Hepatitis C Virus (HCV) Recurrence and Death After Viral Clearance in an HCV-Viremic Donor to HCV-Negative Kidney Recipient.

Current direct-acting antiviral (DAA) regimens have achieved nearly universal viral eradication in hepatitis C virus (HCV) nucleic acid test (NAT)-positive donor to HCV-negative recipient (HCV NAT+/-) transplantation. This case study presents an early HCV recurrence after initial viral clearance with DAA therapy in an HCV NAT+/- kidney recipient that then rapidly progressed to acute liver failure and the death of the transplanted individual. A 52-year-old man with type 2 diabetes underwent a deceased donor HCV NAT+/- kidney transplant. Postoperatively, the allograft function gradually improved without necessitating dialysis. HCV NAT at postoperative day (POD) #3 revealed a viral load of 5 log IU/mL. A 12-week course of sofosbuvir/velpatasvir was completed, and HCV NAT was negative by POD#94. His liver enzymes were significantly elevated at POD#170. Repeat HCV NAT showed viral load at >8 log IU/mL. Sofosbuvir/velpatasvir was reinitiated with a plan to transition to sofosbuvir/velpatasvir/voxilaprevir. On POD#183, the patient was admitted for diabetic ketoacidosis and acute liver failure. His condition rapidly deteriorated to multi-organ failure, and he died on POD#188. Fatal recurrence is rare in HCV NAT+/- kidney transplant recipients after completion of DAA regimen. HCV recurrence should be considered with abnormal liver chemistries in the absence of alternative explanations.