*Purpose: Increased utilization of hepatitis C virus infected organs could reduce the supply demand mismatch in organ transplantation. At this time, there is little data about long-term HCV renal transplantation outcomes in the era of effective direct-acting antivirals (DAA). It is important to determine precise outcomes of HCV-positive (HCV+) organs that are transplanted into HCV+ recipients (HCV D+/R+) to quantify risk for patients and other stakeholders, especially as HCV+ organ transplantation is expanding to HCV-negative (HCV-) recipients.

*Methods: We performed a retrospective cohort study of all cases of renal transplantation involving HCV+ recipients at an academic medical center from 2008-19. We extracted data using the institutional electronic transplant database. Demographics, time to transplantation, incidence of organ rejection, and mortality data were compared between HCV D+/R+ and HCV D-/R+.

*Results: Among 3781 patients who received a kidney transplant between 2008 and 2019, 121 were HCV D-\R+ and 46 were HCV D+\R+. Both groups had similar donor mean age (40 ± 13 Yrs. vs. 36 ± 11 Yrs., p=0.11) and gender distribution (Female: 43% vs. 39%, p>0.20).There were more men (85% vs. 73% p=0.09) and older recipients (61 ± 8 Yrs. vs. 55 ± 10 Yrs., p<0.001) among HCV D+\R+ compared to the HCV D-\R+ group. The follow-up years were similar between both groups (5.1 ± 4 Yrs. vs. 5.4 ± 3 Yrs., p>0.20). The time to transplant for those who consented to receive an HCV+ kidney from the time of signing the consent was 407 days, as compared to 1210 days for those who did not consent to receiving an HCV+ kidney (p=0.0001). The incidence of rejection (20% vs. 22%, p>0.20) and mortality (15% vs. 16%, p>0.20) were similar between two groups. In Cox Hazards Model, we found no association between HCV D+/R+ and increasing risk of rejection or mortality (HR=0.79, 95% CI 0.36-1.74, p>0.20 and HR=0.99, 95% Cl 0.41-2.4, p>0.20, respectively). Using a multivariate analysis, we found recipient age as the only independent risk factor for mortality (HR =1.08, 95% CI 1.01-1.14, p=0.015).

*Conclusions: Over 10-years of data, patients who were HCV+ did not have worse rejection or mortality if they received HCV+ kidneys compared to HCV- kidneys. There was a significant decrease in time to transplant for those who consented to receive an HCV+ kidney as compared to those who did not. Providers can utilize this data to counsel HCV+ patients about accepting an HCV+ kidney for transplant, perhaps even encouraging it. Increasing the utilization of HCV-positive kidneys for transplantation in the era of effective DAA has the potential to offer life-saving treatment to substantially more patients and decrease time to transplant.

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