ORIGINAL ARTICLE
Optimal timing of hepatitis C treatment among HIV/HCV coinfected ESRD patients: Pre- vs posttransplant

https://doi.org/10.1111/ajt.15239Get rights and content
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Patients with end-stage renal disease (ESRD) who are coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) have access to effective treatment options for HCV infection. However, they also have access to HCV-infected kidneys, which historically afford shorter times to transplantation. Given the high waitlist mortality and rapid progression of liver fibrosis among coinfected kidney-only transplant candidates, identification of the optimal treatment strategy is paramount. Two strategies, treatment pre- and posttransplant, were compared using Monte Carlo microsimulation of 1 000 000 candidates. The microsimulation was stratified by liver fibrosis stage at waitlist addition and wait-time over a lifetime time horizon. Treatment posttransplant was consistently cost-saving as compared to treatment pretransplant due to the high cost of dialysis. Among patients with low fibrosis disease (F0-F1), treatment posttransplant also yielded higher life months (LM) and quality-adjusted life months (QALM), except among F1 candidates with wait times ≥ 18 months. For candidates with advanced liver disease (F2-F4), treatment pretransplant afforded more LM and QALM unless wait time was <18 months. Moreover, treatment pretransplant was cost-effective for F2 candidates with wait times >71 months and F3 candidates with wait times >18 months. Thus, optimal timing of HCV treatment differs based on liver disease severity and wait time, favoring pretransplant treatment when cirrhosis development prior to transplant seems likely.

KEYWORDS

health services and outcomes research
infection and infectious agents - viral: hepatitis C
infection and infectious agents - viral: human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
kidney transplantation/nephrology

Abbreviations

AWP
average wholesale pricing
CKD
chronic kidney disease
DAA
direct-acting antiviral
ESRD
end-stage renal disease
HCV+
hepatitis C virus infection
HCV−
hepatitis C negative
HIV
human immunodeficiency virus
ICER
incremental cost-effectiveness ratio
IQR
interquartile range
KDPI
kidney donor profile index
LM
life months
METAVIR
meta-analysis of histologic data in viral hepatitis
NIH
National Institutes of Health
PSR
program-specific report
OPO
organ procurement organization
QALM
quality adjusted life months
QALY
quality-adjusted life years
QoL
quality of life
SD
standard deviation
SRTR
Scientific Registry of Transplant Recipients
SVR
sustained viral response
UNOS
United Network for Organ Sharing
USRDS
United States Renal Data System

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