Selection and management of hepatitis C virus-infected patients for the kidney transplant waiting list.

Hepatitis C virus (HCV) infection has been demonstrated to be present in a significant number of ESRD patients, and infection with this virus has been shown to have a detrimental impact on patient survival in both the dialysis and transplant patient populations. Studies have shown that 10-25% of pre-kidney transplant candidates have advanced liver injury with stage 3 or 4 disease (cirrhosis) when biopsied during the pretransplant evaluation. To identify those patients in whom a more extensive workup is required, all transplant candidates should be initially screened for anti-HCV antibody and/or active viremia using nucleic acid testing depending on the prevalence of HCV in the community. Although efforts have been directed at finding a reliable noninvasive marker of advanced liver disease in this patient population, liver biopsy remains the gold standard and should be obtained during the pretransplant evaluation in all patients determined to have active HCV infection. There is general agreement that patients with established or decompensated cirrhosis should be referred to the liver transplant team for consideration of combined liver-kidney transplantation. Patients on the kidney transplant waiting list should be monitored on a regular basis to identify those who might have progressive liver disease. This is especially relevant in an era when waiting times at some centers approach 5-7 years. There is no consensus on whether the pretransplant patient with active HCV viremia should be treated with antiviral agents prior to transplant. There is some largely anecdotal evidence that inducing a sustained virological response prior to transplant might lessen the risk of developing posttransplant diabetes and immune complex-mediated glomerular disease in the allograft. Whereas there is good evidence that the majority of patients achieving a sustained virological response prior to transplant do not relapse following the introduction of immunosuppression, there are limited data as to whether this has a positive impact on the progression of liver injury. Several studies have demonstrated that the use of interferon in the posttransplant setting is associated with an increased risk of allograft rejection; thus, any efforts to eradicate HCV should be focused on the pretransplant period. In summary, a thorough screening process to identify HCV infection in the pre-kidney transplant candidate, including the staging of liver disease in those determined to have viremia, is necessary so that the most appropriate treatment plan can be developed for each patient.