Impact of Donor Hepatitis C Virus on Kidney Transplant Outcomes for Hepatitis C-positive Recipients in the Direct-acting Antiviral Era: Time to Revise the Kidney Donor Risk Index?

Transplantation. 2020 Jun;104(6):1215-1228. doi: 10.1097/TP.0000000000002949.


Background: Kidneys from donors with hepatitis C virus (HCV) infection are traditionally considered to be at risk for poorer survival outcomes, as reflected in the kidney donor profile index (KDPI). Modern direct-acting antivirals may modify this risk.

Methods: Using United Network for Organ Sharing data, HCV-infected adult first-time kidney transplant recipients from 2014 to 2017 were examined. Graft and patient survival were compared in a propensity-matched cohort of recipients of HCV antibody (Ab)(+) kidneys versus Ab(-) kidneys. Subsequent analysis was performed in a propensity-matched cohort of recipients of HCV-viremic (RNA positive) versus HCV-naïve kidneys.

Results: There were 379 recipients each in the matched cohort of recipients of HCV Ab(+) versus HCV Ab(-) kidneys. Despite a higher KDPI (58.2% for HCV Ab[+] versus 38.8% for HCV Ab[-]), 1-year patient and graft survival were similar in the HCV(+) and HCV(-) groups (95.4% and 94.9% versus 97.9% and 96.0%, P = 0.543 and P = 0.834, respectively). There were 200 recipients each in the cohort of recipients of HCV-viremic versus HCV-naïve kidneys, with the KDPI again higher in the HCV-viremic group (56.8% versus 35.2%). Baseline hazard ratios (HRs) for graft failure (HR, 4.69; P = 0.009) and death (HR, 7.60; P = 0.003) were significantly elevated in the viremic group, but crossed 1 at 21 and 24 months, respectively.

Conclusions: In the modern direct-acting antiviral era, calculated likely KDPI overestimates risk kidneys from HCV (+) donors. Donor viremia conveys an early risk which appears to subside over time. These results suggest that it may be time to revise the kidney donor risk index.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Antibodies, Viral / blood
  • Antibodies, Viral / immunology
  • Antibodies, Viral / isolation & purification
  • Antiviral Agents / therapeutic use*
  • Donor Selection / standards*
  • Female
  • Graft Rejection / epidemiology*
  • Graft Rejection / immunology
  • Graft Rejection / prevention & control
  • Graft Rejection / virology
  • Graft Survival
  • Hepacivirus / genetics
  • Hepacivirus / immunology
  • Hepacivirus / isolation & purification
  • Hepatitis C, Chronic / blood
  • Hepatitis C, Chronic / drug therapy*
  • Hepatitis C, Chronic / transmission
  • Hepatitis C, Chronic / virology
  • Humans
  • Kidney Failure, Chronic / mortality
  • Kidney Failure, Chronic / surgery*
  • Kidney Transplantation / standards*
  • Male
  • Middle Aged
  • RNA, Viral / isolation & purification
  • Retrospective Studies
  • Tissue Donors
  • United States / epidemiology
  • Young Adult


  • Antibodies, Viral
  • Antiviral Agents
  • RNA, Viral