P1790A TWO-CASE COMPARISON: PREEMPTIVE AND PROPHYLACTIC USE OF DIRECT ANTIVIRAL DRUGS IN TRANSPLANTATION OF HCV-INFECTETD KIDNEYS TO UNINFECTED PATIENTS
Authors: Westphal Florian , Reuter Stefan , Wilms Christian , Rovas Alexandros , Jens Brockmann , Haluk Morgül , Pavenstädt Hermann Josef , Thomas Vogel , Suwelack Barbara 
Published: June 2020

Abstract

Background and Aims
The organ shortage especially in blood group 0 forces transplant professionals to discuss new approaches to expand the donor pool. Recently, the successful therapy of HCV with direct antiviral agents in kidney transplanted patients has made the transplantation of HCV-infected kidneys to uninfected patients possible. Furthermore, these organs promise an above-average organ function as HCV-infected donors are usually young and have fewer comorbidities. Since there is no standard procedure for the treatment of kidney recipients with HCV grafts, we compared a preemptive and a prophylactic approach using direct antiviral drugs after kidney transplantation of two patients.

Method
We report the transplantation of two HCV-positive kidneys. One recipient was a 49-year-old female patient, who suffered from ESRD caused by an atypical hemolytic uremic syndrome. The other recipient had autosomal dominant polycystic kidney disease. Since the genotype of the HCV donor was unknown at the time of transplantation, we decided to use the pangenotypic, fixed-dose combinations Glecaprevir/Pibrentasvir and Sofosbuvir/Velpatasvir.

Results
Both patients had blood group 0 and received an AB0-compatible kidney transplant. The initial immunosuppressive therapy consisted of prednisolone, mycophenolate sodium, and tacrolimus. Furthermore, an induction therapy with Basiliximab was given. The first patient received Glecaprevir/Pibrentasvir immediately post-surgery. Treatment was carried on for eight weeks as a prophylactic approach. Frequent HCV-PCRs showed negative results over six months. However, the patient developed anti-HCV antibodies within six days after transplantation. The graft started working on postoperative day four, and the serum creatinine decreased to 1.33 mg/dl on the discharge day and stabilized on this level during further follow-up. Following a preemptive approach, our second patient was treated with Sofosbuvir/Velpatasvir after detection of HCV RNA and rising levels of transaminases on post-transplant day 7. This patient also received Entecavir because of a previous HBV-infection of the donor (non-viremic on the day of transplantation). The graft started working on day two, and the serum creatinine decreased to 1.28 mg/dl on the discharge day and stabilized on this level. Further HCV-PCRs also showed negative results.

Conclusion
We conclude that kidneys from HCV-viremic donors can be transplanted with precaution. Both therapeutic strategies showed equally good results and can easily be implemented into kidney transplantation. Especially, the combination of Glecaprevir/Pibrentasvir offers a safe HCV prophylaxis without the need of adaptions to the renal function or HCV genotype. In case of a permanent absence of a HCV infection, the preemptive approach offers a chance to avoid the HCV-therapy. On the other hand, causing an iatrogenic infection of HCV in a patient with immunosuppression brings up ethical issues due to the risk of HCV-related liver diseases. Therefore, we favor the prophylactic approach. Further studies are needed to identify the optimal time frame for direct antiviral agents in HCV (D+/R-) transplantations.