Transplantation in the patient with hepatitis C

Real-world direct-acting antiviral treatment in kidney transplant and hemodialysis patients: the EpiTer-2 multicenter observational study

Background

Patients who undergo hemodialysis (HD) or kidney transplantation (KTx) previously had limited possibilities for treatment of hepatitis C virus (HCV) infection. Direct-acting antivirals (DAA) give these patients a chance of virus eradication and safe transplantation. The aim of this study was to evaluate the effectiveness and safety of DAA in KTx and HD patients in real-world settings.

Methods

Sustained virologic response (SVR) and treatment safety were analyzed in KTx and HD patients from the EpiTer-2 database, which included HCV-infected subjects treated with DAA between 2015 and 2019. Additionally, for KTx patients, changes in creatinine concentration, estimated glomerular filtration rate (eGFR), proteinuria within a year after treatment, and changes in the need for calcineurin inhibitors were assessed.

Results

Among 10,152 patients from the EpiTer-2 database 148 were selected, 85 after KTx and 63 undergoing HD. The most common genotype, 1b HCV, was found in 73% and 86% of patients, respectively. Cirrhosis was noted in 10% and 19%, respectively. The most common DAA regimen after KTx was sofosbuvir/ledipasvir (54%), whereas in HD patients it was ombitasvir/paritaprevir/ritonavir +/- dasabuvir (56%). All patients with available follow-up results achieved SVR. No deaths, kidney loss or acute rejection episodes were noted. The most common adverse effects in both groups were anemia and weakness. One year after treatment, creatinine concentration, eGFR and proteinuria remained stable in the majority of patients.

Conclusion

DAA treatment of HCV infection demonstrated high effectiveness and safety in hemodialyzed patients and patients who had undergone KTx in this real-world study.

New updates in the world of hepatitis C virus infected organ transplantation

PURPOSE OF REVIEW

With the advent of direct acting antiviral (DAA) therapy, the use of organs from hepatitis C virus infected (HCV+) donors is gaining more traction. In this review, we aim to: provide an overview of recent literature that supports the use of HCV+ organs, outline ongoing challenges to the use of these organs, and highlight the areas within this field where active investigation is ongoing.

RECENT FINDINGS

The present review describes clinical outcomes related to the transplantation of both HCV+ nonviremic and viremic organs and the distinction between hepatic and nonhepatic transplants. It also discusses the current debate pertaining to the ideal treatment strategy for donor-derived HCV infection, that is pre-emptive therapy versus prophylaxis therapy.

SUMMARY

Data suggest that the use of HCV+ organs is an effective and relatively well tolerated strategy to combat the organ scarcity. However, clinicians must be vigilant to a signal of increased inflammation as HCV+ organ transplantation becomes more universal. Recent studies suggest that shorter courses of DAA may sufficiently treat donor-derived HCV infection, however the best treatment approach to minimize risk, cost, and toxicity is still under investigation.

Chronic Hepatitis C Virus Infection After Kidney Transplantation With or Without Direct-Acting Antivirals in a Real-Life Setting: A French Multicenter Experience

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.

Efficacy and safety of the new antiviral agents for the treatment of hepatitis C virus infection in Egyptian renal transplant recipients

PURPOSE

Hepatitis C virus (HCV) infection in kidney transplant recipients (KTRs) is common and can impact on patient and graft survival rates. The efficacy and safety of direct-acting antivirals (DAAs) to treat genotype-4 HCV-infected KTRs have not been fully established.

METHODS

A prospective, single-arm, single-center study was conducted at Mansoura Urology/Nephrology Center (Mansoura University, Egypt). 114 HCV RNA(+) genotype 4 KTRs were enrolled in this study after a hepatology consultation and consented to start treatment with interferon-free DAAs. A sofosbuvir-based regimen was given to 109 recipients that had creatinine clearance (Crcl) of > 30 mL/min/1.73 m². Ritonavir-boosted paritaprevir/ombitasvir was prescribed to five recipients with Crcl < 30 mL/min/1.73 m².

RESULTS

The mean age of the cohort was 45.2 ± 11.2 years; most were male. The mean duration with a transplant was 14.2 ± 3.5 years, with different immunosuppressive regimens, mostly based on calcineurin inhibitors. A rapid virological response (RVR), i.e., clearance of viral load, was achieved in 100% at 4 weeks after starting treatment. All patients had a sustained virological response (SVR) at 12 and 24 weeks posttreatment, with one exception. During DAA therapy serum creatinine increased in 12 patients. In three, this was concomitant with elevated calcineurin inhibitor and sirolimus trough levels. Graft biopsies were performed in 8 of these 12 patients: these revealed an acute rejection in 4 cases (acute cellular rejection grade-1A: n = 2, and grade-1B: n = 2). The rejection episodes occurred at 4-6 weeks after starting treatment.

CONCLUSION

DAAs were highly efficacious and safely treated genotype-4 HCV-infected KTRs and had no significant adverse effects on graft function/survival.

Acute cellular rejection in hepatitis C recipients following liver transplantation in the era of direct-acting antivirals: chronological analysis of the United Network for Organ Sharing database

INTRODUCTION

Interferon (IFN) treatment for liver transplant (LT) recipients with hepatitis C virus (HCV) increases acute cellular rejection (ACR) and worsens graft and patient survival. It is unknown if direct-acting antivirals (DAAs) affect rejection rates or post-transplant survival.

METHOD

The United Network for Organ Sharing STAR files of December 2017 (n = 25,916) were analyzed.

RESULTS

Compared with non-HCV-LT, HCV-LT survival was worse in the IFN-era (2007-2008) and IFN+DAA-era (2011), but not in the DAA-era (2014-2015). ACR6m rate has been less frequent in newer eras and was lower in HCV-LT than in non-HCV-LT in both the DAA-era (6.9% vs. 9.3%, P < 0.001) and in the IFN+DAA-era (8.8% vs. 11.8%, P = 0.001), but not in the IFN-era (10.8% vs. 11.0%, P = 0.39). HCV-LT recipients who had ACR6m had worse 2-year survival than those without ACR6m, in the IFN-era (80.0% vs. 88.4%, P < 0.0001) and in the IFN+DAA-era (81.4% vs. 89.2%, P < 0.01) but not in the DAA-era (90.4% vs. 93.2%, P = 0.085). Cox proportional hazard model identified ACR6m as independent risk factor for mortality in HCV-LT in the IFN-era (HR = 1.88, P ≤ 0.001) and in the IFN+DAA-era (HR = 1.84, P = 0.005), but not in the DAA-era (P = n.s.).

CONCLUSIONS

Two-year survival of HCV-LT recipients were significantly better in the DAA-era; these were associated with reduced rate and impact of ACR6m.

Infection in Kidney Transplantation

Infection is an important cause of morbidity and mortality after kidney transplantation. It has been estimated that 70% of kidney transplant recipients will experience an infection episode within the first 3 years after transplantation (Dharnidharka et al. 2007). After cardiovascular disease, infection is the second leading cause of death in recipients with allograft function (Snyder et al. 2009). The immunosuppressive therapy required to prevent organ rejection places the kidney transplant recipient at increased risk for donor-derived, nosocomial, and community-acquired infections as well as reactivation of latent pathogens. Pretransplant screening, immunizations, and optimal antibacterial and antiviral prophylaxis can help to reduce the impact of infection. Awareness of the approach to infection in the transplant recipient including diagnostic and management strategies is essential to optimizing outcomes.

Sofosbuvir Monotherapy for Asymptomatic and Noncirrhotic Hepatitis C Infection in a Renal Retransplantation Recipient: A Case Report

Renal transplant recipients infected with hepatitis C virus (HCV) have a high risk of progressing to cirrhosis, end-stage liver diseases, and hepatocellular carcinoma. It is also considered as an independent risk for graft loss and is correlated with proteinuria, transplant glomerulopathy, HCV-associated glomerulonephritis, and chronic rejection. Previous therapy involving interferon alfa and ribavirin led to treatment complications, including toxicity, anemia, sepsis, and drug-drug interactions with calcineurin inhibitors, as well as reduced tolerability and efficacy. New direct-acting antiviral drugs simplify and shorten the treatment along with increasing tolerability and efficacy. Nevertheless, limited data and no specific regimen with direct-acting antiviral drugs have been described in the literature for renal transplant recipients with chronic HCV. We describe here the case of a 52-year-old Chinese man who diagnosed with chronic renal failure in 1997 and underwent renal transplantation the same year. In 2012, he was diagnosed with renal graft failure and again underwent hemodialysis. The patient then underwent his second renal transplantation and was administered an immunosuppressive cyclosporine-based regimen in 2015. During hemodialysis, he acquired asymptomatic genotype 1b HCV infection. Serologic test results reflecting liver cirrhosis were all negative, and ultrasound showed no abnormalities in the liver. The patient later required oral sofosbuvir monotherapy for 12 weeks after the second kidney transplantation. Curing HCV in renal transplant recipients is necessary. Although our treatment did not successfully result in a sustained virologic response, it suggests that genotype 1b HCV may have a poor response to a sofosbuvir monotherapy regimen. Specific and effective regimens for renal transplant recipients with HCV infection need to be confirmed in the future.

Early Results of Pilot Study Using Hepatitis C Virus (HCV) Positive Kidneys to Transplant HCV Infected Patients with End-Stage Renal Disease Allowing for Successful Interferon-Free Direct Acting Antiviral Therapy after Transplantation

INTRODUCTION

Hepatitis C virus (HCV) infection in kidney transplant (KTX) patients reduces long-term patient and graft survival. Direct-acting antivirals (DAA) are > 90% effective in achieving sustained viral response (SVR); however, DAAs are not routinely available to patients with end-stage renal disease (ESRD). The University of Utah Transplant Program developed a protocol to allow HCV-positive potential KTX recipients to accept HCV-positive donors' kidneys. Three months after successful KTX, they were eligible for DAA therapy.

METHODS

HCV-positive patients approved for KTX by the University of Utah Transplant Selection Committee were eligible to be enrolled in this study. Patients consented for the use of HCV-positive donor organs. Three to six months after successful KTX, these patients were treated for HCV with interferon-free direct-acting antiviral regimens according to viral genotype and prior treatment experience.

RESULTS

Between 2014-2015, 12 HCV-positive patients were listed for KTX. Eight patients were kidney only eligible, seven patients received HCV-positive deceased donor kidneys, and one received an HCV-negative organ. Currently, six patients have completed treatment, all have achieved sustained viral response (SVR), and one patient is currently awaiting treatment. All seven patients have functioning kidney grafts. Wait time for KTX was reduced amongst all blood groups from an average of 1,350 days to only 65 days.

CONCLUSIONS

HCV-positive patients with ESRD can successfully receive an HCV-positive donor's kidney. Once transplanted, these patients can receive DAA therapy and achieve SVR. Use of HCV-positive organs reduced time on the waitlist by greater than three years and expanded the donor organ pool.

Clinical Presentation and Determinants of Mortality of Invasive Pulmonary Aspergillosis in Kidney Transplant Recipients: A Multinational Cohort Study

The prognostic factors and optimal therapy for invasive pulmonary aspergillosis (IPA) after kidney transplantation (KT) remain poorly studied. We included in this multinational retrospective study 112 recipients diagnosed with probable (75.0% of cases) or proven (25.0%) IPA between 2000 and 2013. The median interval from transplantation to diagnosis was 230 days. Cough, fever, and expectoration were the most common symptoms at presentation. Bilateral pulmonary involvement was observed in 63.6% of cases. Positivity rates for the galactomannan assay in serum and bronchoalveolar lavage samples were 61.3% and 57.1%, respectively. Aspergillus fumigatus was the most commonly identified species. Six- and 12-week survival rates were 68.8% and 60.7%, respectively, and 22.1% of survivors experienced graft loss. Occurrence of IPA within the first 6 months (hazard ratio [HR]: 2.29; p-value = 0.027) and bilateral involvement at diagnosis (HR: 3.00; p-value = 0.017) were independent predictors for 6-week all-cause mortality, whereas the initial use of a voriconazole-based regimen showed a protective effect (HR: 0.34; p-value = 0.007). The administration of antifungal combination therapy had no apparent impact on outcome. In conclusion, IPA entails a dismal prognosis among KT recipients. Maintaining a low clinical suspicion threshold is key to achieve a prompt diagnosis and to initiate voriconazole therapy.

Pretransplant Hepatitis B Viral Infection Increases Risk of Death After Kidney Transplantation: A Multicenter Cohort Study in Korea

Clinical outcomes in kidney transplant recipients (KTRs) with hepatitis B virus (HBV) have not been thoroughly evaluated. Here, we investigated recent posttransplant clinical outcomes of KTRs with HBV and compared them with KTRs with hepatitis C virus (HCV) and seronegative KTRs.Of 3855 KTRs from April 1999 to December 2011, we enrolled 3482 KTRs who had viral hepatitis serology data; the patients were followed up for 89.1 ± 54.1 months. The numbers of recipients with HBV and HCV were 160 (4.6%) and 55 (1.6%), respectively. We analyzed the clinical outcomes, including overall mortality and graft failure, among patients who had undergone kidney transplantation.Patients with HBV showed poorer survival (P = 0.019; adjusted hazard ratio [HR] = 2.370; 95% confidence interval [CI]: 1.155-4.865) than KTRs without HBV. However, the graft survival of patients with chronic hepatitis B did not differ from that of patients without HBV. Hepatic complications were the primary causes of mortality of KTRs with HBV. Mortality significantly correlated with a higher grade of inflammation (P = 0.002) and with the use of lamivudine or adefovir antiviral treatment (P = 0.016). HBV-positive KTRs treated with the new-generation antiviral agent entecavir showed improved patient survival compared with KTRs receiving lamivudine (log-rank P = 0.050). HCV did not affect patient survival; however, it increased the incidence of graft failure (P = 0.010; adjusted HR = 2.899; 95% CI: 1.289-6.519). KTRs with HCV had an increased incidence of acute rejection (log-rank P = 0.005, crude HR = 2.144; 95% CI: 1.341-3.426; P = 0.001).KTRs with chronic hepatitis B may exhibit poor survival due to post-transplantation hepatic complications. Pretransplant histological liver evaluations and adequate antiviral management with potent nucleoside/nucleotide analogues are needed to improve the survival of KTRs with chronic hepatitis B even when liver function is within the normal range.

Hepatitis C in non-hepatic solid organ transplant candidates and recipients: A new horizon

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.

Lack of impact of hepatitis C virus infection on graft survival after kidney transplantation--a Portuguese single-center experience

BACKGROUND

Hepatitis C virus infection (HCV) is a common problem among kidney transplant (KT) recipients. The long-term burden of HCV infection on graft survival after kidney transplantation is controversial.

METHODS

We performed a retrospective study including all renal transplant recipients with HCV infection (n = 34) compared with a control group (n = 80). The prevalence of HCV infection was 2.7%. The median follow-up period was 134 months (11 years). Graft survival and associated risk factors were assessed by means of Cox proportional hazard analysis.

RESULTS

We found that HCV-positive patients remained on dialysis for longer periods (P = .001) and received transplants at a younger age (P = .03). Actuarial graft survival rates at 1, 5, and 10 years after KT were, respectively, 94.1%, 78.1%, and 66.9%, in the HCV-positive group and 94.9%, 89.1%, and 80.4% in the HCV-negative group. Graft survival did not differ significantly between groups (P = .154). A higher incidence of major cardiovascular disease among HCV-positive patients (P = .004) was noted. Multivariate analysis showed that HCV infection was not an important risk factor for graft loss (adjusted hazard ratio, 2.810; 95% confidence interval, 0.925-8.541; P = .069). Among the HCV-positive population, immunosuppression with cyclosporine or azathioprine conveyed better graft survival.

CONCLUSIONS

Our findings suggest that the long-term impact of HCV infection on graft survival after KT is not significant. KT remains a safe and effective modality of renal replacement in HCV-infected patients with end-stage renal disease.

Study of peripheral blood natural killer cells, T-cell helper/T-cell suppressor ratio and intercurrent infection frequency in hepatitis C seropositive prevalent hemodialysis patients

Hemodialysis (HD) may adversely affect the immune system. It is established that intercurrent infection rate and severity may be increased in prevalent HD patients. Moreover, hepatitis C viral infection, a common infection in many HD centers, may further inhibit the immune system. To our knowledge, no previous study in the literature has attempted to investigate the possible effects of hepatitis C seropositivity on rate and severity of intercurrent infection in prevalent HD patients. The aim of this study was to assess the peripheral blood CD16-natural killer cells, CD4/CD8 ratio, as well as rate of intercurrent infection in hepatitis C seropositive prevalent HD patients as compared with hepatitis C seronegative prevalent HD patients. Twenty hepatitis C seropositive stable prevalent HD patients (group A), as well as another twenty hepatitis C seronegative stable prevalent HD patients (group B), were randomly selected from our HD unit and enrolled in the study. Both groups were similar in age, sex, body mass index, and duration of HD. Diabetics, smokers, and cases with advanced liver disease (Child classification stages B and C) were excluded from the study. A third group (group C) of 10 apparently healthy subjects (of similar age, sex, and body mass index), was also enrolled in the study. All subjects were investigated by complete blood count, routine chemistry, assessment of peripheral lymphocytes CD3,CD16, CD4, CD8, CD4/CD8 ratio by flow cytometer, as well assessment of intercurrent infection frequency retrospectively (since the start of HD therapy and seroconversion in HD patients, and prospectively for a period of six months. Although we detected statistically significant higher frequency of intercurrent infection in both HD groups compared with the healthy group, we did not detect significant differences between hepatitis C seropositive and seronegative groups regarding frequency or severity of intercurrent infection. Moreover, we did not detect significant differences among the three studied groups regarding levels of CD16, CD3, CD4, CD8, CD4/CD8 ratio in peripheral lymphocytes. It may be concluded that hepatitis C seropositive prevalent HD patients are not at increased risk of intercurrent infection as compared with hepatitis C seronegative prevalent HD patients, contrary to what is reported in hepatitis C seroconverted organ transplant candidates.

Ombitasvir/paritaprevir/ritonavir and dasabuvir tablets for hepatitis C virus genotype 1 infection

OBJECTIVE

To review the data with ombitasvir/paritaprevir/ritonavir and dasabuvir for the treatment of chronic hepatitis C virus (HCV) genotype 1 infection.

DATA SOURCES

Phase I, II, and III trials and review articles were identified through MEDLINE (1996-January 2015) and PubMed (1996-January 2015), conference abstracts, and US national clinical trials registry, using the keywords NS3/4A protease inhibitor, NS5A inhibitor, NS5B polymerase inhibitor, ABT-450, ABT-267, ABT-333, paritaprevir, ombitasvir, and dasabuvir.

STUDY SELECTION AND DATA EXTRACTION

Preclinical, phase I, II, and III studies describing pharmacology, pharmacokinetics, efficacy, safety, and tolerability were identified.

DATA SYNTHESIS

Noncirrhotic patients with HCV genotype 1b experienced sustained virological response 12 weeks after completion of therapy (SVR12) rates of 96% to 100% when ombitasvir/paritaprevir/ritonavir and dasabuvir were administered for 12 weeks, regardless of inclusion of ribavirin. SVR12 rates of 95% to 97% were seen in noncirrhotic patients with HCV genotype 1a infection who received ombitasvir/paritaprevir/ritonavir and dasabuvir with ribavirin for 12 weeks. Patients with Child-Pugh Class A cirrhosis also experienced high SVR12 rates (91.8%) when ombitasvir/paritaprevir/ritonavir and dasabuvir were administered with ribavirin for 12 weeks. Cirrhotic patients with HCV genotype 1a and a history of prior null response to peginterferon/ribavirin have higher SVR12 rates when ombitasvir/paritaprevir/ritonavir and dasabuvir and ribavirin are administered for 24 instead of 12 weeks (94.2% vs 88.6%). Adverse events are typically mild, most commonly consisting of fatigue, headache, nausea, and diarrhea.

CONCLUSION

The regimen consisting of ombitasvir/paritaprevir/ritonavir and dasabuvir is highly efficacious in the treatment of HCV genotype 1 infection, with minimal adverse events. It is expected to play an important role in the armamentarium of novel agents that have a high chance of curing HCV infection.

Imbalance between CD56+bright and CD56+dim natural killer cell subsets in the liver of patients with recurrent hepatitis C after liver transplantation

Progressive liver fibrosis remains a major problem for patients with recurrent chronic hepatitis C(CHC) after liver transplantation (LT). However, the involvement of natural killer (NK) and natural killer T (NKT) cells, which predominate in the liver, in recurrent CHC after LT remains unclear.In the present study, we investigated the status of NK and NKT cells in the liver and peripheral blood obtained from 10 patients with recurrent CHC after LT (LT-C), 15 patients with CHC, and 7 normal donors for living donor LT. CD56+ NK cells were separated into two subsets: CD56+bright subset, which is identified as major NK cytokine producer, and CD56+dim subset, which has greater spontaneous cytotoxicity. We found a significant decrease in the CD56+bright subset in the liver of patients with LT-C compared to patients with CHC (P<0.01) and normal donors (P=0.03). The expression of inhibitory NK cell receptor NKG2A was significantly increased on intrahepatic CD56+bright subset in LT-C patients, and activated CD69+CD56+dim NK cell subset was significantly increased in the liver of LT-C patients. Our results suggest that a significant imbalance between CD56+bright and CD56+dim NK cell subsets in the liver may contribute to the progression of recurrent CHC after LT.

Long-term pegylated interferon-α-2a treatment for chronic hepatitis C in an elderly renal transplant recipient: case report and literature review

Combination treatment of pegylated interferon (PEG-IFN) plus ribavirin for renal transplant recipients (RTRs) with hepatitis C virus (HCV) infection remains controversial, as it has been associated with a high risk of rejection, resulting in graft loss and a reduction in patient survival.We present a special case of an elderly RTR who experienced treatment of HCV infection 8 years after renal transplant. There was no rejection episode during or after PEG-IFN treatment. The patient first received a 24-week therapy and a further 60-week course due to relapse. Cessation of both courses corresponded to an achieved end-of-treatment response. However, HCV infection reappeared shortly after cessation of the 60-week treatment period.This case highlights the safety of PEG-IFN therapy for elderly RTR and the potential importance of combination pretreatment for patients undergoing renal transplantation.

Hepatitis C virus core antigen testing in liver and kidney transplant recipients

HCV RNA levels correlate with the long-term outcome of hepatitis C in liver transplant recipients. Nucleic acid testing (NAT) is usually used to confirm HCV reinfection and to examine viral loads after liver transplantation. HCV core antigen (HCVcoreAg) testing could be an alternative to NAT with some potential advantages including very low intra- and interassay variabilities and lower costs. The performance of HCVcoreAg testing in organ transplant recipients is unknown. We prospectively studied 1011 sera for HCV RNA and HCVcoreAg in a routine real-world setting including 222 samples obtained from patients after liver or kidney transplantation. HCV RNA and HCVcoreAg test results showed a consistency of 98% with a very good correlation in transplanted patients (r > 0.85). The correlation between HCV RNA and HCVcoreAg was higher in sera with high viral loads and in samples from patients with low biochemical disease. Patients treated with tacrolimus showed a better correlation between both parameters than individuals receiving cyclosporine A. HCV RNA/HCVcoreAg ratios did not differ between transplanted and nontransplanted patients, and HCV RNA and HCVcoreAg kinetics were almost identical during the first days after liver transplantation. HCVcoreAg testing can be used to monitor HCV viral loads in patients after organ transplantation. However, the assay is not recommended to monitor antiviral therapies.

Sofosbuvir, a novel nucleotide analogue inhibitor used for the treatment of hepatitis C virus

OBJECTIVE

To provide an overview of a novel anti-hepatitis C agent, sofosbuvir.

KEY FINDINGS

Sofosbuvir is a novel nucleotide analogue inhibitor of hepatitis C virus (HCV) NS5B polymerase that has recently been approved by the Federal Drug Administration for the treatment of HCV genotypes 1, 2, 3 or 4 in a variety of patients. The emergence of such a novel treatment provides benefit to previously untreated genotypes and patient populations, with little chance of promoting significant viral resistance. Excellent sustained virologic response rates 12 weeks after the end of treatment (SVR12) were seen in phase II and III clinical trials when sofosbuvir was used with ribavirin. Even more promising are the results from phase II and III clinical trials that evaluated sofosbuvir in combination with other oral direct acting antivirals (DAAs). Data with sofosbuvir in the hepatitis C virus (HCV)/HIV coinfected and in the pre- and post-transplantation populations are still emerging. The drug was very well tolerated in clinical studies, with the most common adverse events of headache, nausea and fatigue.

SUMMARY

Overall, sofosbuvir presents a new and effective treatment option for HCV-infected patients.

Sofosbuvir: A Nucleotide NS5B Inhibitor for the Treatment of Chronic Hepatitis C Infection

OBJECTIVE

To review the use of sofosbuvir for the treatment of chronic hepatitis C virus (HCV).

DATA SOURCES

Review and nonreview articles were identified through MEDLINE (1996-April 2014), citations of articles, and meeting abstracts using keywords, including NS5B polymerase inhibitor, GS-7977, sofosbuvir, direct-acting antiviral (DAA), and others.

STUDY SELECTION AND DATA EXTRACTION

Phase 1, 2, and 3 studies describing dose-ranging potential, pharmacokinetics, efficacy, safety, and tolerability of sofosbuvir were identified.

DATA SYNTHESIS

Sofosbuvir is an NS5B polymerase inhibitor that was approved for use by the Food and Drug Administration in December 2013 for the treatment of chronic HCV in combination with pegylated interferon (peg-IFN) and ribavirin (RBV) for genotype 1. Additionally, it has been evaluated with other oral DAAs, such as simeprevir and others in the pipeline. It is not recommended as monotherapy because of lower sustained virological response (SVR) rates in clinical studies. Most of the treatment regimens are 12 weeks in duration; however, certain populations require a longer duration. Sofosbuvir has activity against all 6 genotypes, although most clinical trials evaluated genotypes 1 to 3. Sofosbuvir has a favorable safety and tolerability profile, making it a recommended first-line agent for chronic HCV infection.

CONCLUSION

In clinical trials, 12 weeks of sofosbuvir with concomitant peg-IFN and RBV therapy in treatment-naïve and experienced HCV genotype 1 patients resulted in SVR rates of >90%. An all-oral regimen of sofosbuvir and RBV is highly effective for genotype 2 and 3 patients. Sofosbuvir was found to be tolerable with minimal adverse effects (AEs), and no treatment discontinuations occurred secondary to drug related AEs..

Predictors of disease recurrence post living donor liver transplantation in end stage chronic HCV patients

HCV recurrence represents a universal phenomenon after liver transplantation. In this study Fifty HCV patients who underwent living donor liver transplantation were enrolled and factors that may accelerate HCV reinfection of the allograft such as donor's age and degree of liver steatosis, recipient's age, gender, BMI, MELD score, liver functions, HCV viral load, type of immunosuppressive drug, and genetic polymorphisms of IL28B, OAS, and IL1B were studied. The results of disease-free survival (DFS) rates showed inverse correlation with the recipient's postoperative levels of ALT, AST, ALP (P < 0.001, <0.001, and 0.006 resp.) as well as pre- and postoperative titers of HCV RNA (P < 0.003 and <0.001 resp.). Recipient's IL28B SNP was a significant factor in predicting postoperative DFS (P < 0.025). However, SNPs in OAS and IL1B genes had no apparent correlation with DFS. Cox proportional hazards model revealed that patients with elevated levels of ALT, preoperative viral titers, IL28B CT, and IL28B TT were 8.28, 4.22, 3.35, and 1.36 times, respectively, more likely to develop recurrence. In conclusion IL28B SNP, ALT level, and preoperative HCV titer besides proper choice of immunosuppressant are helpful for predicting posttransplant HCV recurrence and DFS.

Hepatitis C recurrence: the Achilles heel of liver transplantation

Hepatitis C virus (HCV) infection is the most common indication for liver transplantation worldwide; however, recurrence post transplant is almost universal and follows an accelerated course. Around 30% of patients develop aggressive HCV recurrence, leading to rapid fibrosis progression (RFP) and culminating in liver failure and either death or retransplantation. Despite many advances in our knowledge of clinical risks for HCV RFP, we are still unable to accurately predict those most at risk of adverse outcomes, and no clear consensus exists on the best approach to management. This review presents a critical overview of clinical factors shown to influence the course of HCV recurrence post transplant, with particular focus on recent data identifying the important role of metabolic factors, such as insulin resistance, in HCV recurrence. Emerging data for genetic markers of HCV recurrence and their usefulness for predicting adverse outcomes will also be explored.

De Novo Fibrillary Glomerulonephritis (FGN) in a Renal Transplant with Chronic Hepatitis C

Chronic hepatitis C viremia (HepC) has been associated with numerous renal manifestations both in native kidneys and in the setting of renal transplantation. Glomerulonephritis (GN) of the renal allograft in the setting of HepC most commonly manifests as type 1 membranoproliferative GN (MPGN), either representing recurrence of the original disease or arising de novo. Other GNs were reported after transplantation in the patient with HepC including membranous nephropathy and thrombotic microangiopathy, as well as an enhanced susceptibility to transplant glomerulopathy. We describe the first case of de novo fibrillary GN in a renal transplant patient with HepC where the primary renal disease was biopsy proven type 1 MPGN. We discuss this relationship in detail.

New insights in recurrent HCV infection after liver transplantation

Hepatitis C virus (HCV) is a small-enveloped RNA virus belonging to the Flaviviridae family. Since first identified in 1989, HCV has been estimated to infect 170 million people worldwide. Mostly chronic hepatitis C virus has a uniform natural history, from liver cirrhosis to the development of hepatocellular carcinoma. The current therapy for HCV infection consists of a combination of Pegylated interferon and ribavirin. On the other hand, HCV-related liver disease is also the leading indication for liver transplantation. However, posttransplant HCV re-infection of the graft has been reported to be universal. Furthermore, the graft after HCV re-infection often results in accelerated progression to liver failure. In addition, treatment of recurrent HCV infection after liver transplantation is often compromised by enhanced adverse effects and limited efficacy of interferon-based therapies. Taken together, poor outcome after HCV re-infection, regardless of grafts or recipients, poses a major issue for the hepatologists and transplant surgeons. The aim of this paper is to review several specific aspects regarding HCV re-infection after transplant: risk factors, current therapeutics for HCV in different stages of liver transplantation, cellular function of HCV proteins, and molecular mechanisms of HCV entry. Hopefully, this paper will inspire new strategies and novel inhibitors against recurrent HCV infection after liver transplantation and greatly improve its overall outcome.

Survival advantage of kidney transplantation over dialysis in patients with hepatitis C: a systematic review and meta-analysis

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.

Predisposing factors of diminished survival in simultaneous liver/kidney transplantation

Since the adoption of the Model for End-Stage Liver Disease, simultaneous liver/kidney transplants (SLKT) have substantially increased. Recently, unfavorable outcomes have been reported yet contributing factors remain unclear. We retrospectively reviewed 74 consecutive adult SLKT performed at our center from 2000 to 2010 and compared with kidney transplant alone (KTA, N = 544). In SLKT, patient and death-censored kidney graft survival rates were 64 ± 6% and 81 ± 5% at 5 years, respectively (median follow-up, 47 months). Multivariable analyses revealed three independent risk factors affecting patient survival: hepatitis C virus positive (HCV+, hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.1-7.9), panel reactive antibody (PRA) > 20% (HR 2.8, 95% CI 1.1-7.2) and female donor gender (HR 2.9, 95% CI 1.1-7.9). For death-censored kidney graft survival, delayed graft function was the strongest negative predictor (HR 8.3, 95% CI 2.5-27.9), followed by HCV+ and PRA > 20%. The adjusted risk of death-censored kidney graft loss in HCV+ SLKT patients was 5.8 (95% CI 1.6-21.6) compared with HCV+ KTA (p = 0.008). Recurrent HCV within 1 year after SLKT correlated with early kidney graft failure (p = 0.004). Careful donor/recipient selection and innovative approaches for HCV+ SLKT patients are critical to further improve long-term outcomes.

Time of acquisition of HCV infection in renal transplant recipients: a major prognostic factor for disease progression

BACKGROUND

This study aims to identify crucial factors affecting the evolution of liver disease in HCV-infected renal transplant recipients.

METHODS

Forty-two HCV-infected recipients with known time of HCV acquisition were followed up for a mean (SD) of 7.6 ± 3.4 yr after transplantation with consecutive liver biopsies. Hepatitis progression was defined by: a) fibrosis progression ≥ 0.2 stages/yr and/or b) development of a cholestatic syndrome.

RESULTS

Twenty-three patients (54.8%) displayed benign and 19 (45.2%) aggressive hepatitis progression. Hepatitis course was aggressive in 9.1% and 85% of the patients infected pre- and peri/post-transplantation, respectively (p < 0.001). In multivariate analysis, patients who acquired HCV infection peri- or after transplantation had an increased risk of an adverse outcome compared with those infected before transplantation (p = 0.001). HCV RNA levels at the time of first liver biopsy were lower in patients showing a benign course compared with those with aggressive evolution (p = 0.052).

CONCLUSIONS

Time of acquisition of HCV infection is a major prognostic factor for hepatitis progression in the setting of renal transplantation. Immunosuppression was found to be determinant in the progression of HCV infection acquired peri- or post-transplantation. High viral load seems to be crucial in the pathogenetic process.

Common infections in kidney transplant recipients

Infections are a major cause of morbidity and mortality in kidney transplant recipients. To some extent, these may be preventable. Careful pretransplant screening, immunization, and post-transplant prophylactic antimicrobials may all reduce the risk for post-transplant infection. However, because transplant recipients may not manifest typical signs and symptoms of infection, diagnoses may be confounded. Furthermore, treatment regimens may be complicated by drug interactions and the need to maintain immunosuppression to avoid allograft rejection. This article reviews common post-transplant infections, including prophylactic, diagnostic, and treatment strategies, providing guidance regarding care of kidney transplant patients with infection.

The outcome of heart transplantation in hepatitis C-positive recipients

BACKGROUND

Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes.

METHODS

Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease.

RESULTS

Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30-63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients (P = .59).

CONCLUSIONS

There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease.

Should we be using kidneys from hepatitis C virus-infected donors?

PURPOSE OF REVIEW

Transplantation of kidneys from donors with a positive serology for hepatitis C virus (HCVD positive) remains controversial.

RECENT FINDINGS

Registry studies reported that the use of HCVD positive kidneys into HCV positive recipients is associated with shorter time awaiting transplantation but with a small increase in hazard for death and graft loss compared with HCVD negative. Notably, patients who received kidneys from HCVD positive have better survival than those who remain in the waitlist. A collaborative study using HCVD positive kidneys into HCVRNA positive recipients showed that HCV serology was not an independent risk factor for liver disease, graft survival, and patient survival in the long term. The safety of this approach can be improved by matching donors and recipients according to HCV genotypes. Because the incidence and prevalence of HCV infection in dialysis patients are decreasing, kidneys from HCVD positive are becoming surplus organs due to the lack of appropriate recipients in the waitlist. To improve the underutilization of these kidneys, organizational measures, including the offer of these kidneys for preemptive transplantation, are suggested.

SUMMARY

The use of kidneys from HCVD positive into HCVR positive seems to be a safe approach in the long term, showing a better patient survival than that of HCV positive patients on the waitlist.

Immunosuppression, liver injury and post-transplant HCV recurrence

Hepatitis C virus (HCV) infection is a major cause for liver transplantation worldwide. Still, HCV re-infection of the graft occurs in almost all cases. Most liver transplant recipients experience episodes of graft hepatitis associated with fibrosis progression and graft failure. Clinical management of graft hepatitis can be challenging as in addition to rejection and HCV-induced hepatitis various other factors might be involved including toxic liver injury, steatohepatitis, ischaemic bile duct lesions or infections with other pathogens. Treatment options are often contradictory for different causes of graft hepatitis, and the role of distinct immunosuppressive drugs has been discussed controversially. Corticosteroids increase the infectivity of HCV by altering expression levels of entry factors and other immunosuppressive agents may have diverse effects on HCV replication and fibrosis progression. Interferon alpha-therapy of hepatitis C shows limited efficacy and tolerability in liver transplant recipients and may also cause rejection. In this review we summarize the current knowledge on mechanisms of liver injury in post-transplant hepatitis C, discuss the pros and cons of immunosuppressive agents in this specific setting and describe potential novel approaches to prevent HCV reinfection.

Survival after liver transplantation using hepatitis C virus-positive donor allografts: case-controlled analysis of the UNOS database

BACKGROUND

Numerous reports have documented reduced graft and patient survival after use of hepatitis C (HCV) seropositive allografts in liver transplantation (OLT). We aimed to examine if the use of a HCV+ liver allograft affects patient and graft survivals compared to HCV- donor allografts in a case-controlled analysis of the united network for organ sharing (UNOS) database.

METHODS

We examined 63,149 liver transplants (61,905 donors HCV-; 1,244 donors HCV+) from the UNOS standard transplant analysis and research (STAR) file from 1987 to 2007. Donor and recipient demographics and outcomes were collected in which donor HCV serology was complete. A case-controlled cohort from 11 donor and recipient variables comparing donor HCV- and HCV+ allografts (n=540 in each group) was created using propensity scores with a matching algorithm. Graft and patient survival was estimated using Kaplan-Meier survival curves.

RESULTS

Significant differences were evident in the unadjusted cohort between recipients who received HCV+ and HCV- allografts, including HCV+ recipients, donor and recipient age, and model for end-stage liver disease (MELD) exception cases. Use of HCV+ allograft resulted in significantly lower graft survival (8.1 vs. 10.6 years; P=0.001) and patient survival (10.2 vs. 12.3 years; P=0.01) after OLT. In the matched cohort, HCV seropositivity had no detrimental effect on the graft (P=0.57) or patient (P=0.78) survival after OLT.

CONCLUSIONS

This is the first population-based analysis to show that after adjusting for donor and recipient characteristics there was no difference in graft or patient survival with the use of HCV+ donor liver allografts compared to HCV- donor liver allografts.

Chronic viral hepatitis in kidney transplantation

Chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection in potential kidney transplant candidates-once considered absolute contraindications to kidney transplantation-no longer creates overt barriers to transplantation. Advances in the medical management of HBV and HCV infection have created opportunities for a substantial number of patients to be effectively treated with antiviral therapy before transplantation. For HBV infection, a number of new drugs enable clearance of the virus with minimal adverse effects and drug resistance. Pretransplantation antiviral therapy is advisable for patients with HCV infection, but adverse effects are common and viral eradication remains challenging. Regardless of viral clearance, pretransplant patients without bridging fibrosis (as confirmed by liver biopsy) or clinical stigmata of cirrhosis should be considered for kidney transplantation as survival is superior when compared to treatment with dialysis, and progression of liver disease is unlikely. For patients with advanced liver disease, simultaneous liver-kidney transplantation is an important consideration. These treatment advances further increase the burden of organ donor shortage; however, organs from deceased donors with chronic HBV or HCV infection could be efficiently allocated to certain individuals with a viral infection of the same type to increase the pool of available transplant organs.

Influence of preexisting hepatitis C virus antibody positivity in simultaneous pancreas-kidney transplant recipients

BACKGROUND

Preexisting hepatitis C virus (HCV) infection is implicated in diminished patient and graft survivals in renal transplant recipients. The impact of HCV infection on patient and graft survival in simultaneous pancreas-kidney transplantations is unclear. We evaluated the effect of preexisting HCV infection on patient and graft survival in simultaneous pancreas-kidney transplant (SPKT) recipients in the United States.

METHODS

Using the Organ Procurement and Transplant Network/United Network for Organ Sharing database as of March 2009, adult primary SPKT recipients transplanted from 1995 to 2008 were studied. We stratified recipients based on pretransplant HCV status as HCV positive (HCV+) or HCV negative (HCV-). Overall kidney graft, pancreas graft, and patient survival were compared.

RESULTS

A total of 10,809 adults received primary SPKT, of which 350 (3.2%) were HCV+. Less than 2% of the HCV+ recipients received organs from HCV+ donors. There were no significant differences in baseline donor and recipient characteristics between groups. Rates of acute kidney rejection at 1 year were similar: 22.9% for HCV+ and 23.0% for HCV- recipients (P=0.49). There was no difference in serum creatinine between groups up to 3 years. After controlling for confounding factors, HCV positivity was not associated with worsened overall kidney graft (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.61-1.03), pancreas graft (HR 0.80, 95% CI 0.63-1.00), or patient survival (HR 0.78, 95% CI 0.56-1.08).

CONCLUSIONS

Only 3.2% of SPKT recipients had preexisting HCV infection. Preexisting HCV infection had no significant impact on kidney graft, pancreas graft, or patient survival.

Hepatitis C virus recurrence after liver transplantation: biomarkers of disease and fibrosis progression

End-stage liver disease due to hepatitis C virus infection (HCV) is the principal indication for liver transplantation. In the USA, over a third of available liver allografts are transplanted into recipients with chronic HCV infection. Reinfection of the graft is universal, but the impact of reinfection on short- and long-term liver function is highly variable. HCV infection in liver transplantation recipients is characterized by an accelerated fibrogenesis, with approximately a third of patients developing cirrhosis within 5 years of follow-up. HCV is associated with decreased patient and graft survival when compared with other indications of orthotopic liver transplantation. The mechanisms responsible for the accelerated liver damage in HCV-infected orthotopic liver transplantation recipients remain largely unknown.

Long-term graft function changes in kidney transplant recipients

Background. Monitoring changes in glomerular filtration rate (GFR) is the recommended method for assessing the progression of kidney disease. The aim of this study was to assess the decline of graft function defined by the annualized change in GFR and the factors which affect it.Methods. Four thousand four hundred and eighty-eight patients, transplanted during the years 1990, 1994, 1998 and 2002 in 34 centres in Spain with allograft survival of at least 1 year, were included in the study. GFR was estimated using the four-variable equation of the Modification of Diet in Renal Diseases (MDRD) study. Linear mixed effects model was applied to determine the relation between the covariates and the annualized change in GFR after transplantation.Results. The average GFR at 12 months was 51.4 +/- 18.9 mL/min/1.73 m(2); most patients were in stage 3 of chronic kidney disease classification. The average patient slope, calculated in a linear model with varying-intercept and varying-slope without covariates, was -1.12 +/- 0.05 mL/min/year (slope +/- standard error). Some variables were related to both the 12-month GFR (intercept) and the slope: recipient gender, hepatitis C virus (HCV) status, estimated GFR (eGFR) at 3 months and proteinuria at 12 months. Some variables were only related to the slope of eGFR: time on dialysis, primary renal disease and immunosuppression. Others affected only the 12-month GFR: donor age, delayed graft function, acute rejection and systolic blood pressure at 12 months. Higher graft function at 3 months had a negative impact on the GFR slope. Cyclosporine-based immunosuppression had a less favourable effect on the rates of change in allograft function.Conclusions. There was a slow decline in GFR. Poor graft function was not associated with an increased rate of decline of allograft function. Immunosuppression with cyclosporine displayed the worst declining GFR rate.

Renal transplantation in patients with hepatitis C virus antibody. A long national experience

Background. Renal transplantation is the best therapy for patients with hepatitis C virus (HCV) infection with end-stage renal disease. Patient and graft survival are lower in the long term compared with HCV-negative patients. The current study evaluated the results of renal transplantation in Spain in a long period (1990–2002), focusing on graft failure.

Methods. Data on the Spanish Chronic Allograft Nephropathy Study Group including 4304 renal transplant recipients, 587 of them with HCV antibody, were used to estimate graft and patient survival at 4 years with multivariate Cox models.

Results. Among recipients alive with graft function 1 year post-transplant, the 4-year graft survival was 92.8% in the whole group; this was significantly better in HCV-negative vs HCV-positive patients (94.4% vs 89.5%, P < 0.005). Notably, HCV patients showed more acute rejection, a higher degree of proteinuria accompanied by a diminution of renal function, more graft biopsies and lesions of de novo glomerulonephritis and transplant glomerulopathy. Serum creatinine and proteinuria at 1 year, acute rejection, HCV positivity and systolic blood pressure were independent risk factors for graft loss. Patient survival was 96.3% in the whole group, showing a significant difference between HCV-negative vs HCV-positive patients (96.6% vs 94.5%, P < 0.05). Serum creatinine and diastolic blood pressure at 1 year, HCV positivity and recipient age were independent risk factors for patient death.

Conclusions. Renal transplantation is an effective therapy for HCV-positive patients with good survival but inferior than results obtained in HCV-negative patients in the short term. Notably, HCV-associated renal damage appears early with proteinuria, elevated serum creatinine showing chronic allograft nephropathy, transplant glomerulopathy and, less frequently, HCV-associated de novo glomerulonephritis. We suggest that HCV infection should be recognized as a true risk factor for graft failure, and preventive measures could include pre-transplant therapy with interferon.