Effect of kidney transplantation on outcomes among patients with hepatitis C

Abstract

The long-term outcome of kidney transplantation in patients infected with hepatitis C virus (HCV) and end stage renal disease (ESRD) is not well described. We retrospectively identified 230 HCV-infected patients using enzyme immunoassay and nucleic acid testing obtained during the transplant evaluation. Of 207 patients who had a liver biopsy before transplant, 44 underwent 51 follow-up liver biopsies at approximately 5-year intervals either while on the waitlist for a kidney or after kidney transplantation. Advanced fibrosis was present in 10% of patients biopsied, identifying a population that may warrant consideration for combined liver-kidney transplantation. Kidney transplantation does not seem to accelerate liver injury; 77% of kidney recipients who underwent follow-up biopsies showed stable or improved liver histology. There was a higher risk for death during the first 6 months after transplant, but undergoing transplantation conferred a long-term survival advantage over remaining on the waitlist, which was evident by 6 months after transplant (HR, 0.32; 95% CI, 0.17 to 0.62). Furthermore, the risk for death resulting from infection was significantly higher during the first 6 months after transplant (HR, 26.6; 95% CI, 5.01 to 141.3), whereas there was an early (≤6 months) and sustained decrease in the risk for cardiovascular death (HR, 0.20; 95% CI, 0.08 to 0.47). In summary, these data suggest the importance of liver biopsy before transplant and show that kidney transplantation confers a long-term survival benefit among HCV-infected patients with ESRD compared with remaining on the waitlist. Nevertheless, the higher incidence of early infection-related deaths after transplant calls for further study to determine the optimal immunosuppressive protocol.

Figure 1.

Patient flow diagram describing the reasons for not being considered a transplant candidate or not having received a transplant.

Figure 2.

Patient and graft survival in kidney alone recipients. Kaplan-Meier patient and graft (death uncensored) survival for kidney alone transplant recipients (n = 96: 27 deaths and 36 graft failures or deaths).

Figure 3.

Transplant recipients whose transplant occurred more than 6 months ago have the lowest hazard rate of death post-listing compared to patients whose transplant occurred during the past 6 months or those in the pretransplant state. Cumulative hazard plot of the hazard rate of death after listing, using time-dependent covariate methodology to compare three patient states: transplant occurred during the past 6 months (n = 110, 9 deaths; P = 0.02 versus pretransplant), pretransplant (n = 175, 28 deaths), and transplant occurred >6 months ago (n = 95, 27 deaths; P = 0.01 versus pretransplant).

Figure 4.

The cumulative hazard rate of death due to a cardiovascular event post listing is significantly lower in the post transplant patients compared to those in the pretransplant state. Cumulative hazard plot of the hazard rate of death caused by a cardiovascular event after listing, using time-dependent covariate methodology to compare two patient states: pretransplant (n = 175, 19 deaths) versus post-transplant (n = 110, 13 deaths; P = 0.002).