*Purpose: Trials describing 4-12 week courses of direct-acting anti-viral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R- transplants), may be limited in application to the ‘real-world’ by costs and delayed access to expensive DAAs. We previously reported HCV transmission of 12% among D+/R- transplants (N=52) with 2-4 day pangenotypic sofosbuvir/velpatasvir (SOF/VEL) prophylaxis. Here we report new data on HCV transmission rates with 7-day prophylaxis (N=50) and cumulative outcomes of all D+/R- transplants (N=102) performed at our center so far.

*Methods: Eligible D+/R- transplant recipients received escalating duration SOF/VEL over treatment groups (Group 1: 2 or 4 days; Group 2: 7 days) with first dose immediately pre-transplant. The primary outcome was the rate of HCV transmission from donor to recipient defined as a positive qNAT at 90 days post-transplant. Secondary outcomes included sustained virologic response at 12 weeks (SVR-12) after completion of HCV therapy, adverse events related to HCV infection and therapy, and allograft function compared with a contemporary matched cohort of HCV D-/R- transplants

*Results: A total of 102 D+/R- transplants (mean age=52) were performed. Nine patients (9/102; 9%; 95%CI: 5%-16%) met the primary outcome of the development of HCV transmission by 90 days post-transplant with a three-fold decline across the two groups: Group 1 (7/52; 13%; 95%CI: 5%-25%) vs Group 2 (2/50; 4%; 95%CI: 0%-13%). All patients with HCV transmission achieved SVR-12 post-full course therapy. There was a higher incidence of peri-operative PPI use (3/9; 33% vs 10/93; 11%; p=0.05) and re-transplant status (2/9; 22% vs 0/93; p=0.007) among those with transmission vs those that did not. A 1:1 matched analysis with contemporary HCV D-/R- transplants (controls) showed that the pre-transplant wait time was shorter for D+/R- compared with D-/R- (mean: 1.8 vs 4.4 years; p<0.001). There were no differences in infections, rejection, development of de-novo donor-specific antibody, or transplant outcomes between controls vs cases up to 6 months of transplant. At the end of 6 months follow-up, two patients each in the D-/R- group and the D+/R- lost their transplant. Similarly, two patients died in the two groups by 6 months post-follow-up. For the D+/R- group, none of the patients with graft loss or death had HCV transmission. In a linear regression model adjusted for covariates, donor HCV status was not significantly associated with estimated GFR at 3- and 6-months post-transplant.

*Conclusions: This paper describes extremely low transmission rate with a seven-day peri-operative DAA regimen. Compared with a matched HCV negative kidney transplant recipient cohort, D+/R- transplants had reduced wait times and comparable short-term kidney function outcomes.

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