Hepatitis C virus-infected kidney waitlist patients: Treat now or treat later?

Area of Science:

• Nephrology
• Hepatology
• Transplant Surgery

Background:

• Hepatitis C virus (HCV) positive donor kidneys are increasingly transplanted into HCV positive recipients, reducing wait times.
• Direct-acting antiviral (DAA) therapy offers a high cure rate for HCV, raising questions about optimal treatment timing relative to transplantation.
• Limited organ availability for HCV positive candidates necessitates careful consideration of treatment strategies.

Purpose of the Study:

• To compare the long-term outcomes of immediate versus delayed direct-acting antiviral (DAA) therapy in patients waitlisted for kidney transplantation with hepatitis C virus (HCV) infection.
• To evaluate the impact of organ availability and patient mortality risk on the preferred DAA therapy strategy.

Main Methods:

• A Markov medical decision analysis model was employed to simulate and compare two treatment options for HCV positive waitlisted patients.
• Option 1: Delayed DAA therapy with earlier transplantation. Option 2: Immediate DAA therapy.
• Model outcomes included cumulative transplant incidence and life years gained.

Main Results:

• Immediate DAA therapy (Option 2) resulted in 0.43 more life years gained compared to delayed DAA therapy (Option 1).
• Delayed DAA therapy (Option 1) showed a higher cumulative transplant incidence (54% at 5 years) versus immediate DAA therapy (45% at 5 years).
• Delayed DAA therapy was favored in regions with high HCV positive organ availability or for patients with very low HCV-associated mortality.

Conclusions:

• Immediate DAA therapy generally provides superior long-term survival benefits for HCV positive kidney transplant candidates.
• The optimal strategy depends on individual patient factors, including regional organ availability and HCV-related mortality risk.
• Personalized decision-making is crucial for balancing transplantation access and the benefits of early HCV cure.