Current status of renal transplantation from HCV-positive donors

Updated View on Kidney Transplant from HCV-Infected Donors and DAAs

Background: The discrepancy between the number of potential available kidneys and the number of patients listed for kidney transplant continues to widen all over the world. The transplant of kidneys from hepatitis C virus (HCV)-infected donors into HCV naïve recipients has grown recently because of persistent kidney shortage and the availability of direct-acting antiviral agents. This strategy has the potential to reduce both waiting times for transplant and the risk of mortality in dialysis. Aim: We made an extensive review of the scientific literature in order to review the efficacy and safety of kidney transplant from HCV-viremic donors into HCV naïve recipients who received early antiviral therapy with direct-acting antiviral agents (DAAs). Results: Evidence has been rapidly accumulated on this topic and some reports have been published (n = 11 studies, n = 201 patients) over the last three years. Various combinations of DAAs were administered—elbasvir/grazoprevir (n = 38), glecaprevir/pibrentasvir (n = 110), and sofosbuvir-based regimens (n = 53). DAAs were initiated in a range between a few hours before renal transplant (RT) to a median of 76 days after RT. The sustained virological response (SVR) rate was between 97.5% and 100%. A few severe adverse events (SAEs) were noted including fibrosing cholestatic hepatitis (n = 3), raised serum aminotransferase levels (n = 11), and acute rejection (n = 7). It remains unclear whether the AEs were related to the transmission of HCV, the use of DAAs, or kidney transplant per se. It appears that the frequency of AEs was greater in those studies where DAAs were not given in the very early post-kidney transplant phase. Conclusions: The evidence gathered to date encourages the expansion of the kidney donor pool with the adoption of HCV-infected donor organs. We suggest that kidney transplants from HCV-viremic kidneys into HCV-uninfected recipients should be made in the context of research protocols. Many of the studies reported above were externally funded and we need research generating “real-world” evidence. The recent availability of pangenotypic combinations of DAAs, which can be given even in patients with eGFR < 30/min/1.73 m², will promote the notion that HCV-viremic donors are a significant resource for kidney transplant.

Kidney Transplantation From Donors with Hepatitis B

The growing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led most transplant centers to develop protocols that allow safe use of organs from donors with special clinical situations previously regarded as contraindications. Deceased donors with previous hepatitis B may be a safe resource to increase the donor pool even if there is still controversy among transplantation centers regarding the use of hepatitis B surface antigen-positive donors for renal transplantation. However, when allocated to serology-matched recipients, kidney transplantation from donors with hepatitis B may result in excellent short-term outcome. Many concerns may arise in the long-term outcome, and studies must address the evaluation of the progression of liver disease and the rate of reactivation of liver disease in the recipients. Accurate selection and matching of both donor and recipient and correct post-transplant management are needed to achieve satisfactory long-term outcomes.

Characterization and risk of blood-borne virus transmission in organ transplantation: what are the priorities?

ABSTRACT 

Blood-borne virus transmission through organ transplantation, although rare, has been associated with severe complications in recipients. There are few data available to ascertain the risk of infection in organ transplantation for known and emerging pathogens, as most information comes from events of transmission, which are rare and not always well characterized. The balance between quality of life through organ transplantation and the risks of donor-derived infection can be improved through advances in donor screening, enhanced monitoring and a multidisciplinary approach to improving donor assessment and recipient biosurveillance. The involvement of investigators with clinical, laboratory, surveillance and policy expertise is critical to bridge research knowledge and clinical practice.

Impact of donor hepatitis C virus infection status on death and need for liver transplant in hepatitis C virus-positive kidney transplant recipients

BACKGROUND

Only 29% of deceased donor kidney recipients with hepatitis C virus (HCV) receive HCV-positive (HCV+) kidneys. These kidneys are discarded 2.5 times more often than their HCV-negative (HCV-) counterparts, possibly due to the sense that an HCV+ kidney may adversely affect recipient liver function. The goals of this study were to characterize liver disease in HCV+ kidney recipients and compare rates of liver-related outcomes by kidney donor HCV status.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

6,250 patients with HCV who had a kidney transplant in 1995-2008 as captured in the United Network for Organ Sharing (UNOS) database. Liver-related outcomes were assessed by cross-linking with the liver waitlist and transplant data sets.

PREDICTOR

HCV status of transplanted kidney.

OUTCOMES

Joining the liver waitlist, receiving a liver transplant, death.

MEASUREMENTS

Time to event.

RESULTS

Only 63 (1%) of HCV+ kidney recipients eventually joined the liver waitlist during the 13-year study period. Those who received HCV+ kidneys had a 2.6-fold higher hazard of joining the liver list (P < 0.001); however, the absolute difference in rate of listing between recipients of HCV- and HCV+ kidneys was <2%. This is consistent with findings of only 2% lower patient survival at 3 years in HCV+ patients receiving HCV+ versus HCV- kidneys.

LIMITATIONS

We lacked data for HCV viral load and genotype of both HCV+ recipients and transplanted HCV+ kidneys.

CONCLUSIONS

Because transplant with an HCV+ kidney may reduce waiting-time by more than a year for an HCV+ patient and there is a high risk of kidney waitlist mortality, a 2% increased rate of adverse liver outcomes and 2% increased rate of death at 3 years should not universally preclude the use of HCV+ kidneys when the intended recipient is also HCV+.

Hepatitis C virus and kidney: a strong association with different clinical aspects

The most frequent kidney disease associated with chronic hepatitis C virus (HCV) infection is membranoproliferative glomerulonephritis in patients with type II mixed cryoglobulinaemia. The principal clinical manifestations of glomerular disease in HCV-infected patients are the presence of proteinuria and haematuria with or without impaired kidney function. Pharmaceutical regimens vary because the main pathogenesis of renal dysfunction often mediated by cryoglobulins has not been fully elucidated. HCV infection remains common in patients on renal replacement therapy and has an adverse impact on their survival. Safe and effective pharmaceutical regimens have not been yet established and nosocomial spread within dialysis units continues to occur. Monotherapy with interferon for HCV infection is probably more effective in dialysis than in non-uraemic patients, while experience with ribavirin is limited because of its adverse haemolytic effect. Based on shortage of cadaver kidneys and the fact that HCV renal transplant recipients have better survival than stay on maintenance haemodialysis or at list for transplantation, health organization proposed the use of cadaver kidneys from anti-HCV-positive donors, bringing up concerns and conflicting views. This present review describes the main renal manifestations of HCV infection, the epidemiological and clinical characteristics of chronic kidney disease population and comments on the limitations and shortcomings of current therapeutical regiments.

Distinctive gene expression profiles characterize donor biopsies from HCV-positive kidney donors

BACKGROUND

Because of the shortage of organs for transplantation, procurement of kidneys from extended criteria donors is inevitable. Frequently, donors infected with hepatitis C virus (HCV) are used. To elucidate an initial compromise of molecular pathways in HCV graft, gene expression profiles were evaluated.

METHODS

Twenty-four donor allograft biopsies (n=12 HCV positive (+) and n=12 HCV negative (-)) were collected at preimplantation time and profiled using microarrays. Donors were age, race, gender, and cold and warm ischemia time matched between groups. Probe level data were read into the R programming environment using the affy Bioconductor package, and the robust multiarray average method was used to obtain probe set expression summaries. To identify probe sets exhibiting differential expression, a two sample t test was performed. Molecular and biologic functions were analyzed using Interaction Networks and Functional Analysis.

RESULTS

Fifty-eight probe sets were differentially expressed between HCV (+) versus HCV (-) donors (P<0.001). The molecular functions associated with the two top scored networks from the analysis of the differentially expressed genes were connective tissue development and function and tissue morphology (score 34), cell death, cell signaling, cellular assembly, and organization (score 32). Among the differentially affected top canonical pathways, we found the role of RIG1-like receptors in antiviral innate immunity (P<0.001), natural killer cell signaling (P=0.007), interleukin-8 signaling (P=0.048), interferon signaling (P=0.0 11; INFA21, INFGR1, and MED14), ILK signaling (P=0.001), and apoptosis signaling.

CONCLUSIONS

A unique gene expression pattern was identified in HCV (+) kidney grafts. Innate immune system and inflammatory pathways were the most affected.

Hepatitis C infected hemodialysis and renal transplant patients with elevated α-glutathione S-transferase have increased risk for liver damage

Patients on hemodialysis (HD) and renal transplant recipients (RT) have a high prevalence of HCV infection. Theaimof our study was to determine the prevalence of HCV-RNA in the anti-HCV positive patients and to compare the biochemical parameters of PCR(+) and PCR(−) subgroups.Methods:The 525 sera were screened for anti-HCV. HCV-RNA was detected by polymerase chain reaction (PCR) and liver enzymes [SGOT, SGPT, GGT,α-glutathione S-transferase (GST)] were measured.Results:Active viraemia was found only in 187 of 289 (65%) seropositive HD patients in contrast to 53 of 53 (100%) of seropositive RT patients. Significantly increased (p<0.05) GST values (9.9 μg/l) were found in the PCR(+) subgroups compared to GST levels (2.7 μg/l) of the PCR(−) subgroups. Elevated GST concentration was found in 80% (208/251) of PCR(+) patients. The measured enzymes were not elevated in HCV infected patients. Six percent of HD and 11% of RT patients were screened before seroconversion. Diagnostic sensitivity (80%) and specificity (79%) of GST were calculated as good for early liver damage caused by HCV. In contrast, the sensitivity of the measurement of other liver enzymes were very weak (SGOT: 8%; SGPT: 10%; GGT: 42%).Conclusion:The significantly higher viraemia of the RT subgroup could be related to the immunosuppressive therapy. Increased GST level may be a useful indicator of tissue damage during HCV infection. If HCV infection is suspected, PCR and GST measurement should be performed, even if anti-HCV result is negative.

Underutilization of hepatitis C-positive kidneys for hepatitis C-positive recipients

Hepatitis C-positive (HCV(+)) candidates likely derive survival benefit from transplantation with HCV(+) kidneys, yet evidence remains inconclusive. We hypothesized that lack of good survival benefit data has led to wide practice variation. Our goal was to characterize national utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify the risks/benefits of this practice. Of 93,825 deceased donors between 1995 and 2009, HCV(+) kidneys were 2.60-times more likely to be discarded (p < 0.001). However, of 6830 HCV(+) recipients, only 29% received HCV(+) kidneys. Patients over 60 relative rate (RR 0.86), women (RR 0.73) and highly sensitized patients (RR 0.42) were less likely to receive HCV(+) kidneys, while African Americans (RR 1.56), diabetics (RR 1.29) and those at centers with long waiting times (RR 1.19) were more likely to receive them. HCV(+) recipients of HCV(+) kidneys waited 310 days less than the average waiting time at their center, and 395 days less than their counterparts at the same center who waited for HCV(-) kidneys, likely offsetting the slightly higher patient (HR 1.29) and graft loss (HR 1.18) associated with HCV(+) kidneys. A better understanding of the risks and benefits of transplanting HCV(+) recipients with HCV(+) kidneys will hopefully improve utilization of these kidneys in an evidence-based manner.