*Purpose: Kidney transplantation is the treatment of choice in end stage renal disease (ESRD). In 2018, 5% to 8% of eligible adults died while on a kidney transplant waiting list. During the last decade, the opioid epidemic has led to an increase in the amount of available organs, including hepatitis C virus (HCV) positive donors. In 2016, approximately 800 HCV positive kidneys were discarded and hundreds more were never procured because of the concern that no center would accept them. The purpose of this study was to evaluate the safety of transplanting kidneys from HCV-infected donors into HCV-uninfected recipients and assess short term outcomes including the occurrence of rejection, and infections post-transplant.

*Methods: This study was designed as a retrospective, observational case series of kidney transplant patients admitted to CAMC General Hospital between January 1, 2019 and March 31, 2021. The treatment group included negative HCV recipients who received a HCV NAT positive kidney (19 patients). HCV surveillance and treatment were performed according to protocol. The control group included HCV negative recipients who received a HCV negative kidney (38 patients). Patients under 18 years of age or pregnant were excluded. Treatment and control groups were matched 1:2 via stratified random sampling. The primary outcomes of this study were evaluation at three months and 6 months of the following: biopsy proven rejection, and infections: BK, CMV, urinary tract infections, C. difficile infections, and bloodstream infections. Secondary outcome included sustained virologic response after initiation of HCV treatment.

*Results: Within the study period, 2/19 (11%) of patients in the treatment group and 6/38 (16%) in the control group experienced biopsy confirmed rejection. No patients (0%) in the treatment group and 4/38 (11%) patients in the control group demonstrated positive BK virus titers within 6 months of their transplant date. 2/19 treatment and 4/38 control patients (11% each) developed positive BK titers in the same timeframe. Likewise, 4/19 (21%) in the treatment group and 6/39 (15%) in the control group experienced urinary tract infections within 6 months post-transplant. 3/19 (16%) in the treatment group vs. 1/38 (3%) experienced bloodstream infections in the same timeframe. No patients in either group developed C. difficile in the study period. All patients treated with HCV direct-acting antiviral had sustained virologic response.

*Conclusions: In summary, this single-center retrospective observational case series demonstrates similarly low rates of biopsy confirmed rejection and incidence of infection post-transplant. This study adds to existing literature providing support for the safety of HCV-positive donor kidney transplantation.

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