A WORK group of Kidney Disease: Improving Global Outcomes (KDIGO) has updated its 2018 guideline recommendations for the treatment of hepatitis C in patients with chronic kidney disease (CKD).
The updated guideline, entitled ‘KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease’, notes that direct-acting antivirals effectively treat hepatitis C in patients across all stages of CKD, including dialysis and kidney transplant patients, with no need for dose adjustment. Pangenotypic regimens such as sofosbuvir-based regimens, and genotypic-specific direct-acting antiviral regimens are safe and effective in patients with Stage 4–5 CKD, including those on dialysis and receiving kidney transplant. In cases where pangenotypic regimens are not available, genotype-specific treatments can be administered once the patient’s hepatitis C virus genotype has been determined.
Protease inhibitors (i.e., simeprevir, paritaprevir, and grazoprevir) are contraindicated in individuals with cirrhosis or Child–Pugh Class B or C, because of hepatotoxicity.
There have been several reports of apparent reactivation of hepatitis B virus following treatment of hepatitis C infection with direct-acting antivirals. For this reason, the guideline recommends testing for serological markers of hepatis B virus (e.g., hepatitis B surface antigen) prior to antiviral therapy. If hepatitis B surface antigen is present, patients should undergo assessment for hepatis B virus therapy. If hepatis B surface antigen is absent but markers of prior hepatis B infection are detected, reactivation should be excluded by performing hepatitis B DNA testing if levels of liver function tests rise during direct-acting antiviral therapy.
The updated guideline also suggests that kidney transplant candidates with hepatitis C virus are evaluated for severity of liver disease as well as the presence of portal hypertension prior to acceptance. This will help guide the decision between kidney transplantation alone or combined liver–kidney transplantation.
Patients with hepatis C and a typical presentation of immune-complex glomerulonephritis can be managed without a confirmatory kidney biopsy. However, a biopsy should be considered in certain clinical circumstances, for example if either kidney function or proteinuria worsen.