In patients with hepatitis C virus (HCV) infection, transplantation of HCV-infected kidneys followed by treatment of HCV infection is cost-effective and improves quality-adjusted life expectancy, a recent study found.
Researchers used a Markov state-transition decision model to determine whether kidney transplants using HCV-infected or non-HCV-infected kidneys are more cost-effective in patients who have HCV infection. In the target population, which was HCV-infected patients with end-stage renal disease who were receiving hemodialysis in the United States, transplantation of an HCV-infected kidney followed by HCV treatment and transplantation of an HCV-uninfected kidney preceded by HCV treatment were compared. Treatment was determined according to genotype, as current guidelines recommend, and included direct-acting antiviral agents. Outcome measures were effectiveness as measured in quality-adjusted life-years (QALYs) and costs as measured in 2017 U.S. dollars. Results of the study, which was funded by Merck Sharp & Dohme and the National Center for Advancing Translational Sciences, were published by Annals of Internal Medicine on July 10.
The study authors found that transplanting an HCV-infected kidney and then administering HCV treatment was more effective and cost less than transplanting an HCV-uninfected kidney after HCV treatment, mainly because the waiting list for uninfected kidneys is longer. The lifetime probability of dying of end-stage renal disease or related causes was 5% with the first treatment strategy versus 3.4% with the second, but the lifetime probability of dying of chronic kidney disease was 29% with the first strategy versus 34.5% with the second, due to the increased duration of dialysis while waiting for an uninfected kidney. The average QALY gain with the first strategy was calculated to be 0.50 at a lifetime cost savings of $41,591 in a typical 57.8-year-old patient. Transplantation of an HCV-infected kidney followed by HCV treatment was preferred in sensitivity analyses using many model parameters, while transplantation of an HCV-uninfected kidney after HCV treatment was preferred only if the additional wait time for an uninfected kidney was below 161 days.
The researchers noted that the study did not look at the benefit associated with decreased HCV transmission due to HCV treatment and considered the effects of both studied options only on an “average” patient with HCV awaiting a kidney transplant, among other limitations. The availability of new therapies to treat chronic HCV in recipients of kidney transplants, they said, offers new opportunities to transplant HCV-infected kidneys in patients with HCV infection and end-stage renal disease. “Doing so can greatly reduce the wait time for a donated kidney and improve survival by decreasing time spent receiving hemodialysis,” the authors wrote. “In an era of increasing success for kidney transplants and demand that far outstrips supply, deferring antiviral therapy until after transplant of HCV-infected kidneys, when available, should be both cost-saving and effective.”
An accompanying editorial said the study's results are best understood by recognizing that most patients with HCV and end-stage renal disease are more at risk from long-term dialysis than from untreated HCV and noted that the expected time to transplant of an HCV-infected organ, which differs by geography, is an important factor in decision making. Preferences of patients and dialysis providers regarding the timing of curative treatment may also play a role, the editorialists said.
“In summary, the advent of [direct-acting antiviral] treatments should give HCV-infected patients receiving dialysis the confidence of knowing that their infection can almost certainly be cured and the flexibility of deciding when that cure will take place,” the editorialists wrote. “In areas where HCV-infected organs are plentiful, strong evidence now supports the strategy of accepting those organs to reduce wait time. If the availability of HCV-infected organs diminishes, the question of how best to time [direct-acting antiviral] treatment will need a fresh look.”