HCV-positive donor kidneys

Secondary GNmedium

A 58-year-old HCV-negative man with kidney failure has been on the deceased-donor waitlist for 4 years. He is offered a kidney from a donor who is HCV-viremic (NAT-positive). He has no cirrhosis and no contraindication to therapy. Which of the following is the most appropriate recommendation regarding this offer?

  1. A.Decline the offer because an HCV-viremic kidney cannot go to an HCV-negative recipient
  2. B.Accept the kidney and give the recipient DAA therapy in the post-transplant periodCorrect
  3. C.Accept the kidney only if the recipient is first made HCV-antibody positive by vaccination
  4. D.Accept the kidney but withhold antivirals unless decompensated liver disease develops

Explanation

Because DAAs are safe and highly effective (cure rates >95%) even in advanced CKD, kidneys from HCV-viremic donors can now be transplanted into HCV-negative recipients, with the recipient treated with a course of DAA therapy in the peri- or post-transplant period. Trials such as THINKER and EXPANDER demonstrated sustained virologic response and good allograft function with this strategy, which shortens waiting time and expands the donor pool. Declining is no longer justified when DAAs are available, and there is no vaccine against HCV.

Why each option

A.
Donor-derived HCV transmission is expected but reliably curable with DAAs; refusing such offers needlessly prolongs the wait and increases dialysis mortality.
B.
Correct—accept the organ and give DAA therapy; this achieves cure in nearly all recipients and preserves graft function.
C.
There is no HCV vaccine, and prior HCV status of the recipient is no longer a prerequisite for accepting an HCV-viremic kidney.
D.
Deferring treatment risks fibrosing cholestatic hepatitis and extrahepatic/renal complications; prompt DAA therapy is the standard, not watchful waiting.

Reference: KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in CKD (update of the 2018 guideline), Kidney Int Suppl. 2022; THINKER (Reese, Ann Intern Med 2018) and EXPANDER (Durand, Ann Intern Med 2018) trials.

This is one of 1,100 questions in the MedBoardSA nephrology bank, with timed test mode, tutor mode, and progress tracking by topic.

Practise the full bank

More Secondary GN questions

Browse other topics