Liz Meszaros, MDLinx | July 25, 2018
July 28 is World Hepatitis Day 2018. Commemorate this day and help increase awareness of viral hepatitis with the World Hepatitis Alliance, which is working to increase awareness with the theme “Eliminate Hepatitis.”
Of the 325 million people throughout the world living with viral hepatitis, 9 of 10 are unaware that they are infected with hepatitis B or hepatitis C. To end this lack of awareness, screening, diagnosis, and linkage to care for these patients must be stepped up.
The World Hepatitis Alliance has rolled out the 3-year “Find the Missing Millions” global campaign. The goal is to reduce the barriers inhibiting the diagnosis of viral hepatitis. They hope to use this campaign to contribute to the World Health Organization’s goal of a 30% diagnosis rate by 2020.
In more hepatitis-related news, researchers have found that posttransplant treatment of hepatitis C virus (HCV) in dialysis patients infected with hepatitis C (HCV) with organs from HCV-infected donors is more efficacious and cost-effective than treating HCV before transplantation. This approach can also shorten wait times for donated organs. They published their findings in the Annals of Internal Medicine.
In 2016, approximately 500,000 patients received dialysis for end-stage renal disease, of whom only 3.8% received kidney transplants. According to lead author Mark Eckman, MD, Posey Professor, director, University of Cincinnati Division of General Internal Medicine, Cincinnati, OH, a patient who receives an uninfected kidney can wait an average of 2 years or more for that kidney. The wait for a kidney that is infected with HCV, however, is only about 8 months.
"While people are waiting for a kidney, there is a risk of dying on hemodialysis, with a mortality rate of approximately 7.5% per year,” said Dr. Eckman. "If you wait a shorter time to get a kidney transplant by accepting an HCV-infected kidney, you can avoid a year-and-a-half or more of time on a waiting list. Once you have a transplant, the annual mortality rate is roughly 2% per year instead of about 7.5% per year. The shorter the period of time waiting for a kidney on dialysis, the better your outcomes will be.”
Fifteen percent of patients who are undergoing dialysis for end-stage renal disease are HCV-infected.
"There is a high excess mortality risk for patients receiving hemodialysis, and it is associated with a decreased quality of life for some patients,” said Dr. Eckman. "If you can spend less time on dialysis, you will be better off. The annual cost of hemodialysis is more than $90,000.”
Dr. Eckman and colleagues conducted a computer analysis in which they developed a computerized decision analytic model. Using data from the United States Renal Data System, medical literature, and clinical trials, they assessed several factors in these patients as well as treatment costs.
A computer model was necessary because no large clinical trials have been conducted.
"This isn’t something we would have asked or thought about even a year ago,” said Dr. Eckman. "Now, we have very effective HCV treatments that we didn’t have 2 or 3 years ago. Some of these new medications can be used in patients on dialysis. The new drugs have much fewer side effects, and the treatment course is a lot shorter. The treatment of HCV has advanced dramatically.
"Secondly, a year ago we didn’t have drugs to treat HCV that could be used in patients with end-stage renal disease. While treatment of HCV is very expensive, this cost balances out in our analysis as patients in both strategies are getting treated for HCV,” he added.
Cure rates for HCV can be as high as 98% with the newer agents, which include direct-acting antivirals (DAAs) and interferon-free regimens.
Dr. Eckert and colleagues found that transplanting an HCV-infected kidney and treating the HCV after transplant decreased quality-adjusted life-years (QALYs) by increasing the patient’s lifetime probability of dying of end-stage liver disease and related causes to 5%. This compared with a probability of 3.4% in patients transplanted with an uninfected kidney after receiving HCV treatment.
Patients who receive an uninfected HCV kidney had a lower risk of mortality from liver disease because their HCV was treated before transplantation. But HCV-infected patients who receive an HCV-infected kidney were able to stop dialysis sooner and lower their risk for mortality from end-stage kidney disease.
Transplanting an uninfected kidney after HCV treatment decreased QALYs because waiting for a kidney transplant increased dialysis times, which raised their lifetime probability of dying of chronic kidney disease to 34.5%. Patients who received infected kidneys followed by HCV treatment had only a 29% lifetime probability of dying of chronic kidney disease.
Finally, they found that the net benefit of transplanting an infected kidney followed by HCV treatment caused a survival gain of 0.50 QALY, at a lifetime cost savings of $41,591, compared with transplanting an uninfected kidney after HCV treatment.
"It is better to wait less time for a kidney by getting an HCV-infected kidney followed by treatment after transplantation,” said Dr. Eckman.
Recently, the deaths of healthy young people from opioid overdose have increased the supply of HCV-infected kidneys.
"What we hope is that this study will have some impact on policy,” concluded Dr. Eckman.
In their accompanying editorial, David S. Goldberg, MD, MSCE, and Peter P. Reese, MD, MSCE, Perelman School of Medicine, Philadelphia, PA, stressed the benefits of transplanting HCV-infected kidneys in HCV-infected patients and treating HCV infection only posttransplant:
“In summary, the advent of DAA treatments should give HCV-infected patients receiving dialysis the confidence of knowing that their infection can almost certainly be cured and the flexibility of deciding when that cure will take place. In areas where HCV-infected organs are plentiful, strong evidence now supports the strategy of accepting those organs to reduce wait time. If the availability of HCV-infected organs diminishes, the question of how best to time DAA treatment will need a fresh look,” they concluded.
For more information, go to World Hepatitis Alliance, and view their video on World Hepatitis Day.