*Purpose: The kidney donor risk index (KDRI), upon which the kidney donor profile index (KDPI) used for renal allocation is based, was derived before the advent of effective HCV therapy. This study was undertaken to evaluate the impact of donor HCV infection on kidney transplant graft survival in the era of safe and effective HCV therapy.

*Methods: Adult first time recipients undergoing kidney transplant alone in the UNOS database were analyzed. Recipients of kidneys from donors with positive HCV serology were compared to recipients of kidneys from donors without positive HCV serology from 2014 through 2016, a timeframe chosen to correspond with the introduction of direct acting antiretroviral (DAA) therapy for HCV. The groups were matched on all factors included in the KDPI and expected post-transplant survival score (EPTS) other than donor HCV status by propensity matching. A secondary analysis of recipients of kidneys from HCV positive kidneys between 2000 and 2016 was performed, with comparison made of patients transplanted before or after the DAA era (pre vs. post 2014). The groups were matched on the same factors as in the primary analysis, as well as on the KDRI and KDPI. Differences in baseline characteristics in the propensity matched cohorts were assessed by standardized difference (stdiff), with stdiff >0.1 in absolute value considered significant. The primary endpoint for both comparisons was non-death-censored renal graft survival.

*Results: There were 27,404 patients in the HCV negative group and 938 patients in the HCV positive group in the primary analysis. After propensity matching, there were 866 patients in each group, appropriately matched on all factors noted above. The HCV group had a mean KDPI of 52 vs. 31.1 (stdiff = 0.97) in the non-HCV group, due to different donor HCV status. Despite a higher KDPI, graft survival was equivalent (table). In the secondary analysis, there 779 patients in each group after propensity matching, from 2819 pre-DAA and 938 post-DAA patients originally. After matching, all factors noted in the methods were equivalent in both groups. Renal allograft survival was better in the post DAA era (table).

*Conclusions: HCV is no longer a risk factor for intermediate term graft loss in the DAA era; revision of the KDPI should be considered.

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