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. 2018 Oct;18(10):2473-2482.
doi: 10.1111/ajt.14895. Epub 2018 May 29.

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

D A Axelrod  1 , M A Schnitzler  2 , T Alhamad  3 , F Gordon  1 , R D Bloom  4 , G P Hess  5 , H Xiao  2 , M Nazzal  2 , D L Segev  6 , V R Dharnidharka  3 , A S Naik  7 , N N Lam  8 , R Ouseph  2 , B L Kasiske  9 , C M Durand  6 , K L Lentine  2
Affiliations

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

D A Axelrod et al. Am J Transplant. 2018 Oct.

Abstract

Direct-acting antiviral medications (DAAs) have revolutionized care for hepatitis C positive (HCV+) liver (LT) and kidney (KT) transplant recipients. Scientific Registry of Transplant Recipients registry data were integrated with national pharmaceutical claims (2007-2016) to identify HCV treatments before January 2014 (pre-DAA) and after (post-DAA), stratified by donor (D) and recipient (R) serostatus and payer. Pre-DAA, 18% of HCV+ LT recipients were treated within 3 years and without differences by donor serostatus or payer. Post-DAA, only 6% of D-/R+ recipients, 19.8% of D+/R+ recipients with public insurance, and 11.3% with private insurance were treated within 3 years (P < .0001). LT recipients treated for HCV pre-DAA experienced higher rates of graft loss (adjusted hazard ratio [aHR] 1.34 1.852.10 , P < .0001) and death (aHR 1.47 1.681.91 , P < .0001). Post-DAA, HCV treatment was not associated with death (aHR 0.34 0.671.32 , P = .25) or graft failure (aHR 0.32 0.641.26 , P = .20) in D+R+ LT recipients. Treatment increased in D+R+ KT recipients (5.5% pre-DAA vs 12.9% post-DAA), but did not differ by payer status. DAAs reduced the risk of death after D+/R+ KT by 57% (0.19 0.430.95 , P = .04) and graft loss by 46% (0.27 0.541.07 , P = .08). HCV treatment with DAAs appears to improve HCV+ LT and KT outcomes; however, access to these medications appears limited in both LT and KT recipients.

Keywords: clinical research/practice; economics; health services and outcomes research; infection and infectious agents - viral: hepatitis C; kidney (allograft) function/dysfunction; kidney transplantation/nephrology; liver allograft function/dysfunction; liver transplantation/hepatology; patient survival.

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Figures

Figure 1:
Figure 1:
(A) Incidence of HCV treatment after liver transplant, by donor-recipient serostatus and DAA era. (B) Incidence of HCV treatment after kidney transplant.
Figure 2:
Figure 2:
(A) Incidence of HCV treatment after liver transplant in the pre-DAA era, by donor-recipient serostatus and payer. (B) Incidence of HCV treatment after liver transplant in the post-DAA era, by donor-recipient serostatus and payer. (C) Incidence of HCV treatment after kidney transplant in the pre-DAA era, by donor-recipient serostatus and payer. (D) Incidence of HCV treatment after kidney transplant in the post-DAA era, by donor-recipient serostatus and payer.
Figure 2:
Figure 2:
(A) Incidence of HCV treatment after liver transplant in the pre-DAA era, by donor-recipient serostatus and payer. (B) Incidence of HCV treatment after liver transplant in the post-DAA era, by donor-recipient serostatus and payer. (C) Incidence of HCV treatment after kidney transplant in the pre-DAA era, by donor-recipient serostatus and payer. (D) Incidence of HCV treatment after kidney transplant in the post-DAA era, by donor-recipient serostatus and payer.
Figure 3:
Figure 3:
(A) HCV D+/R+ liver recipient survival, by DAA era. (B) HCV D+/R+ kidney recipient survival, by DAA era.
Figure 4:
Figure 4:
(A) HCV+ liver recipient relative risks of death and graft loss, by DAA era. (B) HCV+kidney recipient relative risks of death and graft loss, by DAA era.
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