Equal 3-Year Outcomes for Kidney Transplantation Alone in HCV-Positive Patients With Cirrhosis

Kidney transplantation alone in clinically compensated patients with cirrhosis is not well documented. Current guidelines list cirrhosis as a contraindication for kidney transplantation alone. This is an Institutional Review Board–approved retrospective study. We report our experience with a retrospective comparison between transplants in hepatitis C virus–positive (HCV⁺) patients without cirrhosis and HCV⁺ patients with cirrhosis. All of the patients were followed for at least a full 3-year period. All of the deaths and graft losses were recorded and analyzed using Kaplan-Meier methodology. One- and three-year cumulative patient survival rates for noncirrhotic patients were 91% and 82%, respectively. For cirrhotic patients, one- and three-year cumulative patient survival rates were 100% and 83%, respectively (P = NS). One- and three-year cumulative graft survival rates censored for death were 94% and 81%, and 95% and 82% for the noncirrhosis and cirrhosis groups, respectively (P = NS). Comparable patient and allograft survival rates were observed when standard kidney allograft recipients were analyzed separately. This study is the longest follow-up document in the literature showing that HCV⁺ clinically ompensated patients with cirrhosis may undergo kidney transplantation alone as a safe and viable practice.Key words: Kidney, Transplantation, Cirrhotic patients, SafetyHepatitis C virus (HCV) affects 200 million people.¹ Approximately 85% of people with HCV will develop chronic infection; of those, 10% to 30% will develop cirrhosis. The prevalence of HCV within the dialysis population is as high as 13%.² HCV is a negative prognostic indicator for survival on dialysis and after kidney transplantation. There is an increased risk of death among long-term hemodialysis patients infected with HCV.³ Importantly, overall survival in these patients is improved after kidney transplantation compared with dialysis.⁴ Liver biopsies are indicated in all HCV-positive candidates considered for kidney transplantation. Up to 12% of asymptomatic patients will have cirrhosis. Those with cirrhosis (while on dialysis) have a 35% higher death rate than their counterparts without cirrhosis.⁵Established cirrhosis is an important predictor of death after renal transplantation and is considered a relative contraindication to isolated renal transplantation. American Association for Study of Liver Disease (AASLD) guidelines recommend end-stage renal disease patients with cirrhosis be evaluated for dual-organ transplantation. The core curriculum in nephrology and the Kidney Disease: Improving Global Outcomes (KDIGO) initiative consider HCV-related cirrhosis a contraindication to kidney transplantation alone (KTA).^6,7 Some authors consider cirrhosis a relative contraindication for KTA because the prospect of survival for graft and patient is dismal.⁸The use of KTA in asymptomatic patients with cirrhosis has not been extensively studied. Reports often exclude patients with cirrhosis,⁹ are limited by small numbers, or combine clinically compensated patients with cirrhosis with those who have only mild fibrosis.¹⁰ The United Network for Organ Sharing (UNOS) database does not track biopsy results, so registry data cannot be mined.We performed 18 KTAs on clinically compensated patients with cirrhosis (CCCs) and compared the results to those from a control group of HCV-positive KTA recipients without cirrhosis. We surmised that the results would be equivalent between groups.