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HCV recurrence and death after viral clearance in HCV-viremic donor to HCV-negative kidney recipient - a case report
Abstract   Peer reviewed

HCV recurrence and death after viral clearance in HCV-viremic donor to HCV-negative kidney recipient - a case report

Shengliang He, Sung-Hoon Kim, Tomohiro Tanaka, David Thomsen, Christie Thomas, Daniel Katz, Hassan Aziz and Alan Reed
American journal of transplantation, Vol.25(1 Suppl. 1), p.S94
01/2025
DOI: 10.1016/j.ajt.2024.12.180

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Abstract

Introduction: Effective direct-acting antiviral (DAA) therapies have transformed the landscape of kidney transplantation from HCV nucleic acid test positive donors to HCV-negative recipients (HCV NAT+/-). Meta-analyses show current DAA regimens achieved nearly universal viral eradication after HCV NAT+/- kidney transplantation. This case study presents an early HCV recurrence after initial viral clearance in HCV NAT+/- kidney transplant that rapidly progressed to fibrosing cholestatic hepatitis (FCH) and death. Methods: A 52-year-old male with end- stage renal disease underwent kidney transplant from Donation after Circulatory Death donor (HCV NAT+, KDPI 97%). The patient’s HCV antibody and viral load were initially undetectable. Results: The allograft functioned immediately and improved after surgery without need for dialysis, but never normalized. His best creatinine of 3.16 mg/dl was one-month post-transplant compared to 5.7 mg/dl pre-transplant. Two renal biopsies were performed to assess graft function but showed no evidence of rejection. His post-discharge transplant course was complicated by poor glucose control, resulting in multiple episodes of diabetic ketoacidosis (DKA), impaired wound healing, and urosepsis. Patient’s HCV NAT at POD #3 revealed a viral load of 5 log IU/ml with normal liver chemistry (Genotype 1). Sofosbuvir/Velpatasvir was initiated once available (POD #12). Patient completed 12-week course and HCV NAT was undetectable on POD #94. His liver enzymes uptrended on POD #168 (ALP 375U/L, ALT 225 U/L, AST 168 U/L, and bilirubin 1.5 mg/dL). Repeat HCV NAT showed >8 log IU/ml (Genotype 1). Sofosbuvir/Velpatasvir was reinitiated with a plan to transition to Sofosbuvir/ Velpatasvir/Voxilaprevir. On POD #183, the patient was admitted for DKA, acute liver failure, and acute on chronic renal failure. His clinical condition rapidly deteriorated, with worsening liver chemistries suggestive of FCH. He developed multi-organ failure and died on POD #188. Conclusion: Fatal HCV transmission is rare in HCV NAT+/- kidney transplant recipients in the DAA era. Elevated LFTs after viral clearance should still prompt concern for recurrence. Careful patient and graft selection, along with vigilant monitoring for HCV recurrence, remain essential components in the management of HCV NAT+/- kidney transplantation.

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