Underutilization of Hepatitis C-Positive Kidneys
Underutilization of Hepatitis C-Positive Kidneys
Hepatitis C-positive (HCV(+)) candidates likely derive survival benefit from transplantation with HCV(+) kidneys, yet evidence remains inconclusive. We hypothesized that lack of good survival benefit data has led to wide practice variation. Our goal was to characterize national utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify the risks/benefits of this practice. Of 93,825 deceased donors between 1995 and 2009, HCV(+) kidneys were 2.60-times more likely to be discarded (p < 0.001). However, of 6830 HCV(+) recipients, only 29% received HCV(+) kidneys. Patients over 60 relative rate (RR 0.86), women (RR 0.73) and highly sensitized patients (RR 0.42) were less likely to receive HCV(+) kidneys, while African Americans (RR 1.56), diabetics (RR 1.29) and those at centers with long waiting times (RR 1.19) were more likely to receive them. HCV(+) recipients of HCV(+) kidneys waited 310 days less than the average waiting time at their center, and 395 days less than their counterparts at the same center who waited for HCV(−) kidneys, likely offsetting the slightly higher patient (HR 1.29) and graft loss (HR 1.18) associated with HCV(+) kidneys. A better understanding of the risks and benefits of transplanting HCV(+) recipients with HCV(+) kidneys will hopefully improve utilization of these kidneys in an evidence-based manner.
The prevalence of Hepatitis C virus (HCV) is approximately 12% among end-stage renal disease (ESRD) patients, and HCV(+) patients have an increased risk of death on dialysis when compared with patients who are HCV(−). Similarly, the prevalence of HCV is 4.2% among deceased donors. Kidney transplantation (KT) in HCV(+) recipients is associated with slightly worse outcomes than transplantation in HCV(−) recipients, including increased risk of death and graft loss, and increased incidence of posttransplant diabetes. However, this practice is considered a safe alternative to dialysis treatment, and several single-center studies have shown that HCV(+) recipients derive a survival benefit from KT when compared with remaining on dialysis.
The use of HCV(+) kidneys is controversial, and initial studies recommended excluding them from the organ supply given the near certainty of HCV transmission to the recipient. However, in 1994 a cost-benefit analysis suggested that a policy where HCV(+) kidneys were transplanted into HCV(+) recipients might provide better patient outcomes than a discard policy.
Evidence suggests that outcomes of HCV(+) recipients who receive kidneys from HCV(+) donors are slightly worse than outcomes of HCV(+) recipients who receive kidneys from similar HCV(−) donors. So if an HCV(+) kidney and a comparable HCV(−) kidney were both available for a given HCV(+) patient, the choice would be intuitive. However, a given patient never faces this decision; rather, the true clinical decision is whether to accept the HCV(+) organ offer currently at hand or to wait on dialysis for the next HCV(−) offer. Whether HCV(+) candidates derive a survival benefit from being transplanted with HCV(+) kidneys (versus waiting for HCV(−) kidneys) has been a difficult question to study because no national registry collects HCV status of all candidates on the waiting list; UNOS collects HCV status only when a patient receives a kidney, not when the patient is added to the waiting list. The obvious potential benefit for an HCV(+) patient to accept the currently available HCV(+) kidney, as opposed to waiting for the next available HCV(−) kidney, would be decreased waiting time and as such decreased dialysis mortality. At least one single-center study has observed this, with shorter waiting times for HCV(+) patients who accept HCV(+) kidneys.
We hypothesized that the inability to quantify the survival benefit of HCV(+) KT in HCV(+) candidates has caused high discard rates of HCV(+) kidneys and varied practice patterns among those using them. We further hypothesized that those HCV(+) recipients who did receive HCV(+) kidneys would have significantly shorter waiting times (and thus lower risks of death on the waiting list) than those who waited for HCV(−) kidneys. The goals of our study were to explore national practice patterns in discard and utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify risks and benefits associated with receiving an HCV(+) kidney.
Abstract and Introduction
Abstract
Hepatitis C-positive (HCV(+)) candidates likely derive survival benefit from transplantation with HCV(+) kidneys, yet evidence remains inconclusive. We hypothesized that lack of good survival benefit data has led to wide practice variation. Our goal was to characterize national utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify the risks/benefits of this practice. Of 93,825 deceased donors between 1995 and 2009, HCV(+) kidneys were 2.60-times more likely to be discarded (p < 0.001). However, of 6830 HCV(+) recipients, only 29% received HCV(+) kidneys. Patients over 60 relative rate (RR 0.86), women (RR 0.73) and highly sensitized patients (RR 0.42) were less likely to receive HCV(+) kidneys, while African Americans (RR 1.56), diabetics (RR 1.29) and those at centers with long waiting times (RR 1.19) were more likely to receive them. HCV(+) recipients of HCV(+) kidneys waited 310 days less than the average waiting time at their center, and 395 days less than their counterparts at the same center who waited for HCV(−) kidneys, likely offsetting the slightly higher patient (HR 1.29) and graft loss (HR 1.18) associated with HCV(+) kidneys. A better understanding of the risks and benefits of transplanting HCV(+) recipients with HCV(+) kidneys will hopefully improve utilization of these kidneys in an evidence-based manner.
Introduction
The prevalence of Hepatitis C virus (HCV) is approximately 12% among end-stage renal disease (ESRD) patients, and HCV(+) patients have an increased risk of death on dialysis when compared with patients who are HCV(−). Similarly, the prevalence of HCV is 4.2% among deceased donors. Kidney transplantation (KT) in HCV(+) recipients is associated with slightly worse outcomes than transplantation in HCV(−) recipients, including increased risk of death and graft loss, and increased incidence of posttransplant diabetes. However, this practice is considered a safe alternative to dialysis treatment, and several single-center studies have shown that HCV(+) recipients derive a survival benefit from KT when compared with remaining on dialysis.
The use of HCV(+) kidneys is controversial, and initial studies recommended excluding them from the organ supply given the near certainty of HCV transmission to the recipient. However, in 1994 a cost-benefit analysis suggested that a policy where HCV(+) kidneys were transplanted into HCV(+) recipients might provide better patient outcomes than a discard policy.
Evidence suggests that outcomes of HCV(+) recipients who receive kidneys from HCV(+) donors are slightly worse than outcomes of HCV(+) recipients who receive kidneys from similar HCV(−) donors. So if an HCV(+) kidney and a comparable HCV(−) kidney were both available for a given HCV(+) patient, the choice would be intuitive. However, a given patient never faces this decision; rather, the true clinical decision is whether to accept the HCV(+) organ offer currently at hand or to wait on dialysis for the next HCV(−) offer. Whether HCV(+) candidates derive a survival benefit from being transplanted with HCV(+) kidneys (versus waiting for HCV(−) kidneys) has been a difficult question to study because no national registry collects HCV status of all candidates on the waiting list; UNOS collects HCV status only when a patient receives a kidney, not when the patient is added to the waiting list. The obvious potential benefit for an HCV(+) patient to accept the currently available HCV(+) kidney, as opposed to waiting for the next available HCV(−) kidney, would be decreased waiting time and as such decreased dialysis mortality. At least one single-center study has observed this, with shorter waiting times for HCV(+) patients who accept HCV(+) kidneys.
We hypothesized that the inability to quantify the survival benefit of HCV(+) KT in HCV(+) candidates has caused high discard rates of HCV(+) kidneys and varied practice patterns among those using them. We further hypothesized that those HCV(+) recipients who did receive HCV(+) kidneys would have significantly shorter waiting times (and thus lower risks of death on the waiting list) than those who waited for HCV(−) kidneys. The goals of our study were to explore national practice patterns in discard and utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify risks and benefits associated with receiving an HCV(+) kidney.
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