The Impact of Direct-Acting Antiviral Agents on Liver and Kidney Transplant Costs and Outcomes.

Direct-acting antiviral medications (DAAs) have revolutionized care for hepatitis C positive (HCV+) liver (LT) and kidney (KT) transplant recipients. Scientific Registry of Transplant Recipients registry data were integrated with national pharmaceutical claims (2007-2016) to identify HCV treatments before January 2014 (pre-DAA) and after (post-DAA), stratified by donor (D) and recipient (R) serostatus and payer. Pre-DAA, 18% of HCV+ LT recipients were treated within 3years and without differences by donor serostatus or payer. Post-DAA, only 6% of D-/R+ recipients, 19.8% of D+/R+ recipients with public insurance, and 11.3% with private insurance were treated within 3years (P<.0001). LT recipients treated for HCV pre-DAA experienced higher rates of graft loss (adjusted hazard ratio [aHR] (1.34)1.85(2.10), P<.0001) and death (aHR (1.47)1.68(1.91), P<.0001). Post-DAA, HCV treatment was not associated with death (aHR (0.34)0.67(1.32), P=.25) or graft failure (aHR (0.32)0.64(1.26), P=.20) in D+R+ LT recipients. Treatment increased in D+R+ KT recipients (5.5% pre-DAA vs 12.9% post-DAA), but did not differ by payer status. DAAs reduced the risk of death after D+/R+ KT by 57% ((0.19)0.43(0.95), P=.04) and graft loss by 46% ((0.27)0.54(1.07), P=.08). HCV treatment with DAAs appears to improve HCV+ LT and KT outcomes; however, access to these medications appears limited in both LT and KT recipients. Examination of integrated US transplant registry data and records from a nationwide pharmacy claims warehouse demonstrates patterns of improved patient and graft survival in HCV-positive liver and kidney transplant recipients treated after introduction of direct-acting antiviral medications, but relatively limited access to these expensive medications among patients most likely to benefit. Brown offers comments in his editorial on page 2382.