Background: The prevalence of hepatitis C virus (HCV) infection among kidney transplant (KTx) recipients is higher than that in the general population. With the advent of highly effective antiviral regimens against HCV, the optimal management strategies for KTx recipients continue to evolve. We examine the impact of HCV infection on long-term patient and graft survival after KTx.

Methods: The OPTN database was queried for all adult KTx recipients between January 1, 2004 and December 31, 2006. This study period was chosen to construct the most recent cohort of KTx recipients with up to 10 years of follow-up. A propensity score was created, which was used to select a matching HCV-negative control for each HCV-positive recipient. The Kaplan-Meier and proportional hazards regression analyses were conducted evaluating recipient and death-censored graft survival.

Results: Out of 35,557 adult KTx recipients during the study period, 2,024 (5.7%) were positive for anti-HCV at KTx. Overall, when compared to HCV- recipients, HCV+ patients were more likely to be older, male, and American African and more likely to have HLA mismatch, longer length of time on dialysis and cold ischemic time > 24 hours. Propensity score matching selected 1,733 HCV+ and – pairs. The Kaplan-Meier estimates for recipient survival at 1, 5, 10 year was 92.7%, 75.7%, and 54.3% for HCV+ patients and 95.9%, 84.6%, 66.5% in HCV- patients, respectively (p<0.01). Death-censored graft survival at 1, 5, 10 years was 93.9%, 78.4%, and 58.6% in HCV+ patients and 94.6%, 83.4%, and 66.8% in HCV- patients, respectively (p<0.01). While cardiovascular disease and infection were main causes of death in both groups, hepatic failure were more frequent in HCV+ recipients (6.2% vs. 0.3%). Higher proportions of HCV+ patients experienced graft failure as a result of non-compliance (4.0% vs. 2.7%) or glomerular pathology (3.5% vs. 2.4%) than HCV- patients. Multivariable analysis showed that HCV+ is associated with a higher risk of death (hazard ratio [HR]=1.60, 95% confidence interval [CI]=1.40-1.82) and death-censored graft failure (HR=1.32, 95% CI=1.15-1.52).

Conclusion: HCV infection is associated with decreased long term patient and graft survival. This analysis suggests areas of intervention to improve KTx outcomes, such as patient selection and adherence, which may not be altered with successful antiviral therapy.

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