Hepatitis C Treatment of Renal Transplant and Chronic Kidney Disease Patients: Efficacy and Safety of Direct-Acting Antiviral Regimens Containing Sofosbuvir

Abstract

BACKGROUND: Direct-acting antivirals have revolutionized hepatitis C treatment, also for patients with chronic kidney disease (CKD), but some controversy exists regarding the use of sofosbuvir (SOF) in patients with glomerular filtration rate (GFR) <30 mL/min. OBJECTIVE: To evaluate the efficacy and safety of these regimens for hepatitis C treatment of patients with CKD and after renal transplantation, as well as the impact of SOF on renal function in non-dialysis patients. METHODS: All patients with hepatitis C and CKD or renal transplant treated with direct-acting antivirals at a referral center in Brazil between January 2016 and August 2017 were included. Efficacy was evaluated based on viral load (HCV RNA) and a sustained virological response (SVR) consisting of undetectable RNA 12 and/or 24 weeks after the end of treatment (SVR12 and SVR24) was defined as cure. Safety was determined by adverse events and ribavirin, when combined, was administered in escalating doses to all patients with GFR <60 mL/min. The impact of SOF on renal function was determined by the measurement of baseline creatinine during and after the end of treatment and its increase was evaluated using the Acute Kidney Injury Network (AKIN) classification. RESULTS: A total of 241 patients (52.7% females) with a mean age of 60.72±10.47 years were included. The combination of SOF+daclatasvir was the predominant regimen in 75.6% of cases and anemia was present in 28% of patients who used ribavirin (P=0.04). The SVR12 and SVR24 rates were 99.3% and 97.1%, respectively. The treatment was well tolerated and there were no major clinically relevant adverse events, with the most prevalent being asthenia (57.7%), itching (41.1%), headache (40.7%), and irritability (40.2%). Among conservatively treated and renal transplant patients, oscillations of creatinine levels (AKIN I) were observed in 12.5% of cases during treatment and persisted in only 8.5% after the end of treatment. Of these, 2.0% had an initial GFR <30 mL/min and this percentage decreased to 1.1% after SOF use. Only 0.5% and 1.6% of the patients progressed to AKIN II and AKIN III elevation, respectively. CONCLUSION: The direct-acting antivirals were safe and efficacious in CKD patients treated with SOF-containing regimens, with the observation of high SVR rates, good tolerability and few severe adverse events. The combination with ribavirin increased the risk of anemia and the administration of escalating doses seems to be useful in patients with GFR <60 mL/min. In patients with GFR <30 mL/min, SOF had no significant renal impact, with serum creatinine returning to levels close to baseline after treatment.

A Systematic Review of Direct-Acting Antivirals for Hepatitis C in Advanced CKD

“…We found 29 studies pertaining to KTRs. 29 , 30 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 The studies evaluated the following: GLE/PIB (1 study, N = 20), GZR/EBR (2 studies, N = 21), PrO ± D (2 studies, N = 33), SOF (6 studies, N = 117), SOF/DCV (7 studies, N = 351), SOF/LDV (9 studies, N = 300), and SOF/VEL (1 study, N = 10). Three retrospective, unadjusted studies also compared a variety of DAA regimens ( N = 86), mostly SOF/LDV or SOF/DCV, to no DAA treatment ( N = 63).…”

Impact of direct acting antiviral agents on kidney function in hepatitis C virus infected patients with chronic kidney disease

“…27), as DAAs use caused the same improvement in most of the patients (50% to 70%) and complete clinical response in most of the patients. Our study brings further supporting evidence to the current recommendations of the KDIGO 2018 guidelines on the use of DAAs, which is now recommended as the first-line therapy in cryoglobulinemic glomerulonephritis.…”