Nearly 100,000 patients with end stage kidney disease are waiting for a kidney transplant. Of these patients, 13 patients die every day, 3800 patients are removed from the list every year for being too sick, and only 25% of patients receive a deceased donor kidney transplant within 5 years (1). As nephrologists and transplant physicians, we strive for a system that maximizes equitable access to transplantation for every patient in need and reduces organ discards, which are magnified among donors with documented viral infections.
In the last decade, we have seen an increase in donor deaths from drug overdoses, with a subsequent increase in donors infected with hepatitis C virus (HCV) and hepatitis B virus (HBV). Historically, a majority of organs from these donors were discarded, but with the availability of highly effective direct-acting antiviral (DAA) agents and experience using them, there has been more willingness to accept kidneys from HCV-viremic donors, with an overall increase in recipients willing to accept HCV-viremic kidneys, from about 4% in 2009 to 43.8% in 2020 (1).
The risk of transmission always exists with an HCV-viremic kidney. However, landmark studies, including THINKER (2) and EXPANDER (3), showed promising results with transplanting HCV-viremic kidneys into HCV-negative recipients, with cure rates of >95% with DAAs and very few serious adverse effects. A larger retrospective study (4) showed no significant difference in 5-year graft survival with DAAs in recipients of kidneys from 2551 HCV-viremic donors compared with recipients of HCV-negative kidneys. Additionally, recipients of HCV-viremic donor kidneys were shown to have received better quality kidneys from younger donors. Long-term studies are currently underway to bridge our knowledge gaps regarding these drugs, risks of co-infections, and longevity of these allografts.
HBV infection is a vaccine-preventable infection. The largest series (5) describing transplantation of HBV-viremic kidneys into 56 HBV-negative recipients treated with entecavir showed no difference in patient survival and graft survival at 1 year compared with recipients of HBV-negative kidneys; additionally, these recipients had decreased waitlist times and dialysis duration. Studies have shown that patients who received the HBV vaccine before transplantation were more likely to remain immune following transplantation (6); therefore, early vaccination in patients with chronic kidney disease is strongly encouraged. Utilization of grafts from HBV-viremic donors could represent an opportunity to facilitate timely transplantation in patients with adequate immunity; however, more studies are needed to elucidate optimal protective strategies.
It is noteworthy that DAAs have provided access to a source of good-quality organs for patients on the waiting list and improved quality of life for these patients. The drugs used for both HCV and HBV treatment minimally interact with the standard posttransplant immunosuppressive medications used at most centers.
Today, these infections are treatable, and transplant centers have rigorous protocols to minimize risk of transmission, monitor for infection, and treat it. Given long wait times for deceased donor organs, it is of paramount importance to remember that the benefit of accepting a HCV-viremic or HBV-viremic donor kidney far outweighs the risk of longer duration both on the transplant waitlist and on dialysis.