Kidney Transplantation From Hepatitis C Virus-Infected Donors to Uninfected Recipients: A Systematic Review for the KDIGO 2022 Hepatitis C Clinical Practice Guideline Update

Rationale & Objective: Direct-acting antiviral (DAA) treatment of hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD) has made transplantation of kidneys from H CV-infected donors to uninfected recipients (D+/R-) feasible. To facilitate an update to the 2018 KDIGO guideline for patients with CKD and HCV, we conducted a systematic review of HCV D+/R- kidney transplantation coupled with DAA treatment.Study Design: Systematic review and meta analysis.Setting & Study Populations: We included studies of HCV D+/R- kidney transplantations that used any DAA protocol.Selection Criteria for Studies: Based on a search of PubMed, Embase, Cochrane, CINAHL, and ClinicalTrials.gov through February 1, 2022, conferences from 2019 to 2021, and the 2018 KDIGO HCV guideline we identified single-group (D+/R-) or comparative studies of D+/R- versus D-/R- kidney transplantation.Data extraction: Conducted in SRDR-Plus with review by a second researcher. Analytical Approach: Maximum likelihood meta analyses; the certainty of evidence was assessed per GRADE (Grading of Recommendations Assessment, Development and Evaluation). Results: We identified 16 studies (N = 557). A sustained viral response at 12 weeks after treatment (SVR12) was observed in 97.7% (95% CI, 96.3%-98.8%). Ultrashort duration treatment (<= 8 days) resulted in viremia requiring standard course DAA treatment in some patients, all of whom achieved SVR12 after 1 or rarely 2 DAA courses. Serious adverse events from DAA treatment were rare after D+/R- transplantation (0.4% [95% CI, 0.1%-2.8%]). At >= 1 year after D+/R- transplantation, recipient death occurred in 2.1% (95% CI, 0.9-3.7) and allograft survival was 97.6% (95% CI, 95.7%-98.9%). Estimated glomerular filtration rate 1 year after transplantation ranged from 46 to 74 mL/min/ 1.73 m2.Limitations: Analyses were generally based on low-certainty evidence. Uncertainty exists about the long-term safety and efficacy of D+/ R- transplantation. Few studies investigated ultrashort treatment courses.Conclusions: Kidney transplantation from HCVinfected donors to uninfected recipients followed by DAA treatment appears to be safe and associated with excellent 1-year clinical outcomes.