Management of chronic hepatitis C virus infection in patients with end-stage renal disease: a review

Figures & data

Figure 1 Proposed algorithm for evaluation and allocation of renal transplant candidates with HCV infection.

Abbreviations: ESRD, end-stage renal disease; HCV, hepatitis C virus; HCV (+), positive for hepatitis C virus; HCV (−), negative for hepatitis C virus; HPVG, hepatic portal venous gradient; HD, hemodialysis; IFN, interferon; PEG-IFN, PEGylated IFN; SVR, sustained viral response.

Table 1 Summary by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative of KDIGO guidelines for the prevention, diagnosis, evaluation and treatment of hepatitis C in patients with chronic renal failure 2008⁸⁵

Screening for HCV infection

• It is suggested that patients with chronic renal failure should be evaluated for HCV infection (weak evidence)

• Determine the presence of HCV in patients on hemodialysis therapy (grade 5) and renal transplant candidates (strong evidence)

• Hemodialysis patients should be evaluated for HCV infection when they begin therapy or change hemodialysis machine (strong evidence)

• Patients who have been tested and found to be negative for HCV should again be evaluated every 6–12 months (moderate evidence)

• Assessment should be performed with viral RNA determination in patients with unexplained elevated aminotransferase levels (strong evidence)

• A new case of HCV infection in a hemodialysis unit should prompt the determination of viral RNA in all potentially exposed patients (strong evidence)

Treatment of HCV infection in patients with chronic renal insufficiency

• It is suggested that the decision to initiate treatment should be based on its potential benefits and risks, and it must take into account life expectancy, comorbidities, and availability of kidney transplantation (weak evidence)

• It is suggested that HCV-infected patients accepted for kidney transplant should be treated (weak evidence)

• It is suggested that patients with HCV infection who have received a kidney transplant should consider treatment if benefits outweigh the risk of allogarft rejection due to IFN therapy (life-threatening hepatitis and fibrosing cholestatic vasculitis) (weak evidence)

• Consider antiviral therapy in patients with HCV infection-associated glomerulonephritis (weak evidence)

• In patients with chronic kidney disease grade 1 and 2, suggest the use of combination therapy: use of PEG-IFN and ribavirin (weak evidence)

• Patients with grade 3–5 chronic kidney disease who are not on dialysis therapy should be administered, PEG-IFN should be adjusted according to kidney clearance (weak evidence)

• Patients with grade 5 chronic kidney disease who are on maintenance dialysis therapy, should be treated with standard IFN monotherapy, adjusted according to kidney clearance (<15 mL/min/1.73 m^2) (weak evidence)

• Treatment response was defined as SVR, the absence of viral RNA after 6 months of completing antiviral treatment (weak evidence)

Prevention of HCV transmission in hemodialysis units

• Hemodialysis units should ensure implementation and adherence to strict infection control measures designed to prevent transmission of blood-borne pathogens (strong evidence)

Handling of HCV-infected patients before and after kidney transplantation

• HCV infection should not be considered a contraindication to kidney transplantation (moderate evidence)

• It is suggested that candidates for kidney transplant and coexisting HCV infection should have a liver biopsy before transplantation (weak evidence)

• Renal transplant candidates with HCV infection should be considered for treatment with standard IFN before transplantation (weak evidence)

• All kidney donors should be evaluated for HCV (strong evidence)

• It is suggested that kidney transplantation of grafts from donors infected with HCV should be restricted to recipients with a positive HCV viral load (weak evidence)

• All maintenance immunosuppressive therapy should be considered in patients with kidney transplant recipients and HCV (weak evidence)

• Post-transplant patients requiring antiviral therapy should be treated with standard IFN (weak evidence)

• All patients receiving HCV-infected kidney transplants should be evaluated for development of hyperglycemia after transplantation (weak evidence)

Abbreviations: HCV, hepatitis C virus; IFN, interferon; KDIGO, Kidney Disease: Improving Global Outcomes; PEG-IFN, PEGylated IFN; SVR, sustained viral response.

GordonCEBalkEMBeckerBNKDOQI US Commentary on the KDIGO clinical practice guideline for the prevention diagnosis, evaluation, and treatment of hepatitis C in CKDAm J Kidney Dis200852815825

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