Blog entry by Arif Khwaja
The recent KDIGO guidelines on Hepatitis C have provided clinicians with useful guidance on how to work up Hepatitis C positive dialysis patients for renal transplantaion. A single centre observational study from David Roth's group in Miami, USA has been published in JASN this month which analysed long terms outcomes in 230 patients who were identified as having Hepatitis C during their transplant work up. 207 of the patients had a liver biopsy pre-transplantation and a total of 110 patients underwent a kidney tranplant. Key data from the study showed that:
i) 10% of all patients who underwent a liver biopsy had significant fibrosis supporting the KDIGO guideline that liver biopsies should be undertaken in all who are being evaluated for transplantation. Whether Fibroscan can replace liver biopsy remains to be seen. Interestingly in the 31 patients who underwent liver bioppsy post transplantation, only 23% had progression og liver fibrosis - in contrast to 625 of those patients who remained on the list - suggesting that for a significant cohort of people transplantation doesn not result in worse liver outcomes.
ii) whilst there was an increased relative risk of death (2.5) in the first 6 months post transplantation (predominantly from infection), the risk of death was significantly reduced after 6 months, with a significant reduction in risk of death between 6 and 84 months post transplantion in the transplanted hepatits C group. White race, age>55 and kidney-pancreas transplantation were more likely to be associated with adverse outcomes. The transplanted hepatitis C group had a lower risk of cardiovascular death though a higher risk of new onset diabetes after transplantation (NODAT).
In summary this study confirms previous registry analysis that kidney transplantation confers a survival benefit on Hepatitis C patients compared to haemodialysis. Whilst there is a higher early death rate post transplantion due to infection this is more than offset by the reduced death rate after 6 months.
The paper will be published shortly: Effect of Kidney Transplantation on Outcomes among patients with Hepatitis C. JASN May 5, 2011