Evolving Trends in Kidney Discard from Hepatitis C-Positive Donors Following the Kidney Donor Profile Index Formula Change

Background: Despite the safety of transplanting kidneys from Hepatitis C virus (HCV)–positive donors in the era of direct-acting antivirals (DAAs), discard of these organs persists. In October 2024, the Kidney Donor Profile Index (KDPI) formula was updated to remove race and HCV status. This study examines trends in the discard of HCV-positive kidneys before and shortly after the KDPI change. Methods: We analyzed deceased donor kidneys recovered for transplant in the United States from 2020 to early 2025. Donors were categorized by HCV status as viremic(NAT+), aviremic seropositive(NAT−, Ab+), or seronegative(NAT−, Ab−). Multivariable logistic regression assessed adjusted odds of kidney discard by HCV status, using NAT−, Ab− donors as the reference group. Models were adjusted for donor age, race, sex, body mass index, diabetes, hypertension, kidney donor profile index,donation after cardiac death,cause of death,risk factors for blood-borne disease,creatinine,and glomerulosclerosis. Results: Among 143,439 kidneys recovered between January 1, 2020, and March 31, 2025, 6,911 (4.82%) were from NAT+ donors and 7,692 (5.36%) from NAT−, Ab+ donors. Compared to NAT−, Ab− donors, NAT+ kidneys were associated with significantly increased odds of discard from 2020–2024(aORs ranging from 1.54 to 1.94). In early 2025, this association was no longer significant(aOR=1.18, 95% CI: 0.84–1.65). Conclusion: Kidneys from HCV-viremic donors continued to face significantly higher odds of discard compared to HCV-negative donors from 2020 through 2024. However, in early2025, after the October2024 policy change that removed HCV status from the KDPI calculation, we observed a notable improvement, with no statistically significant difference in discard odds for HCV+ kidneys. These findings suggest ongoing hesitancy in utilizing HCV+ kidneys, though early signals from 2025 indicate progress in reducing discard as clinical and policy environments evolve. Odds Ratios of Discard (Compared to NAT-, Ab-) - Year Total (n) NAT–, Ab+ (OR [95% CI]) NAT+ (OR [95% CI]) 2020 22,808 1.57 (1.30, 1.91) 1.23 (0.91, 1.66) 2021 25,285 1.45 (1.21, 1.73) 1.56 (1.33, 1.84) 2022 27,381 1.62 (1.38, 1.89) 1.87 (1.60, 2.19) 2023 29,739 1.48 (1.28, 1.72) 1.54 (1.31, 1.81) 2024 30,698 1.39 (1.20, 1.62) 1.89 (1.61, 2.22) 2025 7,627 1.23 (0.91, 1.66) 1.18 (0.84, 1.65)