*Purpose: Overall mortality on the kidney transplant waiting list is higher for older diabetic patients. The average age of waitlisted veteran patients is 64, with patients listed up through the age of 75. Expansion of the donor pool would result in increased transplantation rates and decrease mortality on the waitlist. Recent data has shown the safety and benefits of using kidneys from HCV viremic [HCV NAT (+)] donors. However, these studies were limited to younger patients with initiation of therapy post-transplant. This study aims to determine the safety and efficacy of a pre-emptive treatment protocol in an elderly veteran population.

*Methods: This is a prospective, open-label trial. Our cohorts were: 15 deceased donor kidney transplant (DDKT) recipients with HCV NAT (+) kidneys and 20 DDKT recipients with negative HCV NAT testing donors transplanted between 11/2020 and 11/2021. HCV NAT (+) recipients were treated with once-daily Mayvret (Glecaprevir 300mg/Pibrentasvir 120mg) started at least 30 minutes pre-operatively and continued for 8 weeks. Sustained virologic response 12 weeks (SVR 12) was determined by negative NAT testing. Other endpoints included liver function, adverse effects, and patient and graft survival.

*Results: HCV NAT (+) donors were younger (61.3 vs 64.7 yrs., p=0.011). Donor Age, KDPI, and cold ischemia time (CIT) were equivalent amongst both cohorts [HCV NAT (+), 38.85 yrs. vs 41.3 yrs., 59.5% vs 57.56%, and 21.6 hrs. vs. 18.1 hrs.; p>0.05]. Qualifying listing days and dialysis vintage was not-significantly different amongst both cohorts. 40% of HCV NAT (+) recipients had detectable HCV viral load on post-operative day (POD) 1, though all patients achieved undetectable HCV viral load by POD7. SVR12 is 100% in 11/15 patients, with the remaining four patients currently negative. There was no BPAR and 100% Patient and Graft Survival. One patient developed BK viremia. 13% developed persistently elevated bilirubin levels (>1 mg/dl) 1-month post-transplant. One patient developed >1gram of proteinuria after achieving SVR12. However, median serum creatinine was better in the HCV NAT (+) Cohort [1.23 (0.6-2.03) mg/dL vs 1.82 (1-2.62) mg/dL, p-value 0.014].

*Conclusions: Low to no copays allowed for preemptive antiviral initiation in the veteran population. Additionally, differences in KDPI are not truly reflective of actual donor risk as HCV increases KDPI calculation. However, HCV NAT (+) transplants with a pre-emptive treatment protocol results in improved graft function with minimal to no complications in an elderly veteran population. Long-term outcomes will allow for increasing use of HCV NAT (+) donors for all patient populations.

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