Some have recommended that HCV+ kidney wait list patients delay HCV treatment with direct acting antiviral agents (DAAs) with the option of receiving an HCV+/HCV- organ early rather than waiting for a HCV- organ only. Those transplanted would then be treated (Option 1). Alternatively treatment would be immediate however cured subjects would only receive an HCV- organ (Option 2). The trade-off between earlier treatment and earlier transplantation is uncertain. The purpose of this analysis is to determine from the recipient's perspective whether accepting a HCV+ organ earlier with delayed DAA treatment is superior to immediate treatment.

US mortality rates for adult wait-listed, functioning transplant and dialysis cohorts and graft survival rates were used (baseline case age 40). The time horizon was 50 years and assumed no retransplantation. Time 0 was the time of listing. We assumed HCV treatment resulted in cure and patients would not be treated twice.

Net outcomes are determined by how early untreated wait list HCV+ patients (Option 1) receive a transplant relative to the treated candidate and by how much early treatment of HCV benefits the patient (Option 2). Option 1 patients received an HCV+/HCV- organ transplant after a mean time of 1 year on the waitlist compared to 5 years for Option 2. We assumed the relative mortality risk (RR) in HCV+ patients was 1.29 higher than HCV- subjects but that treatment reduced but did not eliminate risk (Baseline RR from 1.29 to 1.10). The model predicted Option 1 subjects lived 0.038 years longer.

Conditions that would result in inferior outcomes for Option 1 were if early treatment reduced the RR of death on the waitlist to <1.08 compared to 1.29 without treatment, if the wait time for a HCV- organ was shorter (<4.3 years), or longer expected wait times (very high PRA patients). Option 2 was consistently more expensive. Even assuming DAA treatment reduced mortality risk to 1.0 (from 1.29) the incremental cost/life year was >$500,000.

The net treatment benefit with DAA on mortality is unknown and the differential transplant rate is uncertain. Small changes in risks/rates make this decision a difficult call. However delayed treatment is most cost-effective. More data is needed to determine by how much and how quickly DAA reduces the mortality risk associated with HCV and how HCV+ organs will be used (HCV+ recipients only or some HCV-recipients).

CITATION INFORMATION: Kiberd B, Tennankore K, Doucette K. Treating Hepatitis C+ Patients Before or After Kidney Transplantation: A Medical Decision Analysis. Am J Transplant. 2017;17 (suppl 3).

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