1. Hepatitis C+ Recipients: Considerations for Exclusion Emily A. Blumberg, M.D.

2. Hepatitis C+ Recipients and Transplantation Decreased long term patient survival Decreased long term graft function Increased risk of chronic liver disease Increased risk of renal disease Impaired immunological function Increased risk of post transplant diabetes mellitus

3. Kidney Transplant Survival Based on HCV Status Legendre, et al. Transplantation 1998

4. Graft Survival in Kidney Transplant Recipients Mathurin, et al. Hepatology 1999

5. Outcome of HCV+ Recipients After OLT Median time to cirrhosis 12 years 28% cirrhotic at 5 years Decompensation < 1 year, typically with ascites Decompensation associated with >50% 1 year mortality Risk factors for fibrosis post transplant HCV RNA level at OLT Immunosuppressive regimen (MMF, Rejection Rx) Year of transplantation

6. Impact of HCV on Liver Disease in Kidney Transplantation Hanafusa, et al, Transplantation 1998

7. Interferon Treatment of HCV Post Transplant Poorly tolerated Limited efficacy Potential increased risk of rejection Potential risk of renal failure

8. Post Transplant Nephropathy and HCV+ Recipients HCV is a risk factor for de novo immune mediated post transplant nephropathy Membranoproliferative GN Membranous GN Changes may be seen in first 4 months Patients with autoimmune renal disease may have decreased progression of hepatic disease

9. Probability of Death Due to Sepsis in Renal Transplant Patients Pereira, et al. Transplantation 1995

10. In vitro Proliferative Responses in Renal Transplant Patients Khanna, et al. Transplant 2001, abstr542

11. Impact of HCV on Post Transplant Diabetes Mellitus HCV+ (n=47) HCV- (n=111) P value PTDM64%28%0.0001 Cumulative mortality 43% (56% if PTDM) 27%0.06 Mortality from Infxn 75%23%0.001 Baid, et al Transplant 2001 abstract 86

12. Impact of HCV on HIV Infection Increased mortality Increased risk of opportunistic infection Impaired/delayed CD4 recovery

13. HCV + Recipients Inclusion of HCV coinfected pts for OLT if we want to minimize harm and improve outcome? Does the high rate of HCV infection justify inclusion? Will liver bx pre kidney tx be adequate to protect subjects from liver disease? Should HCV treatment decisions be left to pt and PCP?