*Purpose: Utilization of Hepatitis C viremic (HCV D+) kidney donors in HCV naïve recipients has increased in the United States. While there are shorter waiting times to receive HCV D+ organs, there is a need for HCV therapy and possible higher rates of other viral infections including cytomegalovirus (CMV) and polyomavirus virus (BK). We conducted this study to compare the outcomes of HCV D+ and HCV D- with a focus on viral infections.

*Methods: A retrospective chart review was conducted to identify deceased donor kidney transplant recipients from December 1, 2018 to November 30, 2019 at a large single-center transplant center. Primary outcome was 1-year patient and kidney allograft survival. Details of kidney allograft function, rejection, HCV therapy, and viral infections were recorded. The recipients were divided into 2 groups according to donor HCV status: HCV D+ (n= 31) and HCV D- (n= 95).

*Results: The groups had similar age (59 vs 56 years, p=0.3), gender (68 vs 55% male, p=0.2), race (Caucasian 55 vs 53%, African American 42 vs 38%, p=0.7), chronic dialysis (94 vs 89%, p=0.5) and dialysis vintage (4 years for both groups, p=0.5). The HCV D+ group had higher BMI (33 vs 30 kg/m2, p =0.03), more primary transplants (97% vs 80%, p =0.02) and lower mean PRA (6 vs 26, p =0.049). Comorbidities were frequent but similar between groups: HTN (90%), DM (44%), CAD (28%) and PAD (5%). Donors in the HCV D+ group were younger (36 vs 45 years, p=0.04) but the proportion of donors with terminal creatinine > 1.5mg/dl was higher (61% vs 34%, p =0.007). While the allocated KDPI was similar, the optimized KDPI was lower in the HCV D+ group (35% vs 55%, p <0.001). Delayed graft function (DGF) (54%) and cold ischemia time (CIT) (22 hours) were similar for the 2 groups. Twenty-nine HCV D+ recipients acquired HCV viremia due to donor transmission; 2 recipients in the HCV D- cohort had HCV viremia prior to transplant. All of these recipients were treated post-transplant and achieved sustained virologic response at 12 weeks. Transaminitis occurred in 9 recipients, with at least 3 times normal aminotransferase levels; no recipients had evidence of advanced hepatic dysfunction. The 1 year patient survival was excellent in HCV D+ recipients (100%) and was similar to HCV D- recipients (90%, p=0.1). No additional kidney allografts were lost at 1 year post-transplant, and both groups had similar GFR at 1 year (56 vs 60 ml/min/1.73 m², p=0.4). CMV and BK infections occurred at similar rates (35 vs 21%, p=0.08 and 26 vs 21%, p=0.6, respectively).

*Conclusions: Our study shows that HCV D+ kidneys can be safely utilized with excellent patient and kidney allograft outcomes. The rates of viral infection were not associated with donor HCV status. HCV D+ kidneys with AKI and long CIT have high rates of DGF, but the short term outcomes are favorable. These results support a more liberal criteria for HCV D+ kidneys for transplantation.

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