Management of hepatitis C in patients with chronic kidney disease

Abstract

Hepatitis C virus (HCV) infection is highly prevalent among chronic kidney disease (CKD) subjects under hemodialysis and in kidney transplantation (KT) recipients, being an important cause of morbidity and mortality in these patients. The vast majority of HCV chronic infections in the hemodialysis setting are currently attributable to nosocomial transmission. Acute and chronic hepatitis C exhibits distinct clinical and laboratorial features, which can impact on management and treatment decisions. In hemodialysis subjects, acute infections are usually asymptomatic and anicteric; since spontaneous viral clearance is very uncommon in this context, acute infections should be treated as soon as possible. In KT recipients, the occurrence of acute hepatitis C can have a more severe course, with a rapid progression of liver fibrosis. In these patients, it is recommended to use pegylated interferon (PEG-IFN) in combination with ribavirin, with doses adjusted according to estimated glomerular filtration rate. There is no evidence suggesting that chronic hepatitis C exhibits a more aggressive course in CKD subjects under conservative management. In these subjects, indication of treatment with PEG-IFN plus ribavirin relies on the CKD stage, rate of progression of renal dysfunction and the possibility of a preemptive transplant. HCV infection has been associated with both liver disease-related deaths and cardiovascular mortality in hemodialysis patients. Among those individuals, low HCV viral loads and the phenomenon of intermittent HCV viremia are often observed, and sequential HCV RNA monitoring is needed. Despite the poor tolerability and suboptimal efficacy of antiviral therapy in CKD patients, many patients can achieve sustained virological response, which improve patient and graft outcomes. Hepatitis C eradication before KT theoretically improves survival and reduces the occurrence of chronic graft nephropathy, de novo glomerulonephritis and post-transplant diabetes mellitus.

Daclatasvir and asunaprevir for genotype 1b chronic hepatitis C patients with chronic kidney disease

“…[27][28][29] The previous SOC, peg-IFN/RBV combination therapy or triple therapy with peg-IFN/RBV and protease inhibitors such as telaprevir and simeprevir, are carefully provided or not recommended for CKD and elderly patients, because RBV is mainly excreted by the kidney and such patients are often intolerant to peg-IFN/RBV. 30 Such patients used to receive peg-IFN monotherapy, but the SVR rate was very low. 18 From now on, they might receive more tolerable and effective IFN/RBV-free DAA regimens such as daclatasvir and asunaprevir combination therapy.…”

Treatment and management options for the hepatitis C virus infected kidney transplant candidate

“…It is estimated that approximately 3 million people in the United States have chronic HCV infection with estimates approaching 170 million worldwide, although these numbers likely underestimate the true prevalence in the context that many people in established at‐risk populations have not been screened and remain undiagnosed. The prevalence of HCV infection among CKD and ESRD patients exceeds that of the general population with reports demonstrating infection in 8% to 44% of dialysis patients in the United States and other developed countries and even higher in parts of Latin America and the Middle East. It has been postulated that the increased prevalence of HCV infection in ESRD patients may be due, in part, to improved screening and increased awareness of the potential for HCV infection in the hemodialysis setting .…”

Efficacy of daclatasvir plus asunaprevir in patients with hepatitis C virus infection undergoing and not undergoing hemodialysis

“…Hepatitis C virus infection in hemodialysis (HD) patients has been closely associated with liver disease‐related deaths due to complications of cirrhosis and hepatocellular carcinoma. The prevalence of HCV infection is higher in HD patients than in the general population; this is an important problem . Because all treatment combinations with RBV have increased toxicity (severe hemolysis) and higher withdrawal rates in patients with end‐stage renal disease, these regimens have been contraindicated in this cohort.…”