Transplantation/Immunology
Elderly Recipients of Hepatitis C Positive Renal Allografts Can Quickly Develop Liver Disease

https://doi.org/10.1016/j.jss.2011.10.028Get rights and content

Our institution explored using allografts from donors with Hepatitis C virus (HCV) for elderly renal transplantation (RT). Thirteen HCV– elderly recipients were transplanted with HCV+ allografts (eD+/R–) between January 2003 and April 2009. Ninety HCV– elderly recipients of HCV– allografts (eD–/R–), eight HCV+ recipients of HCV+ allografts (D+/R+) and thirteen HCV+ recipients of HCV– allografts (D–/R+) were also transplanted. Median follow-up was 1.5 (range 0.8–5) years. Seven eD+/R– developed a positive HCV viral load and six had elevated liver transaminases with evidence of hepatitis on biopsy. Overall, eD+/R– survival was 46% while the eD–/R– survival was 85% (P = 0.003). Seven eD+/R– died during follow-up. Causes included multi-organ failure and sepsis (n = 4), cancer (n = 1), failure-to-thrive (n = 1) and surgical complications (n = 1). One eD+/R– died from causes directly related to HCV infection. In conclusion, multiple eD+/R– quickly developed HCV-related liver disease and infections were a frequent cause of morbidity and mortality.

Introduction

The elderly are the fastest growing population of end-stage renal disease (ESRD) patients [1]. Dialysis for this population is poor treatment option with first year mortality 1.6- to 2.5 fold higher compared with younger patients 1, 2. The surgical option of renal transplantation (RT) for elderly ESRD patients has a well-established survival advantage with a >40% lower overall risk of mortality compared with age-matched waitlist candidates on dialysis [3]. After RT, elderly recipients have a 10 y life expectancy compared with only 6 y for dialysis patients of the same age [4].

Currently, more than 13,000 candidates >65 y are on the RT waitlist; this number has increased 2.3-fold between 1999 and 2004 [5]. The lack of suitable organs, longer wait-times, and worsening co-morbidities are great impedances forcing the use of non-standard allografts, such as those from donors with positive Hepatitis C (HCV) serology. The deceased donor HCV prevalence is 1.08% to 12% worldwide 6, 7, 8, 9.

Abbott et al. observed in all (HCV+ and HCV–) RT-waitlist patients (mean age 47.6 ± 13.8 y), receipt of an allograft from a donor with HCV+ serology was associated with increased mortality compared with an allograft from a donor with negative HCV serology. For all potential recipients, RT with an allograft from an HCV+ donor was, however, independently associated with improved survival compared with those remaining on the RT waitlist [10]. The adverse effects of these allografts, specifically from cirrhosis, were thought to be diminished because of the long duration between viral transmission and liver disease sequelae [11]. Death secondary to hepatic disease was only observed in 8% to 28% of RT recipients of allografts from HCV+ donors surviving more than 5 y [12]. Others have demonstrated that the natural history of HCV is very different depending on age at infection, and is particularly accelerated in those of older age 13, 14. These studies and the multiple studies correlating increased donor age with rapid fibrosis progression in liver transplantation (LT) recipients suggest the elderly liver is more susceptible to HCV-related disease 15, 16, 17, 18, 19, 20.

In this review, we report our institution’s experience with 13 elderly (≥60 y) patients with negative pre-RT HCV serology who received an allograft from a HCV+ donor (eD+/R–). The cohort was compared with a control group of elderly primary RT recipients with negative pre-RT HCV serology receiving an allograft from a HCV– donor (eD–/R–). The cohort was also compared with all adult (≥18 y) deceased donor allograft recipients with positive pre-RT HCV serology (D+/R+ and D–/R+ respectively). Organ Procurement and Transplantation Network (OPTN) data including deceased donor RTs performed from 2003 through 2007 were also analyzed for the number of eD+/R– recipients, patients, and graft survival. The goals of this retrospective review were to (1) compare the patient and graft outcomes for eD+/R– and control groups, and (2) describe the progression of HCV-related liver disease (clinical and histologic) in these unique RT recipients.

Section snippets

Patients and Transplants

From January 2003 to April 2009, 611 patients underwent RT at the University of Virginia, including 160 elderly patients with negative pre-RT HCV serology. One hundred three elderly RT recipients received a deceased donor allograft including 13 eD+/R– and 90 eD–/R–. The eD+/R– outcomes were also compared with all recipients with positive HCV serology, pre-RT, including those receiving an allograft from a HCV+ deceased donor (D+/R+, n = 8) and those receiving an allograft from a HCV– deceased

Demographics

The eD+/R– renal disease, years on hemodialysis, and pre-RT co-morbidities are listed (Table 1). The eD+/R– and control groups’ demographics and outcomes are listed (Table 2, Table 3). Twelve of 13 eD+/R– and all eD–/R– were primary RT recipients. Of the additional comparison groups, six of eight D+/R+ and 12 of 17 D–/R+ were primary RT recipients. The D–/R+ group also included five previous LT recipients.

Donor Characteristics

The thirteen eD+/R– donors included nine males with median donor age 49 (range 21–53) y.

Discussion

These eD+/R– were unlikely to have received a standard allograft before dying. Alternative sources, such as allografts from HCV+ donors, were thought to provide these elderly recipients the best chance for RT. Unfortunately, the overall and 1 y survival associated with the receipt of an allograft from HCV+ donor (46% and 58%, respectively), compared with a HCV– donor, was significantly worse. These results were considerably worse than the USRDS reported elderly RT cadaveric allograft recipients

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