Interferon-alpha facilitates renal transplantation in hemodialysis patients with chronic viral hepatitis

Hepatitis B Virus Infection in the Dialysis Population: Current Perspectives

One of the major advances in the management of patients on regular dialysis has been the control of the spread of hepatitis B virus (HBV) infection in dialysis units. The rate of HBsAg positive patients on regular dialysis in the developed world is currently low, but outbreaks of HBV continue to occur. The diffusion of HBV in dialysis units in developing countries is higher, although available information is not abundant. There are limited data on the natural history of HBV in the dialysis population; they support a detrimental effect of HBV on survival in dialysis patients. The HBV viral load in HbsAg-positive dialysis patients appears low and stable over time and numerous mechanisms have been posited to explain it. Several assays for detecting HBV DNA in serum are available but they should not be used for purposes of routine screening within dialysis units. The epidemiology and clinical significance of occult HBV infection in the dialysis population needs to be addressed adequately - this remains an area of active research. Recent recommendations for the management of HBsAg chronic carriers on maintenance dialysis have been issued. No controlled trials for the treatment of hepatitis B with either interferon or lamivudine in dialysis patients are currently available.

Spectrum of hepatitis B and renal involvement

Renal involvement in hepatitis B occurs in various spectrums and its knowledge is important for clinicians in management of patients. The renal diseases most commonly associated with hepatitis B virus (HBV) infection include membranous nephropathy, membranoproliferative glomerulonephritis and Polyarteritis nodosa. The widespread use of hepatitis B vaccination has decreased the incidence of HBV-related renal diseases. The incidence of HBV infection in dialysis patients has significantly decreased over the past few decades because of screening of blood products for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody, implementation of infection control measures and hepatitis B vaccination. The definition of acute kidney injury has been recently modified in cirrhotic population, helping in prognosis and prediction of mortality. The most common etiologies of acute kidney injury in this cirrhotic population, which account for 80% to 90% of all cases, include volume depletion, acute tubular necrosis and hepatorenal syndrome. Treatment with oral nucleoside/tide analogues (NA) brought a new paradigm in the management of HBsAg positive glomerulonephritis, kidney transplant recipients and dialysis patients, resulting in effective viral suppression, reduced hepatic complications and improved patient survival, without compromising renal allograft outcome. NAs are cleared by the kidneys and therefore their dosage has to be adjusted in all patients with impaired renal function. This article reviews the recent knowledge of the pathogenesis and treatment of HBV-related glomerulonephritis and discusses the management of hepatitis B in patients on dialysis, kidney transplant recipients and cirrhotics, which is continuously evolving.

HBV-related liver disease in renal insufficiency: successful antiviral therapy with entecavir

Hepatitis B virus (HBV) infection persists among patients with renal insufficiency in the industrialized world. A variety of therapeutic options are now available for the treatment of chronic hepatitis B infection, including potent new nucleos(t)ide analogs, along with standard and pegylated interferon. We report on a patient with aggressive hepatitis B and renal insufficiency who was successfully treated with nucleoside analogs (mostly entecavir monotherapy) for two years. He received intense immunosuppression for severe myopathy of lower limbs, probably related to vasculitis. HBV DNA (at the beginning, > 1 x 10(8) IU/mL) was no longer detectable in serum after a few months of antiviral therapy, while HBeAg and HBsAg seroconversion occurred with ALT normalization. Clinical signs of vasculitis disappeared. Five months after discontinuation of entecavir therapy, he remained HBsAg negative with detectable anti-HBs antibody in serum. We conclude that nucleos(t)ide analogs can offer excellent response in selected patients with renal insufficiency and hepatitis B-related liver disease. Prospective, controlled clinical trials are needed to confirm these encouraging results.

Hepatitis B virus infection and related factors in hemodialysis patients in China - systematic review and meta-analysis

AIMS

To provide a comprehensive and reliable tabulation of available data on the epidemiological characteristics and risk factors for hepatitis B virus (HBV) infection in maintenance hemodialysis (HD) patients in China and help to inform prevention programs and guide future research.

METHODS

A systematic review was constructed based on the computerized literature database. Confidence intervals (95% CI) of infection rates were calculated using the approximate normal distribution model. Odds ratios (OR) and 95% CI were calculated by fixed or random effects models. Hepatitis B surface antigen positivity (HBsAg (+)) was set as the sign of HBV infection.

RESULTS

Fifty studies met our inclusion criteria. The pooled prevalence of HBV infection among HD patients in China was 11.9%. Blood transfusion was correlated with an increase in HBV infection (p = 0.05). HD patients with a long-term history were more likely to be infected than those with a short-term history. The levels of alanine aminotransferase were higher in the HBsAg (+) patients (p < 0.001). Large doses of HBV vaccine (80 μg/dose) increased the seroconversion rate. The response rate of intradermal injection of HBV vaccine was higher than that of intramuscular injection.

CONCLUSION

Hepatitis B is still one of the main complications in HD patients in China, and the frequency of blood transfusion and duration of HD were the risk factors. Large doses and intradermal injection of HBV vaccine were recommended to prevent HBV infection in HD patients. The findings of this meta-analysis have implications for optimal prevention and treatment of Hepatitis B in HD patients.

Therapy with nucleos(t)ide analogues: current role in dialysis patients

Hepatitis B virus (HBV) infection persists among patients undergoing maintenance dialysis in the industrialized world. Knowledge of the epidemiology and the natural history of HBV infection in dialysis patients has markedly improved but antiviral therapy for hepatitis B remains a significant challenge in this population. A variety of therapeutic options are now available for the treatment of chronic hepatitis B, including potent new nucleos(t)ide analogues, along with standard and pegylated interferon. The most extensive experience in the dialysis population has been with lamivudine. Although several questions about lamivudine use in dialysis patients remain unanswered, it has shown potent antiviral activity: the range of clearance of HBV viremia (HBV DNA) from serum is between 56% and 100% in dialysis patients with chronic hepatitis B. Its major limitation is emergence of resistance. Tolerance to conventional or pegylated interferon monotherapy is poor in the dialysis population. There is limited data regarding adefovir dipivoxil (ADV) therapy in the dialysis population, while very little information is available about the use of the newer agents, tenofovir and entecavir, in patients with renal failure. It is recommended that dialysis patients with persistent HBsAg seropositive status be evaluated for antiviral treatment and that the decision to treat be based on the potential benefits and risks of therapy including life expectancy, candidacy for kidney transplantation, and comorbidities. Hepatitis B is relatively uncommon among patients undergoing dialysis in developed countries and this clearly hampers prospective clinical trials aimed to evaluate the efficacy and safety of therapy with nucleos(t)ide analogues for chronic hepatitis B in this population.

The management of viral hepatitis in CKD patients: an unresolved problem

Chronic kidney disease (CKD) patients in dialysis (HD) show peculiar, atypical features of clinical presentation and diseases (cardiovascular, metabolic, hematologic). This is also true for viral hepatitis infections, for which CKD patients represent an important risk group. In the past, hepatitis B virus (HBV) was the major cause of viral hepatitis in end-stage renal disease (ESRD). However, the introduction of a rigorous infection-control strategy, routine screening of patients and staff for hepatitis B serologic markers, vaccination of susceptible patients and staff, use of separate rooms and dedicated machines for HD of HbsAg-positive patients have all led to a decline in the spread of HBV infection in dialysis. Despite the prevalence of the antibody-hepatitis C virus (HCV), there has been a marked decrease in HD patients; after the introduction of routine screening for HCV and the use of erythropoietin, its occurrence ranges from 5% to 25% in the United States, with a prevalence of 6.8% in Europe. In CKD and in HD patients, the presence of HBV and HCV is an independent and significant risk factor for death and this risk may be at least partially attributed to chronic liver disease with its attendant complications. Liver disease can progress with modest hepatic inflammation and prominent fibrosis; the natural history of viral hepatitis in these patients is dependent on the immune dysfunction typical of kidney disease. Despite recent advances in antiviral therapy, there are still many uncertainties in regards to the efficacy and long-term outcomes of treatment with antiviral agents.

Hepatitis B virus infection and the dialysis patient

Prevention of nosocomial transmission of hepatitis B virus (HBV) has been a signal achievement in the management of chronic kidney disease. The rate of serum hepatitis B surface antigen (HBsAg) seropositivity in patients on maintenance hemodialysis in the developed world is currently low (0-10%) but outbreaks of acute HBV infection continue to occur in this setting. The prevalence of HBV infection within dialysis units in developing countries appears higher (2-20%) based on relatively few reports. Although data are limited, HBV infection in dialysis population diminishes survival; HBV viral load in HBsAg-positive dialysis patients is reportedly low and stable over time. Updated recommendations for the management of HBsAg chronic carriers on maintenance dialysis have been issued. No rigorously controlled treatment trials for treatment of hepatitis B with either interferon or lamivudine therapy in dialysis patients are currently available.

Hepatitis B viral infection in maintenance hemodialysis patients: a three year follow-up

AIM

To observe the prevalence of hepatitis B virus (HBV) infection in maintenance hemodialysis patients.

METHODS

Eighty-eight hemodialysis patients who had been receiving hemodialysis regularly for an average of 39.45 +/- 7.57 (range from 36 to 49) mo were enrolled in this study. HBV markers were measured in these patients before hemodialysis and in 100 healthy controls by the chemiluminescent microparticle immunoassay (CMI) method in order to compare the incidence of HBV infection in hemodialysis patients versus normal healthy people. All patients were then divided into two groups: patients positive for HBV markers (i.e. those positive for HBsAg, anti-HBc, HBeAg, anti-HBe, with or without positive anti-HBs) (n = 33), and patients negative for HBV markers (including those only positive anti-HBs) (n = 55). The following information was obtained for all patients: socio-demographic data, number of blood transfusions and some laboratory investigations. After 39.45 +/- 7.57 mo follow-up, HBV markers were measured in these patients by CMI.

RESULTS

The incidence of HBV infection in maintenance hemodialysis patients was 37.5%, which was higher than in controls (9%). In the patients positive for HBV markers, there were 13 patients (39.4%) who had a history of blood transfusion, which was more than the number [12 (21.8%), P = 0.04] of patients negative for HBV markers. Eight of the 88 patients negative for HBV markers turned out to be positive, while three of the 33 patients positive for HBV markers turned out to be negative. There was no cirrhosis of the liver or hepatoma occurring in these patients.

CONCLUSION

Maintenance hemodialysis patients have a higher risk of HBV infection than the average population. The number of blood transfusions is associated with an increased prevalence of HBV. While it is hard for hemodialysis patients to eliminate HBV, the prognosis of patients with positive HBV markers is good.

Efficacy and tolerability of pegylated-interferon alpha-2a in hemodialysis patients with chronic hepatitis C

BACKGROUND AND AIM

Hepatitis C virus (HCV) is prevalent in hemodialysis (HD) patients. These patients experience more side-effects with antiviral treatment. The aim of the present study was to evaluate the efficacy and tolerability of pegylated interferon (PEG-IFN) alpha-2a in chronic hemodialysis patients with chronic hepatitis C.

METHODS

Twenty-five patients were included into the study. All of the patients were interferon naive, anti-HCV antibodies positive and polymerase chain reaction HCV-RNA positive. Twelve of the patients received PEG-IFN alpha-2a at a dose of 135 microg weekly for 48 weeks (Group 1). The remaining 13 patients who received no specific treatment were used as controls (Group 2). The patients were prospectively followed up for a period of 18 months. Biochemical and virological responses were evaluated at the end of the study period (end-of-treatment response) and 6 months after the completion of therapy (sustained response).

RESULTS

Virological end-of-treatment response was observed in 10 patients (83.4%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Sustained virological response was observed in nine patients (75%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Alanine aminotransferase (ALT) levels were initially increased in seven patients in Group 1 and normalized in five of these patients at the end of the treatment and sustained biochemical response was 71.4%. In contrast, ALT levels in Group 2 were initially high in five patients and normalized in two of them (40%) at the end of the 48 weeks. Even if most of the patients experienced several side-effects (anemia 75%, fatigue 58.3%, thrombocytopenia 33.3% and leukopenia 33.3%), they did not impose the discontinuation of the treatment.

CONCLUSION

The present study showed that PEG-IFN alpha-2a for 48 weeks is efficacious and well tolerated in hemodialysis patients with HCV.

Treatment of chronic hepatitis C in patients with end-stage renal disease and hemophilia--the Singapore experience

OBJECTIVE

The aim of this study was to determine the response to treatment with interferon-alpha (IFN-alpha) in patients with chronic hepatitis C who had end-stage renal disease (ESRD) or hemophilia in Singapore.

METHODS

Treatment-naive hepatitis patients with ESRD or hemophilia were given IFN-alpha(2a) 3 million units three times per week for 12 months in an open-label study. Hepatitis C virus RNA was determined before treatment, at the end of treatment and 6 months thereafter. Regular clinical examinations including blood counts and biochemistry were carried out during and after the treatment.

RESULTS

Nine consecutive patients with ESRD (8 men and 1 woman) and 6 consecutive male patients with hemophilia, with a mean age of 43 and 40 years, received treatment. Patients in both groups were predominantly infected with hepatitis C virus genotype 1 and had significant cytopenia affecting all three cell lines during the treatment; only 1 patient developed serious neutropenia, temporarily demanding a reduction of his IFN dose. Biochemical and virological responses at the end of treatment were accomplished by 8 of the 9 (89%) patients with ESRD and 4 of the 6 (67%) patients with hemophilia; however, 1 patient with ESRD and 2 with hemophilia relapsed after the treatment. Four of the 7 patients with ESRD who had sustained virological response underwent successful kidney transplantation later on.

CONCLUSION

Monotherapy with IFN-alpha for 12 months is safe for treatment of the patients with chronic hepatitis C who had ESRD or those with hemophilia. A higher sustained virological response rate was observed in patients with ESRD than in those with hemophilia (78 vs. 33%).

Hepatitis B virus infection in dialysis patients

Hepatitis B virus (HBV) infection remains a major issue among dialysis patients. It is associated with a high risk of hepatic complication. The liver disease runs a unique clinical course in dialysis patients, as it can progress with modest hepatic inflammation and prominent fibrosis. The conventional cut-off level of serum alanine aminotransferase (ALT) for commencing antiviral therapy may prove too high and inappropriate for dialysis patients, and liver biopsy appears to be the only definitive means to establish the activity of liver disease in dialysis patients. Liver biopsy should be considered in patients with a serum ALT level that is persistently greater than 30 IU/L, or 0.75-fold the upper limit of the normal level, and/or other clinical and laboratory findings that suggest active liver disease. For antiviral treatment, preliminary reports have shown that lamivudine is effective and well tolerated in dialysis patients. However, the long-term efficacy of lamivudine and its optimal effective dose in dialysis patients remain unknown. The prevention of nosocomial transmission among dialysis patients is also important. Universal precaution measures should be strictly observed and the segregation of hepatitis B surface antigen-positive hemodialysis patients should be considered. For HBV non-immune patients, the importance of HBV vaccination should not be overemphasized. Until a new generation of highly immunogenic vaccines that are proven to be safe and effective in patients with end-stage renal disease becomes available, early vaccination before the development of end-stage renal failure remains the best way to secure immunological protection against HBV infection in dialysis patients.

Treatment of hepatitis C in potential kidney and heart transplant patients

Hepatitis C virus (HCV) is common in certain solid organ transplant recipients, most notably in those undergoing liver or kidney transplantation. Infection typically antedates transplantation but may have been acquired at the time of transplantation via infected blood products or organs. A more rapid and aggressive course of HCV-related infection and liver disease is the major concern in organ transplant recipients compared with immunocompetent patients. HCV-related liver disease is an important cause of morbidity and mortality in patients with end-stage renal disease treated by dialysis or transplantation. The outcome of HCV infection in renal and liver transplant recipients has been extensively investigated, whereas literature on HCV-related liver disease among patients with orthotopic heart transplantation is scanty. This article reviews the literature concerning the treatment of HCV-related liver disease in renal and orthotopic heart transplantation.

Treatment of chronic viral hepatitis in patients with renal disease

In the last several years, numerous studies on the natural history and outcomes of viral hepatitis in dialysis and transplantation have been reported. Despite these, the management of hepatitis C virus or hepatitis B virus-related liver disease in end-stage renal disease continues to be an area of controversy. This article aims to address the current therapeutic options for patients with renal disease and chronic viral hepatitis.

Meta-analysis: interferon for the treatment of chronic hepatitis C in dialysis patients

BACKGROUND

The efficacy of interferon monotherapy in dialysis patients with chronic hepatitis C remains unclear, although a number of small clinical trials have been published addressing this issue.

METHODS AND AIMS

We evaluated the efficacy and safety of initial interferon monotherapy in dialysis patients with chronic hepatitis C by performing a systematic review of the literature with a meta-analysis of clinical trials. The primary outcome was sustained virological response (as a measure of efficacy); the secondary outcome was drop-out rate (as a measure of tolerability). We used the random effects model of Der Simonian and Laird, with heterogeneity and sensitivity analyses.

RESULTS

We have identified 14 clinical trials (269 unique patients); two were controlled studies. The mean overall estimate for sustained virological response (SVR) and drop-out rate was 37%[95% confidence interval (CI) 28-48] and 17% (95% CI 10-28), respectively. The most frequent side-effects requiring interruption of treatment were flu-like symptoms (17%), neurological (21%) and gastrointestinal (18%). The overall weighted estimate for SVR in patients with hepatitis C virus genotype 1 was 30.6% (95% CI 20.9-48). In the sub-group of clinical trials (n = 5) with standard interferon administration (3 million units [MUI] thrice weekly, subcutaneous route, 24-week treatment), the overall mean estimate of SVR was 39% (95% CI 25-56). The studies were heterogeneous with regard to SVR and drop-out rate.

CONCLUSIONS

Tolerance to initial interferon monotherapy was lower in dialysis than nonuremic patients with chronic hepatitis C. However, more than one-third of haemodialysis patients with chronic hepatitis C have been successfully treated with interferon. Longer duration of interferon monotherapy does not appear to have a beneficial effect on the response rate. Further studies are warranted to define the optimal anti-viral regimen for chronic hepatitis C in dialysis population.

Excellent outcome of Lamivudine treatment in patients with chronic renal failure and hepatitis B virus infection

Chronic hepatitis B virus (HBV) is associated with increased morbidity and mortality in patients with chronic renal failure (CRF) and renal transplant recipients. Lamivudine (3TC) has been shown to be a potent inhibitor of HBV replication. It appears to be safe and effective in patients with CRF, though experience is still limited. We describe 4 patients with CRF on hemodialysis who showed a rapid and full response to 3TC, administered for a median of 10 months. All patients had serum alanine transferase (ALT) levels 3 to 6 times the upper limit of normal prior to treatment, and different degrees of histologic inflammatory activity (Knodell score 4 to 8, median 6). All were serum HBsAg- and HBeAg-positive, with serum HBV DNA 1-3.9 x 107 copies/mL (median 1 x 107 copies/mL). Within 4 to 8 weeks of initiation of therapy, HBV DNA became undetectable and serum ALT normalized. Serum HBeAg disappeared in all 4 patients, with the emergence of anti-HBeAb in 3 of them. Three patients also lost HBsAg with the evolution of a protective anti-HBsAb titer. One patient has already undergone successful kidney transplantation with no evidence of HBV recurrence (serum HBV DNA negative) 16 months postoperatively. Although our study sample is small, these data suggest that 3TC can induce a complete biochemical, virological and serological response in patients with CRF and HBV infection. Its use may enable safe kidney transplantation in selected patients.

Interferon monotherapy for dialysis patients with chronic hepatitis C: an analysis of the literature on efficacy and safety

OBJECTIVE

Hepatitis C virus (HCV) is prevalent in patients with end stage renal disease who are on dialysis. Liver disease from HCV is a cause of substantial morbidity and mortality after kidney transplantation in infected recipients. Effective treatment of chronic HCV is needed in this group of patients. We aimed to determine from the literature the efficacy and safety of interferon monotherapy in dialysis patients with chronic HCV.

METHODS

We reviewed the literature from 1986 to 2001 on the efficacy of interferon monotherapy in patients with HCV and end stage renal disease who were on dialysis. The outcomes measured were sustained viral response (SVR) and drop-out rate.

RESULTS

We reviewed 17 studies, of which 11 studies with a total of 213 patients met criteria for our analysis. Eight studies evaluated 3 million units (MU) three times/wk (t.i.w.), and three studies evaluated higher doses. The pooled SVR for 3 MU was 33% (95% CI = 21-51%). The pooled SVR for genotype 1 patients was 26% (95% CI = 15-37%). Of 152 patients in eight studies treated with 3 MU t.i.w. of interferon monotherapy, 45 patients (29.6%) discontinued therapy because of side effects.

CONCLUSIONS

Our analysis suggests that interferon monotherapy is more effective in patients on dialysis than in patients with normal renal function. Interferon monotherapy is associated with more adverse events in dialysis patients. The optimal dose and duration of interferon monotherapy and selection criteria of dialysis patients need to be studied further in clinical trials.

Hepatitis C therapy with long term remission after renal transplantation

Hepatitis C virus infection (HCV) is common in patients with end-stage renal disease (ESRD) and long observation periods have shown the detrimental effect of HCV infection on patient and graft survival after renal transplantation. At present, interferon is the most important agent for the treatment of hepatitis C in ESRD; however, limited information exists concerning the long-term response of patients who undergo renal transplantation after successful antiviral therapy. We describe the evolution of HCV infection in a dialysis patient with hepatitis C who was successfully treated with interferon alpha and then underwent renal transplantation. He received aggressive immunosuppression during the induction phase and for allograft rejection; however, regular screening showed complete absence of biochemical and virological relapse of HCV over a 6-year post-transplantation period. We conclude that interferon can offer excellent response in selected dialysis patients with hepatitis C. Alternative strategies with newer antiviral agents are currently under active investigation.

Management of chronic viral hepatitis before and after renal transplantation

Hepatitis C virus (HCV) infection is present in 2-50% of renal transplant recipients and patients receiving hemodialysis. Renal transplantation confers an overall survival benefit in HCV positive (HCV+) hemodialysis patients, with similar 5-year patient and graft survival to those without HCV infection. However, longer-term studies have reported increased liver-related mortality in HCV-infected recipients. Unfortunately, attempts to eradicate HCV infection before transplant have been disappointing. Interferon is poorly tolerated in-patients with end-stage renal disease and ribavirin is contraindicated because reduced renal clearance results in severe hemolysis. Antiviral therapy following renal transplantation is also poorly tolerated, because of interferon-induced rejection and graft loss. Although the prevalence of hepatitis B virus (HBV) infection has declined in hemodialysis patients and renal transplant recipients since the introduction of routine vaccination and other infection control measures, it remains high within countries with endemic HBV infection (especially Asia-Pacific and Africa). Renal transplantation is associated with reduced survival in HBsAg+ hemodialysis patients. Unlike interferon, lamivudine is a safe and effective antiviral HBV treatment both before and after renal transplantation. Lamivudine therapy commenced at transplantation should prevent early posttransplant reactivation and subsequent progression to cirrhosis and late liver failure. This preemptive therapy should also eradicate early liver failure from fibrosing cholestatic hepatitis. Because cessation of treatment may lead to severe lamivudine-withdrawal hepatitis, most patients require long-term therapy. The development of lamivudine-resistance will be accelerated by immunosuppression and may result in severe hepatitis flares with decompensation. Regular monitoring with liver function tests and HBV DNA measurements should enable early detection and rescue with adefovir. Chronic HCV and HBV infections are important causes of morbidity and mortality in renal transplant recipients. The best predictor for liver mortality is advanced liver disease at the time of transplant, and liver biopsy should be considered in all potential HBsAg+ or HCV+ renal transplant candidates without clinical or radiologic evidence of cirrhosis. Established cirrhosis with active viral infection should be considered a relative contraindication to isolated renal transplantation.

Hepatitis infection in haemodialysis patients

SUMMARY: Known hepatitis infections among haemodialysis patients include hepatitis B, hepatitis C, hepatitis G and TT virus. Haemodialysis patients with hepatitis B and/or hepatitis C infection may progress to develop significant morbidity, such as cirrhosis, hepatitic failure or hepatocellular carcinoma. Hepatitis B infection may be treated with α‐interferon or lamivudine. Hepatitis C infection may be treated with α‐interferon, but frequent severe adverse effects were observed, while ribavirin is contraindicated for patients with renal failure. Treatment for hepatitis B and/or hepatitis C are costly, and the risk of post‐transplant reactivation of hepatitis has been reported. Prevention of nosocomial transmission of hepatitis infection with strict infection control and universal precautions is more important. Accumulating evidence suggests that both hepatitis G virus and TT virus (TTV) are not significant causes of liver disease. Routine screening for hepatitis G or TTV viraemia in haemodialysis patients is not indicated at present.

Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation

Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.

Interferon therapy in haemodialysis patients with acute hepatitis C virus infection and factors that predict response to treatment

In view of the high rate of chronicity of acute hepatitis C and the low efficacy of interferon (IFN) treatment in advanced liver disease, it may be beneficial to treat patients during the acute phase of the infection. Here we assessed the effects of variable-dose IFNalpha-2b treatment in haemodialysis patients with acute hepatitis C virus (HCV) infection, and identified factors that may predict response to this therapy. The study population included 67 patients, but 14 were excluded due to side-effects or because they were lost to follow-up. Seventeen patients who received no specific treatment were used as controls (Group 1). Sixteen and 20 patients received low-(3 MU) and high-dose (6-10 MU) IFNalpha-2b three times weekly for 3 months (Groups 2 and 3, respectively). Virological end-of-treatment response (ETR) was observed in 1 (5.6%), 13 (56.5%), and 17 (65.4%) patients in Groups 1, 2, and 3, respectively, and virological sustained response (SR) was observed in 1 (5.6%), 6 (26.1%), and 13 (50%) patients in the three groups. The rates of virological ETR and SR in the treated groups were significantly higher than those of the control group (P < 0.01 for all comparisons). In multivariate logistic regression analysis, single stranded confirmational polymorphysm (SSCP) band number (P=0.02) was the only factor that was significantly associated with virological SR. In conclusion, IFN-alpha treatment initiated during the acute phase of HCV infection is associated with a higher rate of virological ETR and SR. This study suggested that quasispecies heterogeneity has predictive value with regard to virological SR.

An open-label study of lamivudine for chronic hepatitis B in six patients with chronic renal failure before and after kidney transplantation

OBJECTIVE

The course of hepatitis B virus (HBV) infection after kidney transplantation is aggressive, with a high mortality rate from liver disease mainly in patients who were serum hepatitis B e antigen (HBeAg) or HBV DNA-positive before transplantation. Lamivudine has been shown to be a potent inhibitor of HBV replication. The aim of the study was to examine the efficacy and safety of lamivudine therapy in patients with chronic renal failure and chronic HBV infection.

METHODS

The study population consisted of six potential candidates for kidney or combined kidney and liver transplantation aged 25-49 yr (four patients had already undergone a kidney transplantation and developed chronic rejection). All were serum HBeAg and/or HBV DNA-positive and had been maintained on hemodialysis for 3 months to 3 yr. The duration of HBV infection was 7 months to 14 yr. Serum alanine aminotransferase (ALT) levels ranged from 72 to 610 U/L (median, 158 U/L). Liver histological evaluation showed mild to moderate chronic hepatitis (n = 4) or liver cirrhosis (n = 2). None of the patients was infected with hepatitis C or D viruses. In four patients, treatment consisted of 10 mg of oral lamivudine per day. In the other two patients, a virological and biochemical response could be achieved only when the dose was increased to 40 mg/day.

RESULTS

Lamivudine treatment was associated with 1) normalization of serum ALT levels and rapid disappearance of serum HBV DNA (by hybridization) (five patients, one of whom died from sepsis); 2) seroconversion: disappearance of HBeAg (three patients) and HBsAg (two patients); 3) minor side effects: abdominal pain and nausea (one patient); 4) clinically asymptomatic lamivudine resistance 8 months after treatment (one patient); and 5) successful combined kidney and liver transplantation with no evidence of recurrent HBV infection at 6-8 months postoperatively (two patients with cirrhosis).

CONCLUSIONS

Lamivudine therapy is effective as an HBV replication inhibitor in patients with chronic renal failure and HBV infection. Prospective studies of lamivudine pharmacokinetics and dosing in renal failure are needed to be able to treat patients appropriately. Although our study is small and further follow-up is needed, our data suggest that lamivudine therapy may enable selected patients with chronic hepatitis B to undergo kidney or combined kidney and liver transplantation in patients with established cirrhosis.

Hepatitis C: retreatment and treatment of patients with renal failure

This paper addresses two difficult issues in the treatment of hepatitis C: patients who fail to achieve a sustained response after the first course of treatment, and those who simultaneously suffer from chronic renal failure. With the recent improvements in firstline treatment, retreatment is mainly applicable to those who have previously received 6-month of interferon monotherapy at 3 MU thrice weekly. For those who had an end-of-treatment response but relapsed, there is a choice between interferon monotherapy at increased dose and/or duration of treatment, or a 6-month course of combination therapy. Retreatment of non-responders is generally unsuccessful, but some patients may respond to interferon-alpha 3 MU and ribavirin 1.0-1.2 g/day. For patients with chronic renal failure and hepatitis C, combination treatment is not possible because ribavirin is contraindicated. Interferon given at a dose of 1.5 MU thrice weekly was reported to be fairly well tolerated by patients who were on dialysis and resulted in end-of-treatment and sustained biochemical and virological response in some cases. Interferon given in the usual doses may be associated with severe adverse effects in patients with renal failure, and can precipitate allograft rejection in patients who have undergone renal transplantation.

Efficacy and tolerance of interferon-alpha(2b) in the treatment of chronic hepatitis C virus infection in haemodialysis patients. Pre- and post-renal transplantation assessment

BACKGROUND

Hepatitis C virus (HCV) infection represents an important problem for the dialysis population due to its high prevalence and the long-term development of chronic liver disease, particularly following renal transplantation.

METHODS

In order to assess the efficacy and tolerance of interferon (IFN) in the treatment of chronic hepatitis C in haemodialysis (HD) patients and their clinical course following renal transplantation, a multicentre, randomized, open-label study was conducted to compare IFN therapy vs a control group.

RESULTS

Nineteen HCV RNA-positive patients received 3 x 10(6) U of IFN s.c., three times a week (post-HD), and 17 HCV RNA-positive patients were assigned to the control group. Tolerance to IFN therapy was good in nine patients, while treatment was discontinued in the other 10 due to the occurrence of side effects. HCV RNA was negative at the end of treatment in 14 out of 19 patients (74%) receiving IFN and in one patient (5%) in the control group. Six out of the 14 patients who initially responded to IFN therapy had a virological relapse (43%). Eight patients (42%) remained HCV RNA-negative, three of them until the day that renal transplantation (RT) was performed (7, 12 and 27 months, respectively), as did five patients on HD during the follow-up (27+/-5 months). Eight out of the nine patients (89%) who completed therapy were HCV RNA-negative at the end of treatment, and seven of them (78%) remained HCV RNA-negative during the follow-up on dialysis (21+/-8 months). Mean transaminase (ALT) values were significantly decreased following IFN therapy, while no changes were observed during the follow-up period in the control group. Fifteen patients (10 in the treatment group and five in the control group) underwent RT. Three patients in the treatment group were HCV RNA-negative at RT, and one of them had a virological relapse 20 months after RT, while the other two remained HCV RNA-negative at 3 months and 24 months after RT, respectively. In contrast to the control group, transaminase (ALT) remained within normal limits in all patients in the treatment group. Finally, during the post-RT follow-up, the transaminase mean values were significantly lower in treated patients vs patients in the control group (P<0.05).

CONCLUSIONS

It is concluded that the biochemical and virological response to IFN therapy is good in HD patients. In addition, IFN therapy appears to exert a beneficial effect on the course of liver disease following RT, regardless of the virological response. Despite the fact that IFN therapy was discontinued in 10 out of the 19 patients due to the occurrence of side effects, these disappeared following discontinuation of therapy. Therefore, IFN therapy is advisable for HCV-infected dialysis patients who are candidates for RT.

Interferon-alpha in chronic hepatitis C infection in dialysis patients

This study assesses the efficacy and adverse effects of interferon-alpha (IFN-alpha) administered at a dosage of 3 million units three times weekly for 1 year in 17 hemodialysis patients with hepatitic C virus (HCV)-associated chronic hepatitis (biopsy proven). The patients were prospectively followed up for a period of 18 months. Liver biopsy was repeated after 6 months of treatment in 13 patients. Patients were classified according to the histological activity index. Biochemical and virological responses were evaluated at the end (end-of-treatment response) and 6 months after completion of therapy (sustained response). HCV RNA became negative in 76% of the patients after 12 weeks of treatment, in 88% after 12 months of treatment, and in 71% of the patients 6 months after completion of therapy. HCV genotype 4 was found in 60% of our population. Alanine aminotransferase (ALT) levels were initially increased in only 6 patients and normalized in 4 of these patients after 12 weeks of therapy, with end-of-treatment and sustained biochemical responses of 83% and 67%, respectively. Of 13 patients who underwent liver biopsies after 6 months of therapy, 11 patients (85%) showed histological improvement. One patient could not tolerate therapy because of marked lethargy and myalgia; the other patients had minor side effects that did not require discontinuation of treatment. Two patients received a cadaveric renal transplant after 1 year of IFN treatment, and they continued to maintain biochemical and virological responses after a follow-up of 17 and 28 months, respectively.

Treatment of hepatitis C infection in patients with renal disease

Hepatitis C virus infects 20-40% of the end-stage renal disease population, and has been associated with essential mixed cryoglobulinemia and several forms of immune-complex glomerulonephritis. Overall, treatment with interferon alpha has been disappointing, although certain situations may benefit from dosing regimens that differ in the amount of drug and duration of treatment from the conventional interferon doses currently recommended for non-renal patients.

Histopathological impacts of hepatitis virus infection in hemodialysis patients: should liver biopsy be performed before renal transplantation?

To evaluate the histologic changes in the livers of renal transplant candidates who were infected with hepatitis viruses, we performed a percutaneous liver biopsy in each of 74 regular hemodialysis patients. Forty percent of them were seropositive for the antibody to hepatitis C virus (anti-HCV) whereas 29.7% had anti-HCV and antibody to hepatitis B surface antigen (anti-HBs) concomitantly. Seven (9.5%) were seropositive for only hepatitis B surface antigen HBsAg. Histopathological examination revealed that 30% of patients had chronic active hepatitis (CAH), 11% had chronic persistent hepatitis (CPH), and 3% displayed histopathological evidence of cirrhosis. Eleven of 22 patients with CAH were positive for only anti-HCV, and 2 of 22 were positive for only HBsAg. One patient had HBsAg and anti-HCV together, and 8 of 22 had anti-HBs and anti-HCV concomitantly. None of the anti-HBs positive patients exhibited abnormal histopathological changes. We found no statistically significant difference in histopathological findings between the HBsAg positive and anti-HCV positive patients. As 32 of 74 patients (43%) had some degree of chronic liver disease, we concluded that it is prudent to evaluate liver histology in HBsAg and anti-HCV seropositive renal transplant candidates before transplantation.

Transplantation of kidneys donated from the USA: long-term results and viability testing using 31P-MRS

Since June 1983, 27 kidneys have been shipped to the Kidney Center at the Tokyo Women's Medical College (TWMC) from the United States. These organs were divided into two groups, based on the years of their donation; 13 kidneys were assigned to group 1 and 14 to group 2. The differences between the two groups were as follows: donor age 19.8 +/- 10.0 years vs 51.9 +/- 14.5 years in group 2 (P < 0.0001); total ischemic time 42 h 12 min in group 1 vs. 65 h 42 min in group 2 (P = 0.0002); and Euro-Collins preservation solution in group 1 vs University of Wisconsin (UW) solution in group 2. One hundred percent of the kidneys in group 1 and 85.7% of those in group 2 recovered their function. The lowest serum creatinine levels averaged 96 +/- 38.4 mumol/l and 185.8 +/- 101.0 mumol/l, respectively (P = 0.01). The viability of 9 out of 14 grafts in group 2 were tested using 31P magnetic resonance spectroscopy (31P-MRS). The results showed that all of the grafts having a monophosphate/inorganic phosphate (MP/Pi) ratio higher than 0.3 recovered their function and those lower than 0.2 did not. The problems associated with international organ sharing are discussed, along with the difficulties encountered at TWMC.