Use of HCV-Positive Donors
It is generally accepted that HCV-positive (RNA-positive) grafts should not be used in HCV-negative recipients, as it negatively impacts morbidity and may also increase mortality. Due to the global organ shortage and to reduce the time on the waiting list, the KDIGO guidelines recommend using kidneys from HCV-positive donors in HCV-infected recipients. Receiving a kidney from an HCV-positive donor shortens the waiting time for transplantation for the HCV-infected recipient by approximately 1 year. There are controversial results regarding the impact on survival. Earlier smaller studies showed no impact on mortality, allograft failure or liver disease in the short term, and were further supported by subsequent long-term studies with similar results. In contrast, increased mortality and adverse liver outcomes have been shown in more recent single-center as well as large registry studies with use of HCV-positive kidneys in HCV-infected recipients. The reason for the observed differences in mortality rates remains unclear. It has been speculated that the differences in immunosuppression or superinfection with another genotype could play a role. Therefore, the safety of this approach may be improved ideally by matching donors and recipients according to the HCV genotypes, but more studies are clearly needed.
A recent case report of successful transplantation of a kidney from a treated (with SVR) HCV-infected living donor in an uninfected recipient has raised the question whether this strategy should be considered (from either living or deceased donors), especially with the emerging antiviral therapies. Transmission of the virus into an uninfected recipient with such a practice cannot be ruled out as the donor kidney may also possibly harbor the virus even after having achieved SVR. Furthermore, there is the ethical concern in using a kidney from a living donor who, in spite of the SVR, theoretically might have a risk (although very low) of having a relapse. Therefore, longitudinal studies with close clinical and virologic monitoring of both living donors and recipients would be required to study the safety of such a strategy.
In summary, the use of kidneys from HCV-positive donors may be a safe approach in the long term for HCV-infected recipients, as the risk of increased mortality is likely outweighed by the survival benefit conferred by receiving an allograft with shorter waiting times. However, the benefits and potential risks associated with receiving an HCV-infected allograft should be discussed with the recipient so that a well-informed consensual decision can be made.