In the US today, there is a huge demand for organs for the approximately 120,000 patients waiting for a life-saving transplant. Approximately, 100,000 patients are in need of a kidney and there are numerous efforts under way to increase the donor pool so that a life could be saved. One of the ways is the utilization of kidneys from donors who are infected with the hepatitis C virus (HCV).
Currently, it is estimated that between 7 to 10 percent of all end stage renal disease (ESRD) patients have HCV infection. They have been shown to have a higher mortality rate compared to the patients who do not have HCV.
Multiple questions loom large when deciding whether or not to transplant a patient with HCV. On the positive side, there is a huge survival advantage of transplantation compared to dialysis. However, there are certain disadvantages of having HCV and having a kidney transplant. There is an increased incidence of progression of liver disease after transplant. This can be monitored by assessing the condition of the liver by doing a liver biopsy during the work-up phase and then doing further biopsies should liver dysfunction occur after the transplant. It has also been demonstrated that the incidence of new onset diabetes mellitus after transplant (NODAT) goes up and so does the risk of cardiovascular disease. In summary, short-term survival is comparable to a non-HCV infected recipient but longer survival is definitely inferior.
Using a deceased donor’s kidneys who is infected with HCV was considered a contraindication for transplantation not too long ago. This resulted in a lot of kidneys that were potentially usable but were being discarded at a higher rate. With a growing shortage of available donors, transplant centers revised their policies and HCV positive donor kidneys are being used for ESRD patients with HCV. Recent studies show that although the outcomes of using HCV kidneys for HCV recipients are inferior to using non-HCV kidneys, there is a significant reduction in the wait time, which itself translates into longer survival compared to being on dialysis. If it is shown that the donor is viremic, (actively replicationg HCV, based on the HCV RNA), then those kidneys are usually discarded.
ESRD patients with HCV need to be actively worked up to rule out progressive liver disease, including performing a liver biopsy, especially those with positive HCV RNA. Recent data has shown that approximately 25 percent of ESRD HCV positive patients have liver fibrosis. Monitoring liver enzymes alone is not accurate as it has been shown that the enzyme levels are lower when a patient is on dialysis. Sometimes, based on the severity of liver disease on the biopsy, a decision to proceed with a combined liver-kidney transplant could be made.
Treatment of HCV after renal transplant is complicated and involves many newer drugs on the market and some older medications such as pegylated interferon (PEG-IFN) and ribavirin. Caution is necessary as the PEG-IFN and ribavirin can cause morbidity and may have side effects, especially when immunosuppression is involved for the prevention of rejection