Background

It is unclear whether patients with chronic hepatitis C virus (HCV) infection and end-stage renal disease (ESRD) should be treated for HCV before transplant or should be transplanted with HCV+ organ and treated for HCV afterwards. The aim of this study was to evaluate the optimal HCV treatment strategy and timing in patients listed for kidney transplantation.

Methods

A Markov model with 75 transition states was built to compare the strategy of transplanting HCV-infected patients with HCV+ deceased donor kidneys, followed by anti-viral therapy for HCV versus a strategy of treating HCV-infected patients prior to transplant, then waiting for an HCV− deceased donor kidney. We performed the analysis on a hypothetical cohort of HCV infected patients receiving hemodialysis. HCV treatment included direct-acting antivirals based on genotype. Distributions of age, gender, race, and HCV genotype were based on national data from the United States. The analysis used a lifelong time horizon; main outcome measures were effectiveness measured in quality adjusted life years (QALYs), and costs in 2017 US dollars.

Results

In HCV infected patients, delaying HCV treatment after kidney transplantation with HCV+ organ was more effective and less costly than HCV antiviral treatment prior to transplantation. In the base case, a 58-year-old male receiving hemodialysis would gain an average of 0.22 quality-adjusted life years with lifetime cost savings of $24,358 with the strategy of HCV treatment after transplantation. The superiority of the transplant with HCV+ kidney strategy was robust in sensitivity analyses of the main model parameters. In probabilistic sensitivity analyses of 10,000 second-order Monte Carlo simulations, transplantation with an HCV+ donor kidney was preferred over HCV treatment followed by kidney transplantation with an HCV− donor kidney 92.9 % of the time.

Conclusions

Although new effective antiviral agents for HCV are available for patients with ESRD, the shorter waiting time in case of transplantation with HCV+ deceased donor kidneys results in higher quality-adjusted life expectancy and lower cost compared with a strategy of HCV treatment prior to transplantation. In the current age of increasing organ demand that far outstrips donor supply, a strategy of transplantation of HCV+ kidneys followed by treatment of HCV infection

may be both effective and cost saving.

CITATION INFORMATION: Eckman M., Woodle E., Thakar C., Paterno F., Sherman K. Timing of Treatment for Chronic Hepatitis C Infection in Patients with End-Stage Renal Disease Awaiting Transplantation Am J Transplant. 2017;17 (suppl 3).

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