Accepted Manuscript

Safety and Efficacy of Peginterferon-α2a Plus Ribavirin Treatment in Renal

Transplant Recipients with Chronic Hepatitis C

Faisal M. Sanai, Dujana Mousa, Abdallah Al-Mdani, Ghada Al-Shoail, Hamad

Al-Ashgar, Khalid Al. Meshari, Ahmed Al-Qahtani, Mayssa Saadeh, Khalid I.

Bzeizi, Hassan Aleid

PII: S0168-8278(13)00122-0

DOI: http://dx.doi.org/10.1016/j.jhep.2013.02.004

Reference: JHEPAT 4597

To appear in: Journal of Hepatology

Received Date: 23 September 2012

Revised Date: 16 January 2013

Accepted Date: 4 February 2013

Please cite this article as: Sanai, F.M., Mousa, D., Al-Mdani, A., Al-Shoail, G., Al-Ashgar, H., Meshari, K.A., Al-

Qahtani, A., Saadeh, M., Bzeizi, K.I., Aleid, H., Safety and Efficacy of Peginterferon-α2a Plus Ribavirin Treatment

in Renal Transplant Recipients with Chronic Hepatitis C, Journal of Hepatology (2013), doi: http://dx.doi.org/

10.1016/j.jhep.2013.02.004

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1

Safety and Efficacy of Peginterferon-α2a Plus Ribavirin Treatment in

Renal Transplant Recipients with Chronic Hepatitis C

Faisal M Sanai1,2, Dujana Mousa3, Abdallah Al-Mdani1, Ghada Al-Shoail3, Hamad Al-Ashgar4,

Khalid Al Meshari5, Ahmed Al-Qahtani2,6, Mayssa Saadeh7, Khalid I Bzeizi1, Hassan Aleid5

Affiliations:

1Departments of Gastroenterology & 3Nephrology, Riyadh Military Hospital, Riyadh, Saudi

Arabia 2Liver Disease Research Center, King Saud University, Riyadh, Saudi Arabia 4Division of Gastroenterology, Department of Medicine and 5Kidney and Pancreas

Transplantation Dept, 6Dept. of Infection and Immunity, Research Center, King Faisal Specialist

Hospital & Research Center, Riyadh, Saudi Arabia 7Clinical Research Center, King Abdullah International Medical Research Center, National

Guard Health Affairs, Riyadh, Saudi Arabia

Corresponding Address:

Dr. Faisal Sanai

Department of Hepatobiliary Science & Liver Transplantation

King Abdulaziz Medical City

PO Box 22490 (IMB 1440), Riyadh 11426

Saudi Arabia

Fax: 966 1 8011111 ext 16737

Email: sanaifa@ngha.med.sa

Working Title: Hepatitis C virus and Renal Transplantation

2

Abbreviations: AE, adverse event; ALT, alanine aminotransferase; AST, aspartate

aminotransferase; AAR, acute allograft rejection; CAN, chronic allograft nephropathy; BMI,

body mass index; CI, confidence interval; CNI, calcineurin inhibitor; SD, standard deviation;

HCV, hepatitis C virus; G-CSF granulocyte-colony stimulating factor; eGFR, estimated

glomerular filtration rate; OR, odds ratio; PegIFN, pegylated interferon; RBV, ribavirin; RT,

renal transplant; RVR, rapid virologic response; EVR, early virologic response; SVR, sustained

virologic response

The protocol registration was NCT00881582.

POTENTIAL CONFLICT OF INTEREST: Dr. Sanai is a consultant for, advises, is on the

speakers' bureau of, and received grants from Bristol-Myers Squibb. He is a consultant for, and

advises Merck Sharp Dohme, is on the speakers' bureau of, and received grants from Roche and

Glaxo Smith-Kline. Drs. Bzeizi and Al-Ashgar are consultants for, advice to, and are on the

speakers' bureau of Bristol-Myers Squibb. Dr. Bzeizi is a consultant for, advises and is on the

speakers' bureau of Glaxo Smith-Kline.

3

ABSTRACT

Interferon (IFN)-based therapy in chronic hepatitis C virus (HCV)-infected renal transplant (RT)

recipients has been associated with a high risk of acute allograft rejection (AAR) and poor

efficacy. We assessed the safety and efficacy of PegIFNα-2a and ribavirin (RBV) combination

therapy in HCV-infected RT recipients. Methods: Thirty-two adult RT recipients of >12 months

duration, infected with HCV genotypes 1 (62.5%) and 4 (37.5%), and significant fibrosis

(Metavir ≥F2) were recruited in an open-label trial with PegIFNα-2a 135–180 μg/week, plus

RBV 200–1200 mg/day for 48 weeks, based on estimated glomerular filtration rate. Safety

assessments were performed weekly for 4 weeks, 2-weekly for 8 weeks, and 6-weekly for 36

weeks. Study end-points were sustained virologic response (SVR) or development of AAR.

Allograft biopsies were performed for 20% increase in creatinine from pretreatment levels, or

optionally at week 12 on surveillance protocol. Renal safety was compared with matched

untreated historical controls (n=31). Results: None of the treated patients showed AAR when

biopsied for raised creatinine (12.5%) or during surveillance (37.5%), with incremental and

sustained creatinine increases occurring in 6.3% treated patients and 16.1% of untreated controls

(P = 0.148) by week 72 assessment. Mean pretreatment and end-of-assessment creatinine in

treated patients remained similar (106.8±32.0 vs. 113.4±62.8, respectively; P=0.140), while

levels increased significantly in the controls (106.6±35.6 vs. 142.5±93.0, respectively; P=0.013).

Rapid, early virologic response (EVR) and SVR occurred in 12.5%, 56.3% and 37.5%,

respectively. SVR was similar in both genotypes (P=1.000). PegIFN and RBV dose reductions

were required in 34.4% and 78.1%, respectively; discontinuation was required in 12.5%. Binary

logistic regression identified only EVR (OR, 20.4; 95% CI: 2.2–192.6; P=0.008) as an

4

independent predictor of SVR. Conclusions: PegIFN/RBV therapy is not associated with AAR

in RT recipients at low risk for rejection but has modest efficacy in the treatment of HCV.

Keywords: Hepatitis C virus; renal transplant; treatment; pegylated interferon; acute rejection;

sustained virologic response

5

INTRODUCTION

The prevalence of hepatitis C virus (HCV) infection generally ranges from 5 - 15% in renal

transplant (RT) recipients [1], though substantially higher rates have been reported from

developing countries [2]. HCV adversely impacts on patient and graft survival in RT recipients

[1,3,4], due in part to the development of cirrhosis, hepatocellular carcinoma (HCC), HCV-

related glomerulopathy and a high rate of infectious complications [1,4].

Generally, interferon (IFN)-based therapy is considered a contraindication in RT recipients due

to reports of kidney complications in treated patients [5,6]. Interferon is known to have an

immunomodulatory and immunostimulatory effect, and several mechanisms behind the induction

of acute allograft rejection (AAR) have been postulated. The most popular hypothesis is that

interferon may enhance the expression of HLA-DR antigens on graft cells, thus stimulating an

immune response and subsequent leading to rejection [7]. A recent meta-analysis involving 102

patients treated with various forms of conventional IFN-based therapy revealed that 18%

achieved sustained virologic response (SVR) and 30% developed chronic allograft nephropathy

(CAN) [8]. The risk of AAR, as reported in the larger series specifically, ranged between 17 –

33%, including irreversible rejection in some studies [9,10]. However, the studies included in the

meta-analysis were mostly small case series, and used the conventional IFN in dosages unlikely

to produce optimal SVR. Equally important is the concern that some of these studies did not

elaborate on the manner of diagnosing graft rejection, which raises the possibility of it being

over-diagnosed [8,11].

Physicians managing such patients frequently walk the tightrope of a worsening hepatic disease

in these patients on one hand, and the risk of complications from antiviral therapy on the other.

6

Renewed efforts at antiviral therapy utilizing pegylated interferon (PegIFN) and ribavirin (RBV)

combination therapy have been recently reported in two retrospective analyses. In the first report

in 8 RT recipients, no cases of allograft dysfunction or rejection were reported [12], while the

other reported a 5.3% incidence of acute rejection/CAN in 19 patients undergoing therapy [13].

These preliminary studies, arguably, test the notion of a significantly increased risk of allograft

complications in RT recipients.

While the benefit of PegIFN-based therapy may appear more tangible, this needs to be carefully

weighed against the risk of potential graft loss. Clearly, safer and more effective approaches are

required in managing these patients. In this prospective study, we aimed to assess the safety and

efficacy of PegIFNα-2a and RBV combination therapy in chronic HCV-infected, treatment-naïve

RT recipients.

7

PATIENTS & METHODS

Study Patients:

This study was conducted between November 2007 and December 2011 at two tertiary care

kidney transplant centers in Riyadh, Saudi Arabia (King Faisal Specialist Hospital & Research

Center and Riyadh Military Hospital). The study was conducted in accordance with good clinical

practice and the Declaration of Helsinki, and was approved by the institutional review boards of

both centers. All patients signed an informed medical consent. Kidney recipients of greater than

one year duration, with a detectable HCV RNA (>6 months duration), aged 18 – 68 years, were

included if they were treatment-naïve, had a liver biopsy obtained within the previous 12 months

demonstrating at least ≥F2 fibrosis (Metavir classification), had a negative pregnancy test result,

used contraceptive methods during therapy and for six months after cessation of therapy, and

abstained from alcohol use for at least six months. Exclusion criteria included co-infection with

hepatitis B or human immunodeficiency virus, co-existent autoimmune or metabolic liver

disease, active drug-induced hepatitis, decompensated cirrhosis, evidence of severe retinopathy,

neoplastic disease, coronary artery or cerebrovascular disease, history of clinically relevant

psychiatric disease, recent history of renal allograft rejection (<6 months) and a history of organ

transplantation, other than kidney, or those requiring dialysis or in whom dialysis was

impending. Patients with haemoglobin <11 g/dL, neutrophil count <1500 cells/mm3, and

platelets <90,000 cells/mm3 were also excluded.

A total of 166 patients were screened, of which 32 were enrolled (G1, 62.5% and G4, 37.5%)

who took at least one dose of the study medication (Figure 1). We included as untreated

historical controls (n=31) all HCV-infected RT recipients with ≥F2 fibrosis who either declined

8

study participation (n=18) or were considered unsuitable for study inclusion (pre-RT IFN

exposure [n=6], ineligible for IFN treatment [n=2], liver biopsy >3 years ago and refused re-

biopsy [n=5]), assessed in a parallel timeline to the treated patients.

Study Design:

This was an independent, investigator-initiated, prospective, multicenter, open-label,

nonrandomized trial, designed to assess the safety and efficacy of PegIFNα-2a and RBV

combination in treatment-naïve (no prior exposure to IFN or RBV) chronic HCV-infected

genotype (G) 1 and G4 RT patients. All patients received PegIFNα-2a (Pegasys; Hoffmann–

LaRoche, Basel, Switzerland) 180 or 135 μg/week based on estimated glomerular filtration rate

(eGFR), using the Modification of Diet in Renal Disease [MDRD] formula. Patients with eGFR

of >50 mL/min received 180 μg/week and those with eGFR <50 mL/min received 135 μg/week.

PegIFNα-2a was combined with RBV (Copegus; Hoffmann–LaRoche, Basel, Switzerland), with

the dosage determined by eGFR and body weight: Those with eGFR of >50 mL/min received

daily 800 mg (for weight <65 kg), 1000 mg (65 - 75 kg) or 1200 mg (>75 kg); 400 mg/day for

eGFR of 30 - 50 mL/min, and 200 mg/day for those with eGFR<30 mL/min. All patients were

assigned 48 weeks of treatment.

Measurements:

Serum HCV RNA was measured by the Abbott RealTime HCV assay (Abbott Molecular, Inc.,

Des Plaines, IL), with a lower limit of quantitation of 30 IU/mL. The test was performed at

weeks 0, 4, 12, 24, 48 and 72 (24 weeks after end of therapy). HCV genotype was assessed on

Qiagen extracted RNAby the Abbott RealTime HCV Genotype II M2000rt platform (Abbott

Molecular Inc., Des Plaines, IL, USA).

9

After commencement of therapy, patients were assessed weekly for 4 weeks, 2-weekly for 8

weeks, and 6-weekly for 36 weeks, and 4, 12 and 24 weeks after the end of therapy. Serum urea

and creatinine were measured on all visits or more frequently if necessary. A sustained increase

in serum creatinine by 20% above baseline levels required allograft kidney biopsy [14].

Complete blood counts, serum aminotransferase and calcineurin inhibitor (CNI) levels were

assessed every 2 weeks for the first 2 months of therapy and 4-weekly for 2 months, and then 6-

weekly thereafter or more frequently if necessary. Thyroid function tests were performed at

baseline and every 12 weeks thereafter or more frequently if necessary. Untreated controls were

generally followed at 12-weekly intervals. We separately assessed creatinine levels for an

additional 24 weeks (week 96/off-treatment follow-up week 48) as an unpremeditated extended

safety measure.

Surveillance allograft biopsy at 12 weeks after commencement of antiviral therapy was optional.

All allograft biopsies performed during the study period were analyzed by two blinded nephro-

pathologists using the Banff working classification [15].

Definition of Response and End Points:

The study end points were SVR or development of AAR. End-of-treatment response (ETR) and

SVR were defined, respectively, as an undetectable HCV RNA (lower limit of quantification 30

IU/mL) at the end of treatment and after 24 weeks of untreated follow-up. Rapid virologic

response (RVR), was defined as undetectable HCV RNA at week 4 and early virologic response

(EVR) as undetectable HCV RNA (complete EVR) or a reduction from baseline HCV RNA

level of >2 log10 IU/mL at week 12 (partial EVR). All patients with partial EVR and detectable

HCV RNA at week 24 stopped treatment and were classified as nonresponders, as were those

with a virologic breakthrough. Virologic relapse was defined as reversion to HCV RNA–positive

10

status after an undetectable HCV RNA level at the end of treatment. Adverse events were

recorded during each outpatient visit. Treatment cessation was optional when creatinine

increased in the absence of AAR as determined by kidney biopsy. Administration of

erythropoietin (EPO), granulocyte-colony stimulating factor (G-CSF) or blood transfusion was

allowed upon the discretion of the investigator.

Dose Modifications:

PegIFNα-2a was reduced to 135 μg/week in patients with neutrophils <0.75 x 109/L or to 90

μg/week in patients assigned 135 μg/week, whereas it was withdrawn in patients with <0.50 x

109/L. The same dose reductions were applied if platelets fell <50,000 cells/mm3 and

discontinued when reaching the 25,000 cells/mm3 threshold. In both treatment arms, RBV dose

was tapered by 200 mg/day in patients with hemoglobin<10 g/dL, whereas it was discontinued in

patients with <8 g/dL hemoglobin. Increase in neutrophils >1.0 x 109/L and hemoglobin >10

g/dL within a 2 week period allowed for treatment recommencement of PegIFNα-2a at 90 – 135

μg/week and RBV at 50% of the discontinuation dose.

Statistical analysis:

Quantitative variables were reported in terms of mean ± standard deviation, and categorical

variables were reported as frequencies and percentage. Baseline clinical and demographic

characteristics were compared statistically across treated patients and untreated controls,

genotype levels and SVR using Fisher’s exact test in case of categorical scale and t-test in case

of continuous scale. Binary logistic regression analysis was used to explore the independent

effect of the baseline factors (age, gender, body mass index [BMI], number of years post

transplant, type of immunosuppression, serum alanine aminotransferase [ALT], platelet count,

11

creatinine level, HCV RNA level >800,000, HCV genotype, fibrosis stage, PegIFN and RBV

dosages), and on-treatment factors (RVR, EVR, increases in creatinine levels by 20%,

development of anemia, reductions in PegIFN and RBV dose) on the likelihood of achieving

SVR. Paired Sample t-test was used to compare serum creatinine at baseline with end-of-study

levels (including week 96). All statistical tests were considered significant at α level less than

0.05. All analyses were conducted and reported using SAS (V9.1, SAS institute, NC). All

patients who took at least one dose of the study medication were included in the efficacy analysis

on intention-to-treat (ITT) principle. Patients who withdrew from the study for any reason and

lost follow-up were considered nonresponders in the efficacy assessment. Safety results are

reported for the entire population.

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RESULTS

Characteristics of Patients:

The baseline variables across treated patients and untreated controls (n=31) were similar (Table

1) except that the treated group had more advanced histological changes compared to the control

group (P <0.001) and had a shorter post-RT duration (P = 0.052). These factors were also similar

for the treated cohort when compared across genotypes (Table 2). Tacrolimus was the

commonest immunosuppression used (65.6%) followed by cyclosporine (28.1%) and the vast

majority (87.5%) were taking adjuvant mycophenolate mofetil (MMF).

Efficacy of Treatment:

Overall, 31 patients (96.9%) completed at least 12 weeks of treatment, and SVR was achieved in

12 patients (ITT analysis, 37.5%) and included two patients who withdrew treatment at weeks 6

and 16 due to hematological effects, both having achieved RVR. Overall, 4 patients achieved

RVR (12.5%), of whom 3 achieved SVR. Eighteen patients (56.3%) obtained EVR (77.8% and

22.2% with complete and partial EVR, respectively), and of these 11 (61.1%) achieved SVR

(Table 3). Thirteen patients obtained ETR of whom 3 (9.4%) experienced virologic relapse

during follow-up. Additionally, 2 of the 5 patients who stopped treatment at week 30 and 36 due

to non-hematological effects relapsed.

Although SVR in those assigned PegIFNα-2a 135 μg/week was higher compared to those

assigned 180 μg/week, the difference was not statistically significant (50.0 vs.33.3%, P = 0.432).

Similarly, SVR was not significantly different in patients assigned RBV 200 – 400 mg/day vs.

those assigned 800 – 1200 mg/day (50.0 vs.33.3%; P = 0.432) (Table 3). Among non-cirrhotic

patients, SVR was achieved by 12 of 26 patients (46.2%), including 8 of 15 (53.3%) in HCV-G1,

13

and 4 of 11 (36.4%) in HCV-G4 (P =0.452), while in the 6 patients with cirrhosis, none obtained

an SVR (data not shown).

Safety and Tolerability:

There were no cases of AAR, while non-rejection related graft dysfunction occurred in 2 (6.3%)

treated patients by week 72. An increase in serum creatinine (>20%) above baseline levels (range

of increase, 21 – 195%) occurred on 27 occasions in 53.1% (17/32) patients, and was transient in

all except two patients (6.3%) who developed allograft dysfunction with sustained and

incremental increases, compared to 16.1% (6/31) of untreated historical controls (P = 0.148).

Serum creatinine at baseline in the treated patients (106.8 ± 32.0) did not differ from week 72

levels (113.4 ± 62.8; P = 0.140) while levels were significantly higher in the untreated controls

(106.6 ± 35.6 vs. 142.5 ± 93.0, respectively; P = 0.013). Overall, 14 treated patients underwent

16 allograft biopsies (4 for increases in creatinine, 12 as part of surveillance protocol) and none

of these demonstrated any features of AAR (Table 4). Both treated patients with allograft

dysfunction underwent biopsies that did not demonstrate features of AAR, one of whom had

histological abnormalities explaining the allograft dysfunction at baseline, while the other patient

had refused biopsy at baseline. These two patients opted to continue study medications.

Extended follow up of renal function in the treated cohort (beyond 72 week study closure)

showed an additional two patients (6.3%) to have developed sustained but stable increases in

creatinine levels (1.5 x baseline levels) without AAR on biopsy performed in one patient (Table

4). Serum creatinine at baseline (106.8 ± 32.0) did not differ significantly from week 96 levels

(119.7 ± 59.3; P = 0.140), while it was significantly higher in the untreated controls (106.6 ±

35.6 vs. 150.4 ± 103.3, respectively; P = 0.007). There was no difference in the mean creatinine

14

levels at all time points between the treated patients and control group (P >0.05, Figure 2).

Although allograft dysfunction with sustained increase in creatinine at week 96 was more

frequent in untreated controls (8/31; 25.8%) than in treated patients (4/32; 12.5%), it did not

reach statistical significance (P = 0.213).

The type and incidence of treatment-associated adverse events (AE) are illustrated in Table 5.

Serious, non-kidney AE occurred in two treated patients (6.3%) including development of high

serum-albumin gradient ascites in one patient (week 36, F4 fibrosis at baseline) and perforated

duodenal ulcer with eventual death in another patient (week 30, F4 fibrosis at baseline). Another

3 patients (overall 15.6%) discontinued treatment – two (6.3%) for grade 3/4 hematological

effects (week 6 and 16), and one patient withdrew consent for treatment but continued follow-up

in the study (Table 5). Grades 2/3 anemia requiring RBV dose reduction occurred in 25 (78.1%)

patients, and grade 3/4-neutropenia requiring PegIFNα-2a dose reduction occurred in 11 (34.4%)

patients. Thrombocytopenia grade ≥2 occurred in 6 (18.8%), reaching the threshold for treatment

discontinuation in one (3.1%) patient. GCSF and EPO were administered in 3 (9.4%) and 21

(65.6%) patients, respectively. The dosage of PegIFNα-2a and/or RBV was reduced in most

patients and only 7 (21.9%) patients experienced no hematological AE (Table 5). Reduction of

PegIFNα-2a occurred in 11 of 24 (45.8%) assigned the 180 μg/week dosage and none of those

assigned the 135 μg/week dosage (P = 0.029), while RBV reductions occurred in 20 of 24

(83.3%) of those assigned the 800 – 1200 mg/day dosage vs. 5 of 8 (62.5%) assigned the 200 –

400 mg/day dosage (P = 0.326, Table 5). All hematological AE were transient and returned to

baseline levels at week 72. On extended follow-up to 96 weeks, the patient with hepatic

decompensation required dialysis for diuretic-intractable ascites (normalization of creatinine off

diuretics). Another two non-responders with F4 fibrosis at baseline developed ascites on

15

extended follow-up (9.4%). In the control group, one patient with F3 at baseline developed

ascites at week 86 (3.2%, P = 0.613).

Predictors of Sustained Virologic Response:

Both SVR and non-SVR patients were similar in age, gender, presence of diabetes, number of

years post-transplant, the type of immunosuppression being used, baseline serum ALT, AST,

platelet count, creatinine level, HCV genotype, log10 HCV RNA or >800,000 IU/mL, presence of

advanced fibrosis or cirrhosis, PegIFN and RBV allocated dose or their subsequent reductions,

increases in creatinine levels by 20%, requirement for hematopoietic growth factors and RVR.

Factors significant by bivariate analysis are shown in Table 3. Binary logistic regression analysis

identified only EVR (OR, 20.4; 95% CI: 2.2 – 192.6; P = 0.008) as an independent predictor of

SVR.

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DISCUSSION

In this study, we have for the first time prospectively shown that HCV-infected RT recipients

treated with PegIFNα-2a and RBV are not exposed to an increased risk of AAR. We adopted in

this study, a low threshold strategy for allograft biopsy in any patient with an increase in serum

creatinine, which in turn occurred frequently (27 episodes in 17 patients). However, increase in

creatinine level was transient in most treated patients, and none that were subsequently biopsied

showed evidence of AAR. These findings are distinctly different from previous studies that have

cited a high rate of allograft rejection (17%) and dysfunction (30%) [5,9]. As such, the factors

relevant to this evidently disparate outcome need further examination.

Principally, all treated patients included in this study were at least one-year post RT, with the

mean duration being 7 years. Most episodes of renal rejection occur in the first year post-

transplantation [16], and therefore, our study population may represent a low risk population,

partly explaining the lack of rejection episodes.

Intensive monitoring of the immunosuppressive regimen while on therapy could also have

benefitted our patients. IFN-based therapy may cause reductions in CNI levels due to an

improvement in hepatic microsomal function after viral clearance [17]. While the greater

efficacy and different pharmacokinetics of PegIFN in such settings could be expected to further

compound the problem and potentially increase the risk of rejection, nonetheless, the prevention

of a downward drift of CNI drug levels may have potentially precluded the occurrence of

rejection. Furthermore, the vast majority of our patients were using tacrolimus and MMF, and

both these immunosuppressive drugs have been associated with a lower risk of rejection,

individually and in combination as opposed to cyclosporine-based regimens [16]. Finally, reports

also suggest that RBV may exert a possible protective effect on the allograft [18].

17

It is also important to note that surveillance allograft biopsies were performed in 12 treated

patients (37.5%). All biopsies were stained for C4D, although monitoring for donor specific

antibody was not performed, serving as a possible limitation of the study. Nonetheless, none of

the surveillance biopsies showed any evidence of cellular or antibody-mediated rejection,

corroborating the case against a potential subclinical form of IFN-induced rejection.

In our study, two (6.3%) of the treated patients developed allograft dysfunction, increasing to 4

patients (12.5%) on an extended follow up of one year with eventual graft loss in one patient

(3.1%). These rates were lower than those observed for untreated controls (25.8%, P = 0.213),

and substantially lower than the estimated risk of 30% reported in a meta-analysis [5]. It is worth

mentioning that the rate of graft dysfunction, specifically graft loss, observed in our study is not

different from those reported in long-term non-interventional follow-up studies in HCV or non-

HCV-infected RT patients [1,19,20]. The causes of allograft dysfunction are numerous, and

while IFN has also been implicated in its etio-pathogenesis, this aspect remains speculative and

certainly more evidence is needed.

The dosages of the antiviral medications were individually tailored to minimize haematological

AE by basing the regimen on eGFR. Despite this, 15.6% interrupted therapy and 78% reduced

the dosage of PegIFN and/or RBV. Notably, PegIFN dosages were reduced in 45.8% of our

patients who had been assigned the 180 μg/week while no reductions were made in those

assigned the 135 μg/week, highlighting the poor tolerability of the higher dose. Additionally,

patients assigned the 135 μg/week dosage had a higher SVR (50%) as compared to the full dose

(33.3%), although not reaching statistical significance (P = 0.432). The reduction of PegIFN

dosage was a frequent observation in studies that used the full dosage in LT recipients.

Systematic reviews have shown that dose reductions of RBV and/or PegIFN were necessary in

18

around 70% of patients and the rate of treatment discontinuation was around 30% [21,22],

comparable to our findings.

The rate of RBV dose reduction was seen more frequently in the group of patients assigned to

higher RBV dosage than the lower RBV dosage group (83.3 vs. 62.5%, P = 0.326). There was a

trend towards a better SVR rate in the lower RBV dose patients when compared to the patients

allocated the higher RBV dosage (50 vs. 33.3%) although, this was not statistically significant.

Additionally, patients who developed anaemia in our study achieved a similar SVR rate

compared to those who did not (66.7 vs. 60.0%), consistent with a previous report on LT

recipients [23]. Based on these findings, we feel it is appropriate to adopt a lower starting dose of

PegIFNα-2a/RBV strategy in order to improve treatment tolerance in such patients, without

necessarily compromising SVR rates. This could obviate the need for utilizing EPO, particularly

since its use or the development of anaemia did not impact on overall SVR rates. An alternative

strategy would be to assign an individualized RBV dose based on drug pharmacokinetics.

Our SVR rates are sub-optimal at 37.5% but remain generally comparable to SVR rates of 30%

in LT recipients [21,22], a population not dissimilar to ours. Importantly, the SVR rate in our

patients was a considerable improvement over the summary SVR rate of 18% shown in the

aforementioned meta-analysis of conventional IFN-based therapy in RT recipients [8].

Nonetheless, the low overall SVR rates in our study may be explained in part to the patient

population selected for our study which included high pretreatment viremia (75%), difficult-to-

treat genotypes and a predominant patient pool with advanced fibrosis/cirrhosis (65.6%).

In our study, EVR was independently associated with SVR, consistent with earlier reports in LT

patients. On the other hand, the lack of correlation with RVR could be related to the small

19

number of patients who achieved RVR (4 patients, of whom 3 achieved SVR while one died and

as such was considered a non-SVR). Hence, in order to better delineate the role of on-treatment

virologic factors in predicting outcome, larger studies, with a more homogenous RT recipient

population, should be performed.

We encountered two unusual SAEs during antiviral therapy, including one patient with hepatic

decompensation and another with a perforated duodenal ulcer. Hepatic decompensation with

ascites has been described previously and can be rarely expected in those with pre-existing

established cirrhosis [24], as was the case in our patient. The higher rate of hepatic

decompensation on extended follow-up in the treated group as compared to controls is not

unusual given the higher rate of advanced fibrosis/cirrhosis (65.6 vs. 16.1%, P <0.001) in the

treated patients. Furthermore, while RBV has been frequently associated with gastrointestinal

symptoms, we are unaware of any reports where RBV (or PegIFN) caused or exacerbated peptic

ulcers.

In conclusion, the results of this study suggest that PegIFNα-2a and RBV combination therapy

may be safe in RT recipients infected with HCV at low risk for allograft rejection, albeit with

modest efficacy rates. Treatment related AE are common which in turn may have contributed to

the suboptimal response with the frequent PegIFNα-2a and RBV dose reductions. A PegIFNα-2a

dose of 135 µg/week and RBV dose of 400 mg/day may be an appropriate dosing strategy in

order to improve treatment tolerance without necessarily compromising SVR rates. The results

of this study provide an impetus for conducting a larger, randomized controlled trial aiming to

define the optimal dosage of PegIFNα-2a and RBV and identify predictors of graft dysfunction.

20

Figure 1: Flow-chart of the trial

Figure 2: Serum creatinine plotted serially at different time points in the treated patients and

untreated controls over 48 weeks of treatment and 48 weeks of follow up (FU) duration. Levels

were not significantly different (P >0.05) at all time points between the treatment and control

groups.

21

Table 1: Baseline characteristics of hepatitis C virus infected untreated historical

controls and treated patients

Parameter Control

(n=31)

Treatment

(n=32)

P value

Age (yrs) 49.5 ± 13.2 46.0 ± 12.4 0.336

Male sex 18 (58.1) 19 (59.4) 0.916

BMI (Kg/m2) 27.9 ± 6.6 26.9 ± 5.2 0.520

Diabetes mellitus 16 (51.6) 22 (68.8) 0.165

Post transplant duration (yrs) 9.7 ± 6.5 7.2 ± 4.2 0.052

Alanine aminotransferase (U/L) 71.7 ± 83.2 103.6 ± 89.8 0.152

Aspartate aminotransferase (U/L) 50.1 ± 37.1 77.6 ± 48.7 0.027

Bilirubin (µmol/L) 9.9 ± 5.5 14.0 ± 6.9 0.013

Albumin (mg/L) 39.3 ± 3.0 39.5 ± 3.6 0.776

Platelet count (109/L) 231.4 ± 77.4 204.5 ± 87.3 0.201

Hemoglobin (g/dL) 13.0 ± 2.0 13.4 ± 1.6 0.423

Creatinine (µmol/L) 106.6 ± 35.6 106.8 ± 32.0 0.983

HCV RNA Log10 6.1 ± 0.8 6.3 ± 0.7 0.207

HCV Genotype 1 19 (67.9) 20 (62.5)

4 9 (32.1) 12 (37.5) 0.664

Fibrosis (≥3) 5 (16.1) 21 (65.6) < 0.001

Data expressed as mean ± standard deviation or n (%) as appropriate. BMI; body mass index. HCV; hepatitis C

virus. AFP ; alpha-fetoprotein.

22

Table 2: Baseline characteristics and on-treatment virologic response of treated

patients in relation to hepatitis C virus genotypes 1 and 4

Parameter HCV-G1 (n = 20)

HCV-G4 (n = 12)

P Value

Age 46.6 ± 12.8 46.2 ± 10.9 0.920

Age >40 years 14 (70.0) 10 (83.3) 0.676

Male sex 15 (75.0) 4 (33.3) 0.030

Diabetes mellitus 15 (75.0) 7 (58.3) 0.483

Alanine aminotransferase (U/L) 117.3 ± 99.8 80.8 ± 68.0 0.230

Aspartate aminotransferase

(U/L)

78.9 ± 42.7 75.4 ± 59.3 0.863

Creatinine (µmol/L) 115.7 ± 39.2 91.9 ± 29.9 0.064

Alkaline phosphatase (U/L) 129.8 ± 64.7 118.5 ± 65.8 0.641

Bilirubin (µmol/L) 13.9 ± 6.0 14.1 ± 8.5 0.948

Albumin (mg/L) 39.9 ± 3.8 38.9 ± 3.4 0.482

HCV RNA Log10 6.3 ± 0.8 6.3 ± 0.6 0.937

HCV RNA >800,000 (IU/mL) 15 (75.0) 9 (75.0) 1.000

Leukocyte count (109/L) 6.4 ± 1.6 7.3 ± 2.9 0.333

Platelet count (109/L) 178.5 ± 56.4 247.8 ± 112.7 0.066

Hemoglobin (g/dL) 13.5 ± 1.6 13.2 ± 1.5 0.598

Necroinflammation (≥A2) 19 (95.0) 8 (66.7) 0.053

Fibrosis (≥3) 15 (75.0) 6 (50.0) 0.149

Rapid virologic response 3 (15.0) 1 (8.3) 1.000

Early virologic response 13 (65.0) 5 (41.7) 0.277

Sustained virologic response 8 (40.0) 4 (33.3) 1.000

Data expressed as mean ± standard deviation or n (%) as appropriate. BMI; body mass index. HCV; hepatitis C

virus. G1; genotype 1. G4; genotype 4.

23

Table 3: Baseline and on-treatment patients’ characteristics in relation to sustained

and non-sustained virologic response to Peginterferon-α2a plus ribavirin therapy

Variables SVR (n = 12)

Non-SVR (n = 20)

P value

Age (yrs) 42.7 ± 13.4 48.7 ± 10.8 0.199 Male gender 10 (50.0) 3 (25.0) 0.267 Body mass index (Kg/m2) 24.7 ± 4.3 28.2 ± 5.3 0.046 Diabetes mellitus 8 (66.7) 14 (70.0) 0.844 Alanine aminotransferase (U/L) 114.1 ± 79.0 97.3 ± 97.2 0.598 Aspartate aminotransferase (U/L) 85.7 ± 51.7 72.7 ± 47.4 0.487 Alfa fetoprotein (ng/mL) 23.4 ± 49.7 18.6 ± 30.1 0.762 Bilirubin (µmol/L) 13.3 ± 5.9 14.4 ± 7.5 0.636 Albumin (mg/L) 39.4 ± 3.6 39.6 ± 3.7 0.921 Creatinine (µmol/L) 113.7 ± 44.9 102.6 ± 32.6 0.467 HCV RNA Log10 6.2 ± 0.7 6.4 ± 0.7 0.572 HCV RNA > 800000 (IU/mL) 7 (58.3) 17 (85.0) 0.116 Fibrosis ≥3 7 (58.3) 14 (70.0) 0.501 HCV genotype 1 8 (66.7) 12 (60.0) 0.706 ALT normalization 10 (83.3) 10 (52.6) 0.128 Anemia grade≥2 10 (66.7) 12 (60.0) 0.100 Thrombocytopenia grade≥2 3 (25.0) 3 (15.0) 0.647 Rapid virologic response 3 (25.0) 1 (5.0) 0.136 Early virologic response 11(91.7) 7 (35.0) 0.003 Peginterferon dose 180 μg/week

135 μg/week Dose reduction

8 (66.7) 4 (33.3) 3 (25.0)

16 (80.0) 4 (20.0) 6 (75.0)

0.433

1.000 Ribavirin dose 200-400 mg/d

800-1200 mg/d Dose reduction

4 (33.3) 8 (66.7) 7 (30.0)

4 (20.0) 16 (80.0) 14 (70.0)

0.433

0.633 Creatinine increase by 20% 5 (41.7) 12 (60.0) 0.314

Data expressed as mean ± standard deviation or n (%) as appropriate. HCV; hepatitis C virus. ALT; alanine

aminotransferase. SVR; sustained virologic response

24

Table 4: Findings of allograft kidney biopsies in treated and untreated patients

prior to commencement of antiviral therapy, on-therapy, and during extended

follow-up (week 96) with their indications

Treated Patients (n=15) Controls (n=6)

Pre-treatment On/Post-treatment Untreated‡

Indication

biopsy (n=11)

1 Diabetic changes

1 Mild IFTA

2 Diabetic changes

**2 Mild IFTA

1 Glomerulosclerosis

Surveillance

biopsy (n=12)*

5 Mild IFTA

5 Mild IFTA

1 Moderate IFTA

1 Diabetic changes

1 HCV-related MPGN

1 Normal

1 Glomerulosclerosis

1 Diabetic changes +

moderate IFTA

1 HCV-related MPGN

+ IFTA

2 Moderate IFTA

1 FSGS

1 Chronic antibody-

mediated rejection

*Two patients had biopsy twice, once each for surveillance and indication. **Two patients biopsied during follow-

up period. ‡All untreated controls biopsied for indication. IFTA, interstitial fibrosis and tubular atrophy. MPGN,

membranoproliferative glomerulonephritis. FSGS, focal and segmental glomerulosclerosis. HCV, hepatitis C virus.

25

Table 5: Adverse events in treated patients reported with a frequency more than

5%

N (%)

Discontinuation 4 (12.5) Laboratory abnormality 2 (6.3)

Adverse event 2 (6.3)

Dose modification 25(78.1)* Neutropenia (grade 3/4) 11 (34.3)

Thrombocytopenia (grade 3) 1 (3.1) Anemia (grade 2/3) 25(78.1)

PegIFNα-2a dose reduction 180 μg/week 135 μg/week

11 (34.4) 11 (45.8) 0 (0%)

Ribavirin dose reduction 800 – 1200 mg/day 200 – 400 mg/day

25 (78.1) 20(83.3) 5 (62.5)

Adverse event 117 (84.7) Fatigue 23 (71.9)

Myalgia 13 (40.6) Arthralgia 16 (50.0)

Fever 18 (56.3) Anorexia 8(25.0)

Dermatitis/itching 4 (12.5) Shortness of breath 12 (37.5)

Nausea/vomiting 2 (6.3) Diarrhoea Headache

Depression Sustained creatinine increase

5 (15.6) 10 (31.3) 4(12.5) 2 (6.3)

*=Twelve patients had more than one indication for dose modification

26

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28

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thrombocytopenia. Wien Klin Wochenschr 2006;118(19-20):595-600.

HCV-positive Renal Recipients

Screened for eligibility (n=166)

Patients enrolled for treatment

(n=32)

Week 4 (n=32)

Undetectable HCV RNA (n=4)

Detectable HCV RNA (n=28)

Not meeting inclusion criteria (n=103)

Refused or unsuitable for treatment (n=31)

Week 24 (n=16)

Undetectable HCV RNA (n=15)

Week 12 (n=31)

Undetectable HCV RNA (n=14)

Detectable HCV RNA, ≥2 Log reduction (n=4)

Treatment cessation:

•Severe thrombocytopenia (n=1)

Untreated historical controls

(n=31)

Treatment cessation:

•Severe anemia (n=1)

•Patient withdrew treatment (n=1)

Treatment cessation:

•Severe adverse event (n=2)

Week 48 (n=13)

Undetectable HCV RNA (n=13)

Death (n=1)

Treatment cessation:

HCV RNA < 2 Log reduction (n=13)

Treatment cessation:

•Detectable HCV RNA (n=1)

Figure 1

Cre

ati

nin

e (µ

mo

l/L

)

Figure 2