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de la Plaza Llamas R, Ortega Azor L, Hernández Yuste M, Gorini L, Latorre-Fragua RA, Díaz Candelas DA, Al Shwely Abduljabar F, Gemio del Rey IA. Quality-adjusted life years and surgical waiting list: Systematic review of the literature. World J Gastrointest Surg 2024; 16:1155-1164. [PMID: 38690041 PMCID: PMC11056653 DOI: 10.4240/wjgs.v16.i4.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/26/2024] [Accepted: 02/25/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs. AIM To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature. METHODS The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published. RESULTS Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain. CONCLUSION The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.
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Affiliation(s)
- Roberto de la Plaza Llamas
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Lorena Ortega Azor
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Marina Hernández Yuste
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ludovica Gorini
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
| | - Raquel Aránzazu Latorre-Fragua
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | | | - Farah Al Shwely Abduljabar
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ignacio Antonio Gemio del Rey
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
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Shah KK, Hedley JA, Robledo KP, Wyld M, Webster AC, Morton RL. Cost-effectiveness of Accepting Kidneys From Deceased Donors With Common Cancers-A Modeling Study. Transplantation 2024:00007890-990000000-00695. [PMID: 38499509 DOI: 10.1097/tp.0000000000004984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND The disparity between the demand for and supply of kidney transplants has resulted in prolonged waiting times for patients with kidney failure. A potential approach to address this shortage is to consider kidneys from donors with a history of common cancers, such as breast, prostate, and colorectal cancers. METHODS We used a patient-level Markov model to evaluate the outcomes of accepting kidneys from deceased donors with a perceived history of breast, prostate, or colorectal cancer characterized by minimal to intermediate transmission risk. Data from the Australian transplant registry were used in this analysis. The study compared the costs and quality-adjusted life years (QALYs) from the perspective of the Australian healthcare system between the proposed practice of accepting these donors and the conservative practice of declining them. The model simulated outcomes for 1500 individuals waitlisted for a deceased donor kidney transplant for a 25-y horizon. RESULTS Under the proposed practice, when an additional 15 donors with minimal to intermediate cancer transmission risk were accepted, QALY gains ranged from 7.32 to 20.12. This translates to an approximate increase of 7 to 20 additional years of perfect health. The shift in practice also led to substantial cost savings, ranging between $1.06 and $2.3 million. CONCLUSIONS The proposed practice of accepting kidneys from deceased donors with a history of common cancers with minimal to intermediate transmission risk offers a promising solution to bridge the gap between demand and supply. This approach likely results in QALY gains for recipients and significant cost savings for the health system.
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Affiliation(s)
- Karan K Shah
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - James A Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Kristy P Robledo
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Angela C Webster
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Rachael L Morton
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Park H, Lee H, Baik S, Kim MS, Yang J, Jeong JC, Koo TY, Kim DG, Lee JM. Kidney Transplantation From Brain-Dead Donors With Hepatitis B or C in South Korea: A 2015 to 2020 Korean Organ Transplantation Registry Data Analysis. Transplant Proc 2024; 56:1-9. [PMID: 38245494 DOI: 10.1016/j.transproceed.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/01/2023] [Accepted: 11/30/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND According to the current Center for Korean Network for Organ Sharing guidelines for kidney transplantation from brain-dead donors with hepatitis B or C infection, organs from hepatitis B surface antigen-positive (HbsAg+) or anti-hepatitis C virus-positive (HCV+) donors can only be transplanted into HBsAg+ or anti-HCV+ recipients. We aimed to confirm the status and the outcomes of kidney transplantation from brain-dead donors with hepatitis B or C virus in Korea. METHODS This retrospective study included all kidney transplantations from brain-dead donors in the Korean Organ Transplantation Registry database between January 2015 and June 2020, divided into 3 groups according to donor hepatitis status. Finally, kidney transplantations from 80 HBV+, 12 HCV+, and 2013 HBV-/HCV- donors were included. RESULTS No statistically significant differences were observed in the recipient characteristics and the transplant outcomes except the waiting time (HBV+ to HBV-/HCV-, P < .001; HCV+ to HBV-/HCV-, P = .10; HBV+ to HCV+P = .95). Five-year graft survival rates of the HBV+, HCV+, and HBV-/HCV- recipients were 95%, 83%, and 85%, respectively (HBV+ to HCV+, P = .22; HCV+ to HBV-/HCV-, P = .81; HBV+ to HBV-/HCV-, P = .02). Five-year patient survival rates of the HBV+, HCV+, and HBV-/HCV- recipients were 95%, 100%, and 76%, respectively (HBV+ to HCV+, P = .61; HCV+ to HBV-/HCV-, P = .13; HBV+ to HBV-/HCV-, P < .001). CONCLUSION HBV+/HCV+ brain-dead donor kidney transplantation outcomes were comparable to HBV-/HCV-. South Korea should consider conditionally permitting transplantation from HBV+ or HCV+ donors to HBV- or HCV- recipients to accumulate new data and conduct further studies.
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Affiliation(s)
- Hoonsung Park
- Korea University College of Medicine, Graduate School, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Department of Trauma Surgery. Seoul, Republic of Korea
| | - Hanyoung Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Seungmin Baik
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tai Yeon Koo
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Myeong Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Seoul, Republic of Korea.
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Scurt FG, Fischer-Fröhlich CL, Wassermann T, Ernst A, Schwarz A, Becker JU, Chatzikyrkou C. Histological and clinical evaluation of discarded kidneys in a European cohort of deceased brain death donor kidneys of marginal quality. J Nephrol 2023; 36:2587-2600. [PMID: 37856068 DOI: 10.1007/s40620-023-01785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Despite organ shortages, the discard rate of deceased donor kidneys is high. Risk factors for this trend warrant further study. METHODS We investigated reasons for discard in a cohort of brain death donors with marginal kidneys and procurement biopsies. Paraffin embedded procurement biopsies were systematically reevaluated and graded for the purpose of the study. Assessment included percentage of global glomerulosclerosis, Banff Lesion scores and tubular epithelial damage. Donor-, transplant process-, perfusion quality-, histopathology-, and recipient-related parameters were compared between discarded and transplanted organs. RESULTS Although most clinical characteristics were similar between donors whose kidneys were transplanted and those whose kidneys were procured but discarded, discarded kidneys were more likely to be from donors with hepatitis C, to have undergone wedge biopsies, to show changes of acute and chronic injury and to be deemed poor quality. Except for obvious anatomic abnormalities, kidneys were often discarded due to the findings of procurement biopsies. Donors of kidneys discarded for histologic reasons more often had hypertension, coronary artery disease, stroke, and increased serum creatinine. The reason for discard was unknown in 20% of cases. Discarded kidneys came from donors who appeared to be clinically similar to donors whose kidneys were utilized for transplant. CONCLUSION A considerable proportion of discarded kidneys were of acceptable quality. The analysis of the outcome of every recovered organ could help to overcome this problem. Procurement biopsies more often lead to discard than to transplantation of recovered organs. Proper handling during allocation has to be determined.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Otto-von Guericke University, Magdeburg, Germany
| | | | - Tamara Wassermann
- Otto-von Guericke University, Magdeburg, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Anke Schwarz
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany.
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany.
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Shah KK, Wyld M, Hedley JA, Waller KMJ, De La Mata N, Webster AC, Morton RL. Cost-effectiveness of Kidney Transplantation From Donors at Increased Risk of Blood-borne Virus Infection Transmission. Transplantation 2023; 107:2028-2042. [PMID: 37211651 DOI: 10.1097/tp.0000000000004632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Demand for donor kidneys outstrips supply. Using kidneys from selected donors with an increased risk of blood-borne virus (BBV) transmission (hepatitis B virus and hepatitis C virus [HCV], human immunodeficiency virus) may expand the donor pool, but cost-effectiveness of this strategy is uncertain. METHODS A Markov model was developed using real-world evidence to compare healthcare costs and quality-adjusted life years (QALYs) of accepting kidneys from deceased donors with potential increased risk of BBV transmission, because of increased risk behaviors and/or history of HCV, versus declining these kidneys. Model simulations were run over a 20-y time horizon. Parameter uncertainty was assessed through deterministic and probabilistic sensitivity analyses. RESULTS Accepting kidneys from donors at increased risk of BBVs (2% from donors with increased-risk behaviors and 5% from donors with active or past HCV infection) incurred total costs of 311 303 Australian dollars with a gain of 8.53 QALYs. Foregoing kidneys from these donors incurred total costs of $330 517 and a gain of 8.44 QALYs. A cost-saving of $19 214 and additional 0.09 QALYs (~33 d in full health) per person would be generated compared with declining these donors. Increasing the availability of kidneys with increased risk by 15% led to further cost-savings of $57 425 and additional 0.23 QALY gains (~84 d in full health). Probabilistic sensitivity analysis using 10 000 iterations showed accepting kidneys from donors at increased risk led to lower costs and higher QALY gains. CONCLUSIONS Shifting clinical practice to accept increased BBV risk donors would likely produce lower costs and higher QALYs for health systems.
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Affiliation(s)
- Karan K Shah
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - James A Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Karen M J Waller
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nicole De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Angela C Webster
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Rachael L Morton
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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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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Yaghoubi M, Cressman S, Edwards L, Shechter S, Doyle-Waters MM, Keown P, Sapir-Pichhadze R, Bryan S. A Systematic Review of Kidney Transplantation Decision Modelling Studies. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:39-51. [PMID: 35945483 DOI: 10.1007/s40258-022-00744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Genome-based precision medicine strategies promise to minimize premature graft loss after renal transplantation, through precision approaches to immune compatibility matching between kidney donors and recipients. The potential adoption of this technology calls for important changes to clinical management processes and allocation policy. Such potential policy change decisions may be supported by decision models from health economics, comparative effectiveness research and operations management. OBJECTIVE We used a systematic approach to identify and extract information about models published in the kidney transplantation literature and provide an overview of the status of our collective model-based knowledge about the kidney transplant process. METHODS Database searches were conducted in MEDLINE, Embase, Web of Science and other sources, for reviews and primary studies. We reviewed all English-language papers that presented a model that could be a tool to support decision making in kidney transplantation. Data were extracted on the clinical context and modelling methods used. RESULTS A total of 144 studies were included, most of which focused on a single component of the transplantation process, such as immunosuppressive therapy or donor-recipient matching and organ allocation policies. Pre- and post-transplant processes have rarely been modelled together. CONCLUSION A whole-disease modelling approach is preferred to inform precision medicine policy, given its potential upstream implementation in the treatment pathway. This requires consideration of pre- and post-transplant natural history, risk factors for allograft dysfunction and failure, and other post-transplant outcomes. Our call is for greater collaboration across disciplines and whole-disease modelling approaches to more accurately simulate complex policy decisions about the integration of precision medicine tools in kidney transplantation.
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Affiliation(s)
- Mohsen Yaghoubi
- Department of Pharmacy Practice, Mercer University College of Pharmacy, Atlanta, USA
| | - Sonya Cressman
- Faculty of Health Sciences, Simon Fraser University, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Louisa Edwards
- School of Population and Public Health, University of British Columbia, Vancouver, V6T 1Z3, Canada
| | - Steven Shechter
- Sauder School of Business, University of British Columbia, Vancouver, Canada
| | - Mary M Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - Paul Keown
- Department of Medicine, Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | | | - Stirling Bryan
- School of Population and Public Health, University of British Columbia, Vancouver, V6T 1Z3, Canada.
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Adejare AA, Duncan HJ, Motz RG, Shah S, Thakar CV, Eckman MH. Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study. JMIR Form Res 2022; 6:e33562. [PMID: 35900828 PMCID: PMC9377480 DOI: 10.2196/33562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys. OBJECTIVE As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process. METHODS We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments. RESULTS A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients. CONCLUSIONS Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.
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Affiliation(s)
- Adeboye A Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH, United States
| | - Heather J Duncan
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - R Geoffrey Motz
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Silvi Shah
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Charuhas V Thakar
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, United States
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Pan-genotypic direct-acting antivirals for patients with hepatitis C virus infection and chronic kidney disease stage 4 or 5. Hepatol Int 2022; 16:1001-1019. [PMID: 35876967 PMCID: PMC9309604 DOI: 10.1007/s12072-022-10390-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/03/2022] [Indexed: 12/17/2022]
Abstract
Hepatitis C virus (HCV) infection is a major health problem with significant clinical and economic burdens in patients with chronic kidney disease (CKD) stage 4 or 5. Current guidelines recommend pan-genotypic direct-acting antivirals (DAAs) to be the first-line treatment of choice for HCV. This review summarizes the updated knowledge regarding the epidemiology, natural history, public health perspectives of HCV in patients with CKD stage 4 or 5, including those on maintenance dialysis, and the performance of pan-genotypic DAAs in these patients. The prevalence and incidence of HCV are much higher in patients with CKD stage 4 or 5 than in the general population. The prognosis is compromised if HCV patients are left untreated regardless of kidney transplantation (KT). Following treatment-induced HCV eradication, patient can improve the health-related outcomes by maintaining a long-term aviremic state. The sustained virologic response (SVR12) rates and safety profiles of pan-genotypic DAAs against HCV are excellent irrespective of KT. No dose adjustment of pan-genotypic DAAs is required across CKD stages. Assessing drug–drug interactions (DDIs) before HCV treatment is vital to secure on-treatment safety. The use of prophylactic or preemptive pan-genotypic DAAs in HCV-negative recipients who receive HCV-positive kidneys has shown promise in shortening KT waiting time, achieving excellent on-treatment efficacy and safety, and maintaining post-KT patient and graft survival. HCV elimination is highly feasible through multifaceted interventions, including mass screening, treatment scale-up, universal precautions, and post-SVR12 reinfection surveillance.
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El Helou G, Jay C, Nunez M. Hepatitis C virus and kidney transplantation: Recent trends and paradigm shifts. Transplant Rev (Orlando) 2022; 36:100677. [DOI: 10.1016/j.trre.2021.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/28/2021] [Accepted: 12/31/2021] [Indexed: 12/09/2022]
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Kidney Transplantation From Hepatitis C Viremic Deceased Donors to Aviremic Recipients in a Real-world Setting. Transplant Direct 2021; 7:e761. [PMID: 34514116 PMCID: PMC8425827 DOI: 10.1097/txd.0000000000001217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background. Transplantation of hepatitis C viremic (HCV+) deceased donor kidney transplants (DDKT) into aviremic (HCV–) recipients is a strategy to increase organ utilization. However, there are concerns around inferior recipient outcomes due to delayed initiation of direct-acting antiviral (DAA) therapy and sustained HCV replication when implemented outside of a research setting. Methods. This was a retrospective single-center matched cohort study of DDKT recipients of HCV+ donors (cases) who were matched 1:1 to recipients of HCV– donors (comparators) by age, gender, race, presence of diabetes, kidney donor profile index, and calculated panel-reactive antibody. Data were analyzed using summary statistics, t-tests, and chi-square tests for between-group comparisons, and linear mixed-effects models for longitudinal data. Results. Each group consisted of 50 recipients with no significant differences in baseline characteristics. The 6-mo longitudinal trajectory of serum creatinine and estimated glomerular filtration rate did not differ between groups. All recipients had similar rates of acute rejection and readmissions (all P > 0.05). One case lost the allograft 151 d posttransplant because of acute rejection, and 1 comparator died on postoperative day 7 from cardiac arrest. HCV+ recipients initiated DAA on average 29 ± 11 d posttransplant. Ninety-eight percent achieved sustained virologic response at 4 and 12 wks with the first course of therapy; 1 patient had persistent HCV infection and was cured with a second course of DAA. Conclusions. Aviremic recipients of HCV+ DDKT with delayed DAA initiation posttransplant had similar short-term outcomes compared with matched recipient comparators of HCV– donors.
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12
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Chen R, Li D, Zhang M, Yuan X. Sofosbuvir/Velpatasvir Prophylaxis for 12 Weeks in Hepatitis C Virus (HCV)-Negative Recipients Receiving Kidney Transplantation from HCV-Positive Donors. Ann Transplant 2021; 26:e933313. [PMID: 34489392 PMCID: PMC8434773 DOI: 10.12659/aot.933313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The aim of this study was to evaluate the efficacy and safety of Sofosbuvir/Velpatasvir prophylaxis in hepatitis C virus (HCV)-negative recipients who received a transplant kidney from HCV-infected donors. Material/Methods This retrospective cohort study enrolled consecutive HCV-negative recipients between January 2019 and February 2021. All the recipients were treated with Sofosbuvir/Velpatasvir (400 mg/100 mg) once daily for 12 weeks after receiving a transplant kidney from HCV-infected donors. We collected data on renal function and liver function and HCV RNA were collected during the study. We also compared the rates of adverse events. Results A total of 26 patients were included in the cohort. All the recipients (100%) completed 12 weeks of treatment and the entire follow-up. All recipients (100%) had negative HCV RNA, but 4 recipients (15.4%) were HCV antibody (Ab)-positive after transplantation. Fifteen adverse events (57.7%) occurred during the study. Three recipients (11.5%) experienced graft rejection, 6 recipients (23.1%) had delayed graft function, and 3 recipients (11.5%) had bleeding. However, none of them were related to study medication. Renal function was stable in all patients. Conclusions Sofosbuvir/Velpatasvir pre- and post-transplantation treatment was effective and safe in HCV-uninfected recipients who received a transplant kidney from HCV-infected donors.
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Affiliation(s)
- Ruoyang Chen
- Department of Urology, Affiliated Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Dawei Li
- Department of Urology, Affiliated Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Ming Zhang
- Department of Urology, Affiliated Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Xiaodong Yuan
- Department of Urology, Affiliated Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
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13
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Strohbehn IA, Seethapathy R, Lee M, Sise ME. Curative Therapies for Hepatitis C Virus Infection in Patients with Kidney Disease. KIDNEY360 2021; 2:1316-1325. [PMID: 35369667 PMCID: PMC8676392 DOI: 10.34067/kid.0001812021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/21/2021] [Indexed: 02/04/2023]
Abstract
Through the discovery of direct-acting antiviral therapies over the last decade, hepatitis C virus (HCV) has been transformed from a highly morbid and potentially fatal chronic viral infection to a curable illness. HCV is common in patients with kidney disease, is a risk factor for progression of CKD, is associated with higher morbidity and mortality in patients receiving dialysis, and leads to worse allograft and patient outcomes in recipients of kidney transplants. Clinical trial and real-world data of direct-acting antivirals in patients with kidney disease demonstrate extremely high cure rates and favorable adverse event profiles. This review covers the transformative effects of curative HCV therapies on patients with kidney disease, including patients with CKD, ESKD, and those who have received a kidney transplant.
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Affiliation(s)
- Ian A Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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14
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Daloul R, Pesavento T, Goldberg DS, Reese PP. A review of kidney transplantation from HCV-viremic donors into HCV-negative recipients. Kidney Int 2021; 100:1190-1198. [PMID: 34237327 DOI: 10.1016/j.kint.2021.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/29/2022]
Abstract
The safety and efficacy of direct-acting antiviral therapies have allowed the transplantation of organs from hepatitis C virus (HCV)-viremic donors into uninfected recipients. This novel strategy contrasts with the previous standard-of-care practice of limiting the transplantation of HCV infected-donor organs to HCV-infected recipients, or all too often, discarding viable organs. In this review, we summarize the published literature about the safety and feasibility of transplanting organs from HCV-viremic donors, the challenges that hinder wider adoption of this strategy, and future research needs.
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Affiliation(s)
- Reem Daloul
- The Ohio State University Medical Center, Columbus, Ohio, USA.
| | - Todd Pesavento
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - David S Goldberg
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Eckman MH, Adejare AA, Duncan H, Woodle ES, Thakar CV, Alloway RR, Sherman KE. Incorporating Patients' Values and Preferences Into Decision Making About Transplantation of HCV-Naïve Recipients With Kidneys From HCV-Viremic Donors: A Feasibility Study. MDM Policy Pract 2021; 6:23814683211056537. [PMID: 34734119 PMCID: PMC8558609 DOI: 10.1177/23814683211056537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction. While use of (hepatitis C virus) HCV-viremic kidneys may result in net benefit for the average end-stage kidney disease (ESKD) patient awaiting transplantation, patients may have different values for ESKD-related health states. Thus, the best decision for any individual may be different depending on the balance of these factors. Our objective was to explore the feasibility of sampling health utilities from hemodialysis patients in order to perform patient-specific decision analyses considering various transplantation strategies. Study Design. We assessed utilities on a convenience sample of hemodialysis patients for health states including hemodialysis, and transplantation with either an HCV-uninfected kidney or an HCV-viremic kidney. We performed patient-specific decision analyses using each patient's age, race, gender, dialysis vintage, and utilities. We used a Markov state transition model considering strategies of continuing hemodialysis, transplantation with an HCV-unexposed kidney, and transplantation with an HCV-viremic kidney and HCV treatment. We interviewed 63 ESKD patients from four dialysis centers (Dialysis Clinic Inc., DCI) in the Cincinnati metropolitan area. Results. Utilities for ESKD-related health states varied widely from patient to patient. Mean values were highest for -transplantation with an HCV-uninfected kidney (0.89, SD: 0.18), and were 0.825 (SD: 0.231) and 0.755 (SD: 0.282), respectively, for hemodialysis and transplantation with an HCV-viremic kidney. Patient-specific decision analyses indicated 37 (59%) of the 63 ESKD patients in the cohort would have a net gain in quality-adjusted life years from transplantation of an HCV-viremic kidney, while 26 would have a net loss. Conclusions. It is feasible to gather dialysis patients' health state utilities and perform personalized decision analyses. This approach could be used in the future to guide shared decision-making discussions about transplantation strategies for ESKD patients.
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Affiliation(s)
- Mark H. Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Adeboye A. Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Heather Duncan
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Rita R. Alloway
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio
| | - Kenneth E. Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, Ohio
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16
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Weinfurtner K, Reddy KR. Hepatitis C viraemic organs in solid organ transplantation. J Hepatol 2021; 74:716-733. [PMID: 33212088 DOI: 10.1016/j.jhep.2020.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
Although rates of organ donation and solid organ transplantation have been increasing over the last few decades, demand for organs still greatly exceeds supply. Several strategies have been utilised to increase organ supply, including utilisation of high-risk (e.g. HCV antibody-positive) donors. In this context, organs from HCV antibody-positive donors have been used in recipients with chronic HCV since the early 1990s. Recently, transplantation of HCV-viraemic organs into HCV-naïve recipients has garnered significant interest, owing to the development of safe and highly effective direct-acting antivirals and increased experience of treating HCV in the post-transplant setting. Preliminary studies based largely in the US have shown excellent outcomes in kidney, liver, heart, and lung transplantation. This practice has the potential to significantly increase transplantation rates and decrease waitlist mortality; however, intentionally transmitting an infectious disease to recipients has important practical and ethical implications. Further, the generalisability of the US experience to other countries is limited by significant differences in HCV-viraemic donor populations. This review summarises the current data on this practice, discusses barriers to implementation, and highlights areas that warrant further study.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania.
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17
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Ariyamuthu VK, Tanriover B. Optimizing Utilization of Kidneys from Hepatitis C-Positive Kidney Donors. Clin J Am Soc Nephrol 2021; 16:188-190. [PMID: 33451991 PMCID: PMC7863653 DOI: 10.2215/cjn.19431220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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18
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Lentine KL, Peipert JD, Alhamad T, Caliskan Y, Concepcion BP, Forbes R, Schnitzler M, Chang SH, Cooper M, Bloom RD, Mannon RB, Axelrod DA. Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers. ACTA ACUST UNITED AC 2020; 1:1291-1299. [PMID: 33251523 DOI: 10.34067/kid.0004592020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly. Methods We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients. Results Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%). Conclusions Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | - John D Peipert
- Northwestern University, Feinberg School of Medicine, Chicago, IL.,Northwestern University Transplant Outcomes Research Core, Chicago, IL
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Mark Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Roy D Bloom
- University of Pennsylvania, Philadelphia, PA
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19
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Financial Evaluation of Kidney Transplant With Hepatitis C Viremic Donors to Uninfected Recipients. Transplant Direct 2020; 6:e627. [PMID: 33204825 PMCID: PMC7665247 DOI: 10.1097/txd.0000000000001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023] Open
Abstract
Kidney transplantation with hepatitis C viremic (dHCV+) donors appears safe for recipients without HCV when accompanied by direct acting antiviral (DAA) treatment. However, US programs have been reluctant to embrace this approach due to concern about insurance coverage. While the cost of DAA treatment is currently offset by the reduction in waiting time, increased competition for dHCV+ organs may reduce this advantage. This analysis sought to demonstrate the financial benefit of dHCV+ transplant for third-party health insurers to expand coverage availability. Methods An economic analysis was developed using a Markov model for 2 decisions: first, to accept a dHCV+ organ versus wait for a dHCV uninfected organ; or second, accept a high kidney donor profile index (KDPI) (>85) organ versus wait for a better quality dHCV+ organ. The analysis used Medicare payments, historical survival data, cost report data, and an estimated cost of DAA of $29 874. Results In the first analysis, using dHCV+ kidneys reduced the cost of end-stage kidney disease care if the wait for a dHCV uninfected organ exceeded 11.5 months. The financial breakeven point differed according to the cost of DAA treatment. In the second analysis, declining a high-KDPI organ in favor of a waiting dHCV+ organ was marginally clinically beneficial if waiting times were <12 months but not cost effective. Conclusions dHCV+ transplant appears to be economically and clinically advantageous compared with waiting for dHCV-uninfected transplant but should not replace high-KDPI transplant when appropriate. Despite the high cost of DAA therapy, health insurers benefit financially from dHCV+ transplant within 1 year.
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20
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Torabi J, Rocca JP, Ajaimy M, Melvin J, Campbell A, Akalin E, Liriano LE, Azzi Y, Pynadath C, Greenstein SM, Le M, Goldstein DY, Fox AS, Carrero J, Weiss JM, Powell T, Racine AD, Reinus JF, Kinkhabwala MM, Graham JA. Commercial insurance delays direct-acting antiviral treatment for hepatitis C kidney transplantation into uninfected recipients. Transpl Infect Dis 2020; 23:e13449. [PMID: 32810315 DOI: 10.1111/tid.13449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies. METHODS A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs). RESULTS Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (β = 0.39, R2 = .15, P = .01) and longer time to HCV viral load clearance (β = 0.41, R2 = .17, P = .01). CONCLUSIONS D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.
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Affiliation(s)
- Julia Torabi
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan P Rocca
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Maria Ajaimy
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | | | - Alesa Campbell
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Enver Akalin
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Luz E Liriano
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Yorg Azzi
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Cindy Pynadath
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Stuart M Greenstein
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Marie Le
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Doctor Y Goldstein
- Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| | - Amy S Fox
- Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| | - Jin Carrero
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Jeffrey M Weiss
- Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Tia Powell
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Bioethics, Montefiore Medical Center, Bronx, NY, USA
| | - Andrew D Racine
- Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Pediatrics, Montefiore Medical Center, Bronx, NY, USA
| | - John F Reinus
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Milan M Kinkhabwala
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Jay A Graham
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
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21
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Sise ME, Goldberg DS, Kort JJ, Schaubel DE, Alloway RR, Durand CM, Fontana RJ, Brown RS, Friedewald JJ, Prenner S, Landis JR, Fernando M, Phillips CC, Woodle ES, Rike-Shields A, Sherman KE, Elias N, Williams WW, Gustafson JL, Desai NM, Barnaba B, Norman SP, Doshi M, Sultan ST, Aull MJ, Levitsky J, Belshe DS, Chung RT, Reese PP. Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC): An Open-Label Study of Combined Glecaprevir and Pibrentasvir to Treat Recipients of Transplanted Kidneys from Deceased Donors with Hepatitis C Virus Infection. J Am Soc Nephrol 2020; 31:2678-2687. [PMID: 32843477 DOI: 10.1681/asn.2020050686] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/06/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Single-center trials and retrospective case series have reported promising outcomes using kidneys from donors with hepatitis C virus (HCV) infection. However, multicenter trials are needed to determine if those findings are generalizable. METHODS We conducted a prospective trial at seven centers to transplant 30 kidneys from deceased donors with HCV viremia into HCV-uninfected recipients, followed by 8 weeks of once-daily coformulated glecaprevir and pibrentasvir, targeted to start 3 days posttransplant. Key outcomes included sustained virologic response (undetectable HCV RNA 12 weeks after completing treatment with glecaprevir and pibrentasvir), adverse events, and allograft function. RESULTS We screened 76 patients and enrolled 63 patients, of whom 30 underwent kidney transplantation from an HCV-viremic deceased donor (median kidney donor profile index, 53%) in May 2019 through October 2019. The median time between consent and transplantation of a kidney from an HCV-viremic donor was 6.3 weeks. All 30 recipients achieved a sustained virologic response. One recipient died of complications of sepsis 4 months after achieving a sustained virologic response. No severe adverse events in any patient were deemed likely related to HCV infection or treatment with glecaprevir and pibrentasvir. Three recipients developed acute cellular rejection, which was borderline in one case. Three recipients developed polyomavirus (BK) viremia near or >10,000 copies/ml that resolved after reduction of immunosuppression. All recipients had good allograft function, with a median creatinine of 1.2 mg/dl and median eGFR of 57 ml/min per 1.73 m2 at 6 months. CONCLUSIONS Our multicenter trial demonstrated safety and efficacy of transplantation of 30 HCV-viremic kidneys into HCV-negative recipients, followed by early initiation of an 8-week regimen of glecaprevir and pibrentasvir.
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Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Jens J Kort
- Global Medical Affairs Research and Development, AbbVie Inc., North Chicago, Illinois
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa Fernando
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin C Phillips
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adele Rike-Shields
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.,The Christ Hospital, Cincinnati, Ohio
| | - Kenneth E Sherman
- Division of Digestive Disease, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nahel Elias
- Transplant Center and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jenna L Gustafson
- Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Silas P Norman
- Division of Nephrology, Michigan Medicine, Ann Arbor, Michigan
| | - Mona Doshi
- Division of Nephrology, Michigan Medicine, Ann Arbor, Michigan
| | - Samuel T Sultan
- Division of Transplant Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Meredith J Aull
- Division of Transplant Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dianne S Belshe
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond T Chung
- Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter P Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Chevallier E, Büchler M, Caillard S, Bouvier N, Colosio C, Rivalan J, Sayegh J, Bertrand D, Le Meur Y, Thierry A, Garrouste C, Rerolle JP, Rostaing L, Gatault P. Chronic Hepatitis C Virus Infection After Kidney Transplantation With or Without Direct-Acting Antivirals in a Real-Life Setting: A French Multicenter Experience. Transplant Proc 2020; 52:3179-3185. [PMID: 32636068 DOI: 10.1016/j.transproceed.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Kidney transplant recipients (KTRs) are frequently infected with chronic hepatitis C virus (HCV), which can increase the risk of graft loss. Active HCV infections among KTRs are associated with shorter survival times. The emergence of very efficient interferon-free treatments (direct-acting antivirals [DAAs]) has revolutionized prognoses for chronic viral hepatitis. We performed a multicenter study where HCV (+)/RNA (+) KTRs were followed up and either received DAAs (group A) or not (group B) according to the transplant center. The aim was to assess, in a real-life setting, the impact of DAA therapy and to compare these results with those from HCV RNA (+) KTRs where HCV infection was not treated during the same period. METHODS This study included 66 patients from 11 centers: 44 patients (66.7%; group A) received DAAs, whereas 22 patients did not (group B); the 2 groups were comparable according to baseline data. Most patients (88.6%) received sofosbuvir, 50% received ledipasvir, and 34.7% received daclatasvir. The duration of treatments ranged from 8 to 24 weeks. RESULTS HCV RNA clearance (ie, a sustained virologic response) was observed in 95.4% of treated patients. Eradication of HCV led to a significant decrease in liver enzymes (50% reduction for alanine aminotransferase [P ≤ .001] and 41% for gamma glutamyl transpeptidase [P < .001]). Conversely, liver enzymes did not decrease in group B. Death occurred significantly more frequently in nontreated than treated patients (3 in group B vs none in group A, P = .003). Of the 10 treated patients with severe renal impairment before DAA therapy, 6 experienced graft loss. CONCLUSION DAAs are very effective at treating chronic HCV and have an excellent tolerance profile.
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Affiliation(s)
- Eloi Chevallier
- Department of Nephrology, Hemodialysis, Apheresis and Kidney Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble-Alpes University, Grenoble, France
| | - Matthias Büchler
- Department of Nephrology and Clinical Immunology, CHU Tours, Tours, France
| | - Sophie Caillard
- Department of Nephrology, Strasbourg University Hospital, Strasbourg, France
| | - Nicolas Bouvier
- Department of Nephrology, Caen University Hospital, Caen, France
| | | | - Joseph Rivalan
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | - Johnny Sayegh
- Department of Nephrology, Angers University Hospital, Angers, France
| | | | - Yannick Le Meur
- Department of Nephrology, Brest University Hospital, Brest, France
| | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont Ferrand University Hospital, Clermont Ferrand, France
| | | | - Lionel Rostaing
- Department of Nephrology, Hemodialysis, Apheresis and Kidney Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble-Alpes University, Grenoble, France.
| | - Philippe Gatault
- Department of Nephrology and Clinical Immunology, CHU Tours, Tours, France
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Abstract
Hepatitis C virus (HCV) is associated with increased mortality and morbidity in patients with chronic kidney disease (CKD). The early detection and treatment of Hepatitis C associated with kidney disease is paramount to preventing the progressive loss of kidney function. HCV treatment until the advent of direct acting anti-viral agents (DAAs) was limited to interferon and ribavirin. Interferon and ribavirin treatment resulted in only modest success but with frequent adverse events and poor tolerability. Furthermore, interferon and ribavirin could not be used in certain patient populations including those with advanced CKD, were on dialysis, or those who have received a kidney transplant. DAAs have now made treatment possible in these sub-groups with a sustained viral response (SVR) of 90-100% and minimal side effects. DAAs have helped increase transplant rates by allowing for the use of HCV positive kidneys in recipients who are HCV negative. Although the choice of DAAs should be carefully considered and based on patient characteristics, concomitant medications, and HCV genotype.
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24
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Reddy YNV, Reddy KP, Sise ME. HCV-Infected Deceased Donor Kidney Transplantation-Time to Take Up the Offer. Am J Kidney Dis 2020; 75:827-829. [PMID: 32317120 DOI: 10.1053/j.ajkd.2020.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Yuvaram N V Reddy
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
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