HCV, not HIV, associated with inferior kidney transplant outcome

Last Updated: 2014-08-01

By Megan Brooks

NEW YORK (Reuters Health) - HIV infection does not affect kidney transplant graft or patient outcomes but hepatitis C virus (HCV) infection has a negative impact on both, according to a study by researchers from the Penn Transplant Institute at the University of Pennsylvania in Philadelphia.

The researchers say pretransplant HCV eradication should be a priority to improve outcomes in this population.

Dr. Deidre Sawinski reported the study findings during a July 30 Plenary Session at the 2014 World Transplant Congress on San Francisco.

In an interview with Reuters Health, she said their research was motivated by a clinical observation.

"We noticed in our practice that a lot of HIV-positive kidney transplant recipients had excellent outcomes, but unfortunately, a lot of our hepatitis C patients over time lost their grafts and some patients died," she explained.

So the Penn team looked beyond their own practice to the United Network for Organ Sharing (UNOS) database, which collects information on all transplants across the country, and confirmed that what they were seeing is happening across the country.

They compared the effect of HIV, HCV, or HIV/HCV co-infection on kidney transplant outcomes in patients transplanted between 1996 and 2012.

They examined patient and overall graft survival in 429 HIV-positive patients, 5145 HCV-positive patients, 129 HIV/HCV co-infected patients and 106,288 HIV-negative/HCV-negative patients (reference population).

They found that patient and graft survival in the HIV-positive group did not differ markedly from the reference population and was superior to both HCV-positive and HIV/HCV-positive patients.

The hazard ratios for graft loss and death were 1.41 and 1.53 in HCV-positive patients, compared with 1.13 and 1.31 in HIV-positive patients, and 2.58 and 3.28 in HIV/HCV co-infected patients.

"The key findings are that HIV-positive patients did not have a difference in their outcomes compared to uninfected recipients, for either patient or kidney survival," Dr. Sawinski said, "but that hep C patients did worse than the HIV patients or uninfected normals. And the unfortunate finding is that patients who are co-infected did the absolute worse in terms of patient and graft survival."

Dr. Sawinski said the stigma of HIV in the transplant field provided another motivation for the study.

"There still is a lot of stigma for patients with HIV, they definitely have decreased access to transplantation. Only about a quarter of centers will be willing to take them on as transplant recipients and we thought that this was unjustified," she told Reuters Health. "These patients are perceived to be very high risk but if anything our data shows that they are not, and that hep C patients, which pretty much any center will transplant without a second thought, actually probably are more high risk than the HIV folks."

Dr. Sawinksi said more study is needed to figure out why HCV patients do worse, "whether this is due to uncontrolled hep C, or are we as physicians perhaps too cautious in our use of immunosuppression in these patients because we worry about their hep C getting out of control."

She also told Reuters Health, "The study has caused us to look more closely at our co-infected recipients and perhaps be more selective but it's also motivated us as a center to try to get more actively involved in trials of new hep C direct-acting antivirals in dialysis patients. Currently, there is an FDA warning that patients who have kidney function less than 30% and who are on dialysis are not supposed to be treated with these new hep C therapies because there is no dosing information." Trials are needed to figure out appropriate dosing in these patients, she added.