The Kidney Transplant Recipient with Hepatitis C Infection

Abstract

Liver disease secondary to chronic hepatitis C virus (HCV) infection is an important cause of morbidity and mortality in dialysis patients and kidney transplant recipients. Evaluation of patients with chronic HCV infection is warranted to determine stage of disease and the need for HCV therapy. Although combination therapy with interferon (IFN) plus ribavirin is the standard of care for chronic HCV infection, IFN monotherapy is recommended in dialysis patients because ribavirin is contraindicated in the presence of renal failure. The goals of pretransplantation HCV therapy are to decrease the risk for progression of HCV-associated liver disease, stabilize renal function in patients with HCV-related glomerulopathy, and prevent development of HCV-associated renal disease after transplantation. Posttransplantation HCV therapy is generally not recommended because of concerns regarding risk for precipitating acute rejection; however, antiviral therapy may be indicated to treat HCV-related glomerulopathy or prevent progression of chronic hepatitis C in patients with more advanced stages of fibrosis. When treatment is required, restored renal function allows use of combination therapy with IFN and ribavirin. Limitations of current HCV therapy include lack of tolerability and suboptimal response rates. New antiviral agents that can be used in dialysis patients (e.g., ribavirin alternatives) and in the posttransplantation setting (e.g., IFN alternatives) are needed to improve outcomes in these populations.

Hepatitis C infection in hemodialysis patients: A review

“…As HCV replication progresses, there is greater risk of accelerated liver disease, including hepatic failure and hepatocellular carcinoma [46] . KT is not contraindicated for these individuals, but each such candidate must be informed of all difficulties (i.e., those related to progression of HCV and restricted antiviral treatment) after transplantation [47] .…”

Common Infections in Kidney Transplant Recipients

“…It is important to identify advanced liver disease in candidates for kidney transplantation before transplantation to limit the risk for a poor outcome; consequently, all HCV-positive candidates should undergo liver biopsy. Post-transplant complications include GN, post-transplant diabetes mellitus, and accelerated progression to cirrhosis with fibrosing cholestatic hepatitis (50,(52)(53)(54)(55). Viral loads typically increase to high levels after transplantation, regardless of the degree of liver disease, and about 20%-51% of patients may have normal liver enzyme levels with abnormal histologic features; this makes noninvasive monitoring of kidney transplant recipients with HCV infection more difficult.…”

Development of Novel Combination Therapies

“…Compared to non-HCV-infected CKD Stage 4/5 patients, HCV-infected CKD Stage 4/5 patients have poor graft survival and higher overall mortality outcomes following renal transplantation (Fabrizi, Martin, et al 2005;Terrault and Adey 2007).…”