The scarcity of kidneys for transplantation has led to continued challenges and subsequent changes in kidney allocation policies. Kidneys that previously would have been discarded are now being transplanted. The impressive success of treating the hepatitis C virus (HCV) with direct-acting antiviral agents (DAAs) has changed the landscape of how HCV is managed in both the non-transplant population as well as in the immediate post–kidney transplantation setting. Recently, studies have shown encouraging outcomes in HCV-positive or -negative recipients who receive a HCV-positive kidney transplant (defined in this post as a kidney from a donor with detectable blood HCV RNA). Most importantly, DAAs have been shown to be efficacious and safe to treat HCV post–kidney transplantation.
The use of HCV-positive kidneys could reduce the number of people on the kidney transplant waitlist impact by facilitating more kidney transplants. Looking at the numbers from 2004-2014, 2,698 kidneys from HCV-positive donors were discarded. One study showed that patients transplanted with an HCV-positive kidneys waited approximately 484 days (1.3 years) less than those transplanted with HCV-negative kidneys.
Post–transplant outcomes were best when DAAs were administered the day prior or immediately post–kidney transplantation. The cost of DAAs is an important limiting factor in the utilization of HCV-positive kidneys in transplantation due to limited insurance coverage for these drugs. Twelve weeks of ledipasvir/ sofosbuvir (Harvoni) regimen can cost $75,000 in the United States without insurance.
Cost Effectiveness?
Several studies have examined the cost-effectiveness of transplanting HCV-positive kidneys into HCV-positive and -negative recipients. An early example by Eckman et al showed that patients on dialysis in the US gained an average of 0.5 quality-adjusted life years (QALYs) with a lifetime cost savings of $41,591. A UK Trial looking at transplanting HCV-positive kidneys into HCV-negative recipients was cost-neutral with dialysis 5 years from transplantation, even with the high cost of DAAs.
A recent article by Eckman et al published in AJKD used a computer program to develop a Markov state transition decision model in the US population to compare two strategies for patients without HCV — the traditional approach (waiting for an unexposed kidney) versus transplanting an HCV-positive kidney, followed immediately by DAA treatment. They found that transplantation with HCV positive kidneys not only improved survival by 0.91 QALYs, but also netted a lifetime cost savings of nearly $38,000 compared with the traditional strategy.
Table 2 from Eckman et al, AJKD © National Kidney Foundation
In conclusion, transplanting HCV-positive kidneys into HCV-positive or -negative recipients is not only associated with cost savings, but also improved clinical outcomes and could reduce the number of people on the kidney transplant waitlist. Rather than discarding kidneys from HCV-positive donors, they can be transplanted into the appropriate patients.
– Post prepared by Anju Yadav @docanjuyadav, AJKDBlog Guest Contributor.
To view Eckman et al (subscription required), please visit AJKD.org.
Title: Cost-effectiveness of Using Kidneys From HCV-Viremic Donors for Transplantation Into HCV-Uninfected Recipients
Author: Mark H. Eckman, E. Steve Woodle, Charuhas V. Thakar, Rita R. Alloway, and Kenneth E. Sherman
DOI: 10.1053/j.ajkd.2019.11.005
