MPGN and mixed cryoglobulinemia in a patient with hepatitis C – new treatment implications and renal outcomes

Abstract

Abstract. Introduction: The association of hepatitis C virus (HCV), cryoglobulinemia, and membranoproliferative glomerulonephritis (MPGN) is well known. Treatment of underlying HCV infection has greatly improved in recent years with the introduction of direct-acting antivirals (DAA), which have demonstrated curative sustained viral response (SVR) rates for select viral genotypes with the added benefit of less drug side effects. However, a mainstay of newer DAAs is sofosbuvir, which is contraindicated in patients with severe renal impairment. Case history: We are reporting the case of a 65-year-old female with chronic systolic heart failure, hypertension, and chronic HCV genotype 1b with biopsy-proven type I MPGN with cryoglobulinemia type II, who presented with rapidly progressive renal failure requiring emergent hemodialysis. After initiation of DAA therapy including ombitasvir-paritaprevir-ritonavir plus dasabuvir, in conjunction with plasmapheresis, corticosteroids, and rituximab, there was significant improvement in renal function such that hemodialysis was no longer needed. Discussion: This patient’s HCV treatment is estimated to induce a greater than 90% SVR, which is notably promising for the reduction and/or reversal of HCV-related glomerulopathy. Most recent HCV guidelines from 2015 recommend this regimen; however, there is little data to evaluate the safety and efficacy of treatment. Therefore, it is valuable to report positive preliminary results at this time. Overall, we anticipate this treatment regimen to become a basis in the management of HCV-related renal disease; however, larger studies will still be needed to prove its efficacy in improving renal outcomes.

Prognosis and incidence of immunological and oncological complications after direct-acting antiviral therapy for chronic hepatitis C

“…The simplified disease activity index decreased significantly from baseline to 24 weeks after the end of DAA therapy in 11 RA patients (23). MPGN was ameliorated following DAA therapy in some but not all cases (24)(25)(26). Our results showed several cases of newonset RA, one of which we reported previously (5), and new-onset MPGN observed after DAA therapy.…”

KDIGO 2018 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease

“…By multivariate analysis, age > 50 years, purpura, splenomegaly, cryocrit levels > 10%, C3 plasma levels < 54 mg/dl, and serum creatinine > 1.5 mg/dl (> 133 μmol/l) were independent risk factors for death or dialysis 330 . Other case reports have also documented improvement following the administration of a combination of steroids and antivirals (IFN and RBV) or of the 3D regimen combined with plasmapheresis, corticosteroids, and rituximab 333, 334 5.2.3: We recommend immunosuppressive therapy in patients with histologically active HCV-associated glomerular disease who do not respond to antiviral therapy, particularly those with cryoglobulinemic kidney disease (1B).…”

KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease

“…330 Other case reports have also documented improvement following the administration of a combination of steroids and antivirals (IFN and RBV) or of the 3D regimen combined with plasmapheresis, corticosteroids, and rituximab. 333,334 5.2.3: We recommend immunosuppressive therapy in patients with histologically active HCV-associated glomerular disease who do not respond to antiviral therapy, particularly those with cryoglobulinemic kidney disease (1B). 5.2.3.1: We recommend rituximab as the first-line immunosuppressive treatment (1C).…”