|LETTER TO EDITOR
|Year : 2018 | Volume
| Issue : 2 | Page : 159-160
Transplantation of kidneys from hepatitis C virus-positive donors into uninfected recipients
William J. Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
|Date of Web Publication||29-Jun-2018|
Dr. Nitin Abrol
William J. Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abrol N. Transplantation of kidneys from hepatitis C virus-positive donors into uninfected recipients. Indian J Transplant 2018;12:159-60
Kidney transplantation is a cost-effective and superior treatment option for patients with end-stage renal disease (ESRD) compared to long-term dialysis. There is a disparity between the number of ESRD patients waiting for transplantation and the availability of donor kidneys. Various strategies have been used to expand the living donor as well as deceased donor pool to match demand with the supply. Kidney transplantation from ABO-incompatible or human leukocyte antigen-incompatible living donor and paired kidney donation increase living donor pool. Donation after circulatory death, accepting kidneys from marginal donors, and desensitizing highly sensitized recipients have been suggested to increase the deceased donor pool. Despite these strategies in place, 4% wait-listed patients die every year.
Transplant programs had avoided kidneys from hepatitis C virus-positive donors (HCVD+) due to the legitimate concerns of transmitting HCV infection. HCV has been associated with post-transplantation cirrhosis and glomerulonephritis. Moreover, interferon that was once the main treatment option for HCV can cause transplant rejection. Despite these concerns, kidney transplantation from HCVD+ into HCV-positive recipient (HCVR+) became acceptable option to increase the donor pool. Long-term experience showed that HCV was not significant risk factor for allograft failure, liver disease, or mortality, and immunosuppression related to transplantation did not significantly affect the efficacy of antiviral treatment. Reese et al. studied national registry data and reported underutilization of HCVD+ kidneys. Only 37% HCVD+ kidneys were transplanted while others were discarded.
The treatment of HCV using direct-acting antiviral drugs is associated with high cure rates and minimal side effects. Goldberg et al. conducted a pilot trial to study safety and efficacy of using HCVD+ kidneys for HCVR− (transplanting hepatitis C kidneys into negative kidney recipients trial; ClinicalTrials.gov number, NCT02743897). All adults on dialysis who were waiting for kidney transplantation were eligible, but patients with risks of liver disease or allograft failure were excluded from the study. In this trial, 10 HCV-negative patients received HCVD+ kidneys (HCV genotype 1). HCV genotype 2 or 3 donors were rejected because direct-acting agent elbasvir-grazoprevir is not approved by the Food and Drug Administration for the patients with HCV genotype 2 or 3. Immunosuppression for the allograft was not changed due to HCV status of the donor. All recipients received intravenous glucocorticoids and rabbit antithymocyte globulin followed by oral tacrolimus, mycophenolate, and prednisone. As per the protocol, all recipients were tested for HCV on postoperative day 3. All recipients showed HCV RNA positivity, and they received elbasvir-grazoprevir for 12 weeks. All recipients were cured of HCV infection based on the definition of cure as a sustained virologic response 12 weeks after finishing the treatment. Importantly, proteinuria developed in only one patient who had IgA nephropathy before transplantation. Allograft biopsy of kidney showed focal segmental glomerulosclerosis in this patient. None of the patients showed clinically significant liver toxicity or allograft dysfunction.
This trial adds to the growing body of evidence that transplanting HCVD+ kidneys into HCVR− is safe. Transplantation-related immunosuppression does not decrease the efficacy of direct-acting antiviral drugs. In the era of highly efficacious and safe therapy for HCV, it would be unethical to deny HCVD+ kidney to HCV-negative recipient on the waiting list for transplantation. Short-term data on the outcome of HCVR− transplanted with HCVD+ kidneys are encouraging. One major impediment to use HCVD+ kidneys in the developing countries would be the cost of antiviral treatment. As more data are gathered to define the most effective use of HCVD+ kidneys, HCV-infected organs will substantially expand the donor pool.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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