Therapy of hepatitis C by direct-acting anti-virals: the end of HCV in dialysis population?

Abstract

The advent of direct-acting anti-viral (DAA) drugs is dramatically changing the treatment of hepatitis C virus (HCV) in patients with intact kidney function (‘cure rates’ >90% and infrequent adverse events). The information on efficacy and safety of DAAs for HCV therapy in patients with renal failure is limited. We have reviewed the available evidence regarding efficacy and safety of numerous DAAs (boceprevir, telaprevir, sofosbuvir, simeprevir, grazoprevir, elbasvir, ombitasvir, paritaprevir, ritonavir, dasabuvir, ledispavir, daclatasvir, asunaprevir, beclabuvir) in treating HCV-infected patients with renal impairment and/or end-stage renal disease. The major limitation of this review is the paucity of published data and its reliance on abstracts and product monographs. Preliminary data suggest that combination antiviral therapy (grazoprevir and elbasvir) is provided with great efficacy in patients with HCV genotype 1 and chronic kidney disease stage 4 or 5 including those on intermittent dialysis, SVR12, 99% (114/115), according to a per-protocol analysis. In another trial, patients with HCV genotype 1 and chronic kidney disease stage 4 or 5 were given the 3D regimen; an interim evaluation reported that all patients completing treatment to date had viral response (100%, 14/14) but data on sustained viral response are under evaluation. Treatments were generally well tolerated.

Keywords:

• dialysis
• direct-acting anti-virals
• hepatitis C
• interferon
• ribavirin

Financial & competing interests disclosure

This work has been supported in part by the grant ‘Project Glomerulonephritis’, in memory of P Neglia. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Direct-acting antiviral agents (DAAs) are changing the treatment of hepatitis C in patients with intact kidney function.

• The evidence regarding the treatment (by DAA drugs) of hepatitis C in patients with chronic kidney disease (CKD) is currently very limited.

• Interim analyses suggest that some DAAs agents can be effective and safe for the treatment of hepatitis C in the CKD population

• All DAAs drugs are very expensive; in this era of cost containment and budgets tightening this is a crucial point either in developed and developing countries.

• Combination antiviral therapy (pegylated IFN plus low-dose ribavirin) has given encouraging results and should be still considered in the therapeutic armamentarium of HCV in patients with CKD, particularly in those who are in the waiting list for renal transplant.