Outcomes of patients with hepatitis C undergoing simultaneous liver–kidney transplantation

Background/Aims

The number of simultaneous liver–kidney transplants (SLK) has increased since the MELD era. Data on short- and long-term outcomes of hepatitis C virus positive (HCV+) SLK compared to HCV+ liver transplant alone (LTA) recipients are limited.

Methods

A case-control study comparing outcomes of HCV+ SLK versus transplant year-matched HCV+ LTA (1:1) was performed.

Results

38/142 (26.7%) SLK recipients were HCV+. LTA controls had lower MELD (17.4 ± 8.6) at transplant than SLK (34.5 ± 6.6) (p = 0.001). There were increased early post-transplant infection episodes in SLK (56.3%) versus LTA (21.6%) (p = 0.001) and a trend towards increased early mortality in the SLK group (p = 0.08). However, there was no difference in long-term patient and graft survival, time to HCV recurrence, % ⩾  stage 2 fibrosis, renal function, and graft function between the groups. Ten SLK recipients were treated for HCV recurrence with pegylated interferon + ribavirin: two had sustained virologic response, five stopped due to side effects, and three had no response. None had liver or kidney rejection on treatment.

Conclusion

Our data represent the largest analysis of HCV+ SLK outcomes to date. We demonstrate increased early complications in SLK versus LTA recipients, likely due to being more critically ill at transplant (higher MELD) and complications unrelated to HCV within the first year. However, long-term outcomes, i.e. HCV recurrence, graft/renal dysfunction, are similar to LTA. In addition, while data are limited, treatment of HCV recurrence with interferon appeared safe in our SLK recipients.

Introduction

When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease [1]. Critics of the MELD system have suggested that because creatinine is given considerable weight in the MELD formula, liver grafts are being preferentially allocated to patients with renal insufficiency [2], [3]. As such, the introduction of the MELD has coincided with a significant increase in the number of simultaneous liver–kidney transplants (SLK) performed annually [2]. However, data are conflicting within studies aimed at predicting which candidates will fail to recover renal function and need SLK, thus creating controversy over the role of SLK transplantation and a clear need for ongoing re-examination of outcomes [1], [4], [5], [6], [7], [8].

With the impetus towards increased SLK transplants, data on outcomes are needed surrounding the current leading indication for liver transplantation in the United States – Hepatitis C Virus (HCV) [9]. Hepatitis C infection has been associated with the development of chronic kidney disease before and after transplantation, either due to immune complex injury, co-existing diabetes, or other factors [10], [11], [12], [13], [14]. What has not been clearly delineated is whether HCV+ SLK recipients have more rapid progression of HCV recurrence or have worse outcomes (rejection, infection, patient/graft survival) compared to liver transplant alone (LTA) recipients. In addition, the management of HCV recurrence in the SLK population is not well-defined or reported. Of concern are studies within the renal transplant literature that have shown an unacceptably high risk of precipitating renal allograft rejection with interferon (IFN) therapy [15], [16], [17], [18], [19], [20], [21]. More recent reports have demonstrated successful HCV treatment with pegylated IFN and ribavirin (RBV) in SLK recipients without development of renal rejection on therapy, although data are limited to small numbers of patients [22], [23], [24].

Therefore, the purpose of this study was to analyze outcomes of a cohort of patients with hepatitis C undergoing SLK compared to LTA in terms of patient and graft survival, rejection episodes, infectious complications and most importantly hepatitis C recurrence.