wjg.v20.i11.2801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 12/01/2013] [Accepted: 01/02/2014] [Indexed: 02/07/2023] Open
Abstract
The increasing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led to most transplant centers developing protocols that allow safe utilization from donors with special clinical situations which previously were regarded as contraindications. Deceased donors with previous hepatitis C infection may represent a safe resource to expand the donor pool. When allocated to serology-matched recipients, kidney transplantation from donors with hepatitis C may result in an excellent short-term outcome and a significant reduction of time on the waiting list. Special care must be dedicated to the pre-transplant evaluation of potential candidates, particularly with regard to liver functionality and evidence of liver histological damage, such as cirrhosis, that could be a contraindication to transplantation. Pre-transplant antiviral therapy could be useful to reduce the viral load and to improve the long-term results, which may be affected by the progression of liver disease in the recipients. An accurate selection of both donor and recipient is mandatory to achieve a satisfactory long-term outcome.
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39
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Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013; 128:247-343. [PMID: 23814319 DOI: 10.1177/003335491312800403] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Debbie L Seem
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Office of Blood, Organ, and other Tissue Safety, Atlanta, GA 30329, USA.
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40
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Mgbako O, Glazier A, Blumberg E, Reese PP. Allowing HIV-positive organ donation: ethical, legal and operational considerations. Am J Transplant 2013; 13:1636-42. [PMID: 23758835 PMCID: PMC3808247 DOI: 10.1111/ajt.12311] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/11/2013] [Accepted: 04/16/2013] [Indexed: 01/25/2023]
Abstract
Case reports of kidney transplantation using HIV-positive (HIV+) donors in South Africa and advances in the clinical care of HIV+ transplant recipients have drawn attention to the legal prohibition of transplanting organs from HIV+ donors in the United States. For HIV+ transplant candidates, who face high barriers to transplant access, this prohibition violates beneficence by placing an unjustified limitation on the organ supply. However, transplanting HIV+ organs raises nonmaleficence concerns given limited data on recipient outcomes. Informed consent and careful monitoring of outcome data should mitigate these concerns, even in the rare circumstance when an HIV+ organ is intentionally transplanted into an HIV-negative recipient. For potential donors, the federal ban on transplanting HIV+ organs raises justice concerns. While in practice there are a number of medical criteria that preclude organ donation, only HIV+ status is singled out as a mandated exclusion to donation under the National Organ Transplant Act (NOTA). Operational objections could be addressed by adapting existing approaches used for organ donors with hepatitis. Center-specific outcomes should be adjusted for HIV donor and recipient status. In summary, transplant professionals should advocate for eliminating the ban on HIV+ organ donation and funding studies to determine outcomes after transplantation of these organs.
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Affiliation(s)
- O Mgbako
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - E Blumberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Division of Infectious Diseases, Department of Medicine, Philadelphia, PA
| | - PP Reese
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Renal Division, Department of Medicine, Philadelphia, PA
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Abstract
: Hepatitis C virus (HCV) infection is common in solid organ allograft recipients and is a significant cause of morbidity and mortality after transplantation, so effective management will improve outcomes. In this review, we discuss the extent of the problem associated with HCV infection in donors and kidney, heart, and lung transplant candidates and recipients and recommend follow-up and treatment.Patients with end-stage kidney disease without cirrhosis and selected patients with early-stage cirrhosis can be considered for kidney transplant alone. In HCV-infected kidney allograft recipients, the progression of fibrosis should be evaluated serially by Fibroscan or serologic measures of fibrosis. Transplantation of kidneys from HCV-positive donors should be restricted to HCV-positive recipients as it is associated with a reduced time waiting for a graft and does not affect posttransplant outcomes. Hepatitis C virus antiviral therapy should be considered for all HCV-RNA-positive kidney transplant candidates, irrespective of the baseline liver histopathology. Protease inhibitors have yet to be fully evaluated in patients with renal dysfunction and in the transplant population. As these agents may cause anemia in patients with normal renal function, tolerability may be a problem in patients with end-stage kidney disease.The impact of HCV infection on survival in heart and lung transplantation is unclear. Because of the shortage of organs, few HCV-infected patients are accepted for transplantation.Universal use of nucleic acid amplification testing (NAT) for the screening of potential organ donors should be reserved to high-risk donors. Assays that quantify HCV core antigen may become more cost-effective than NAT for the screening of potential organ donors.
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42
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Chow EKH, Massie AB, Muzaale AD, Singer AL, Kucirka LM, Montgomery RA, Lehmann HP, Segev DL. Identifying appropriate recipients for CDC infectious risk donor kidneys. Am J Transplant 2013; 13:1227-34. [PMID: 23621162 DOI: 10.1111/ajt.12206] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/23/2012] [Accepted: 11/19/2012] [Indexed: 01/25/2023]
Abstract
Over 10% of deceased donors in 2011 met PHS/CDC criteria for infectious risk donor (IRD), and discard rates are significantly higher for kidneys from these donors. We hypothesized that patient phenotypes exist for whom the survival benefit outweighs the infectious risk associated with IRDs. A patient-oriented Markov decision process model was developed and validated, based on SRTR data and meta-analyses of window period risks among persons with IRD behaviors. The Markov model allows patients to see, for their phenotype, their estimated survival after accepting versus declining an IRD offer, graphed over a 5-year horizon. Estimated 5-year survival differences associated with accepting IRDs ranged from -6.4% to +67.3% for a variety of patient phenotypes. Factors most predictive of the survival difference with IRD transplantation were age, PRA, previous transplant, and the expected time until the next non-IRD deceased donor offer. This study suggests that survival benefit derived from IRD kidneys varies widely by patient phenotype. Furthermore, within the inherent limitations of model-based prediction, this study demonstrates that it is possible to identify those predicted to benefit from IRD kidneys, and illustrates how estimated survival curves based on a clinical decision can be presented to better inform patient and provider decision-making.
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Affiliation(s)
- E K H Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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43
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Ingsathit A, Kamanamool N, Thakkinstian A, Sumethkul V. Survival advantage of kidney transplantation over dialysis in patients with hepatitis C: a systematic review and meta-analysis. Transplantation 2013; 95:943-8. [PMID: 23425817 DOI: 10.1097/tp.0b013e3182848de2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The clinical outcomes of hepatitis C infection in kidney transplantation and maintenance dialysis patients remain controversial. Here, we conducted a systematic review and meta-analysis that aimed at comparing 5-year mortality rates between waiting list and kidney transplantation patients with hepatitis C infections. METHODS We searched Medline, EMBASE, and Scopus databases published since inception to June 2011 and found nine studies with 1734 patients who were eligible for pooling. Eligible studies were cohort studies that analyzed adult end-stage renal disease patients with hepatitis C virus infection and compared death rates between waiting list and kidney transplantation. The crude risk ratio of death along with its 95% confidence interval was estimated for each study. Data were independently extracted by two reviewers. RESULTS The pooled risk ratio of death at 5 years by using a random-effect model was 2.19 (95% confidence interval, 1.50-3.20), which significantly favored the kidney transplantation when compared with the waiting list. There was evidence of heterogeneity of death rates across studies (χ(2) = 22.6; df = 8; P = 0.004). From the metaregression model, age and male gender could be the source of heterogeneity or variation of treatment effects. A major cause of death in the waiting list was cardiovascular diseases, whereas infection was a major cause in the transplant group. There was no evidence of publication bias suggested by an Egger test. CONCLUSIONS This systematic review suggested that hepatitis C virus-infected patients who remain on dialysis are at higher risk of death when compared with those who received kidney transplantations.
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Affiliation(s)
- Atiporn Ingsathit
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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44
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Chow EKH, Massie AB, Muzaale AD, Singer AL, Kucirka LM, Montgomery RA, Lehmann HP, Segev DL. Identifying Appropriate Recipients for CDC Infectious Risk Donor Kidneys. Am J Transplant 2013. [DOI: 10.1002/ajt.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- E. K. H. Chow
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore, MD
| | | | | | - A. L. Singer
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore, MD
| | - L. M. Kucirka
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore, MD
| | - R. A. Montgomery
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore, MD
| | - H. P. Lehmann
- Division of Health Sciences Informatics; Johns Hopkins University School of Medicine; Baltimore, MD
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45
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Levitsky J, Doucette K. Viral hepatitis in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:147-68. [PMID: 23465008 DOI: 10.1111/ajt.12108] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J Levitsky
- Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Kadambi PV, Chon WJ, Josephson MA, Desai A, Thistlethwaite JR, Harland RC, Meehan SM, Garfinkel MR. Reuse of a previously transplanted kidney: does success come with a price? Clin Kidney J 2012; 5:434-437. [PMID: 23986860 PMCID: PMC3755571 DOI: 10.1093/ckj/sfs086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 06/21/2012] [Indexed: 11/13/2022] Open
Abstract
Longer wait times for deceased donor kidney transplant have prompted newer initiatives to expedite the process. Reuse of a previously transplanted kidney might be appropriate in certain circumstances. However, one must also consider the unique issues that may arise after such transplants. We describe our experience in one such case where the donor kidney had lesions of focal and segmental glomerulosclerosis and signs of alloreactivity (positive C4d staining) prior to transplantation and the recipient developed ganciclovir-resistant cytomegalovirus (CMV) infection, which was perhaps transmitted from the donor. Despite the challenges, the allograft function remained stable 5 years after reuse.
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Affiliation(s)
- Pradeep V Kadambi
- Division of Nephrology and Hypertension, Department of Medicine , University of Texas Medical Branch , Galveston, TX , USA
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47
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Sureshkumar KK, Thai NL, Marcus RJ. Kidney transplantation in hepatitis C-positive recipients: does type of induction influence outcomes? Transplant Proc 2012; 44:1262-4. [PMID: 22663997 DOI: 10.1016/j.transproceed.2011.12.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 12/06/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Kidney transplantation in hepatitis C virus-seropositive (HCV+) recipients improves survival compared to staying on the waiting list. A concern for using depleting (versus nondepleting) induction agent during kidney transplantation in HCV+ recipients is the possibility that the associated enhanced immunosuppression might favor the progression of hepatitis C infection, leading to adverse outcomes. METHODS Utilizing data from the Organ Procurement and Transplant Network, we identified HCV+ patients ≥ 18 years of age who underwent deceased donor kidney (DDK) transplants from either HCV+ or HCV- donors between 1998 and 2008. Patients were divided into two groups based on the induction type they received during the transplant: depleting agent (rabbit-antithymocyte globulin or alemtuzumab) or nondepleting agent (basiliximab or daclizumab) groups. Unadjusted and adjusted graft and patient survivals (Cox regression) between the groups were compared. RESULTS A total of 3490 HCV+ DDK recipients were identified (1859 in the depleting and 1631 in the nondepleting groups). When compared to nondepleting agent, adjusted graft (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.96-1.28, P = .16) and patient (HR 1.15, 95% CI 0.93-1.42, P = .2) survivals were similar with depleting agent induction. HCV donor seropositivity did not adversely impact either graft (HR 1.11, 95% CI 0.96-1.29, P = .17) or patient (HR 1.15, 95% CI 0.93-1.42, P = .2) outcomes. CONCLUSIONS Our analysis supports the practice of transplanting HCV+ donor kidneys into HCV+ recipients to alleviate waiting list burden. Recipient HCV positivity should not influence selection of induction agent.
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Affiliation(s)
- K K Sureshkumar
- Department of Medicine, Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA
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Flohr TR, Bonatti H, Hranjec T, Keith DS, Lobo PI, Kumer SC, Schmitt TM, Sawyer RG, Pruett TL, Roberts JP, Brayman KL. Elderly recipients of hepatitis C positive renal allografts can quickly develop liver disease. J Surg Res 2012; 176:629-38. [PMID: 22316669 PMCID: PMC3401245 DOI: 10.1016/j.jss.2011.10.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/17/2011] [Accepted: 10/24/2011] [Indexed: 02/08/2023]
Abstract
Our institution explored using allografts from donors with Hepatitis C virus (HCV) for elderly renal transplantation (RT). Thirteen HCV- elderly recipients were transplanted with HCV+ allografts (eD+/R-) between January 2003 and April 2009. Ninety HCV- elderly recipients of HCV- allografts (eD-/R-), eight HCV+ recipients of HCV+ allografts (D+/R+) and thirteen HCV+ recipients of HCV- allografts (D-/R+) were also transplanted. Median follow-up was 1.5 (range 0.8-5) years. Seven eD+/R- developed a positive HCV viral load and six had elevated liver transaminases with evidence of hepatitis on biopsy. Overall, eD+/R- survival was 46% while the eD-/R- survival was 85% (P = 0.003). Seven eD+/R- died during follow-up. Causes included multi-organ failure and sepsis (n = 4), cancer (n = 1), failure-to-thrive (n = 1) and surgical complications (n = 1). One eD+/R- died from causes directly related to HCV infection. In conclusion, multiple eD+/R- quickly developed HCV-related liver disease and infections were a frequent cause of morbidity and mortality.
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Affiliation(s)
- Tanya R Flohr
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0709, USA.
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Patzer RE, Pearson TC. Racial disparities in kidney graft survival: does donor quality explain the difference? Am J Transplant 2012; 12:1670-1. [PMID: 22741752 PMCID: PMC3950901 DOI: 10.1111/j.1600-6143.2012.04093.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R. E. Patzer
- Emory Transplant Center, Emory University, Atlanta, GA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA,Corresponding author: Rachel E. Patzer,
| | - T. C. Pearson
- Emory Transplant Center, Emory University, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA
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