Risk of death among chronic dialysis patients infected with hepatitis C virus

Prevalence of Hepatitis C Infection and its Genotypes in Suspected Hemodialysis Patients, Southwest of Iran

Background: Hemodialysis patients are more prone to Hepatitis C Virus (HCV) infection due to the need for long-term hemodialysis and blood transfusions. Objectives: The present study aimed to determine the HCV infection burden, viral load, and genotype pattern in hemodialysis patients referred to a research center from 2011 to 2018. Methods: Among 131 hemodialysis patients with suspected HCV infection, referred to Prof. Alborzi Clinical Microbiology Research Center, Shiraz, Iran, from 2011 to 2018, the HCV rate was assessed with the enzyme-linked immunosorbent assay and the HCV RNA load and genotypes by one-step TaqMan real-time PCR. Results: The prevalence of HCV-Ab positivity was 29% among hemodialysis patients, of whom 21 (57%) were HCV RNA-positive. In the rest of the hemodialysis patients who were HCV-Ab-negative, the HCV RNA was detected in five (12%) patients. Genotype 3 (Gt-3) was the most prevalent one detected in 50% of the patients whose genotypes were determined. Also, the HCV viral load in HCV-seropositive patients was generally higher than that in HCV-seronegative ones. Conclusions: This study showed that high HCV infection and different genotype patterns among hemodialysis patients compared to the general population are the main predictors of HCV infection, which indicates healthcare facility transmission because of inappropriate infection management practices.

The prevalence and associated factors of hepatitis B and C virus in hemodialysis patients in Africa: A systematic review and meta-analysis

BACKGROUND

Due to its invasive procedure patients on hemodialysis (HD) are at high risk of infections. Infections acquired in dialysis units can prolong hospitalization date and/or prolong illness in patients, and increase treatment cost. There are no adequate data on the prevalence of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections in HD patients. Therefore, this study aimed to estimate the pooled prevalence and associated factors of HBV and HCV infections among HD patients in Africa.

METHOD

The databases PubMed, Medline, EMBASE, Cochrane library, web of science, African Journals Online, Science Direct, and Google Scholar were searched to identify relevant studies. The review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted independently by two authors and analyzed using STATA 11. A random-effect model was fitted to estimate the pooled prevalence with their 95% confidence interval. To detect publication bias funnel plots analysis and Egger weighted regression tests were done.

RESULTS

The overall pooled prevalence of HBV and HCV infection among HD patients in Africa was 9.88% (95% CI: 7.20-12.56) I2 = 97.9% and 23.04% (95% CI: 18.51-2757) I2 = 99.6%, respectively. In addition, the pooled prevalence of HBV and HCV co-infection was 7.18% (95% CI: 3.15-11.20) I2 = 99.6%. Duration of dialysis was found to be the contributing factor for the occurrence of HBV and HCV among HD patients (OR = 1.44; 95% CI: 1.04, 2.01).

CONCLUSION

This study showed that there is high prevalence of HBV and HCV infections in HD patients in Africa. Therefore, strict adherence to precautions of infection control measures, isolation of seropositive patients, improvement in infrastructures, adequate screening of HBV and HCV for the donated blood, and decentralized HD services is needed to minimize the risk of HBV and HCV infections in HD facilities.

Eradication of hepatitis C virus infection in kidney transplant recipients using direct-acting antiviral therapy: Qatar experience

Introduction

Hepatitis C virus (HCV) infection has detrimental effects on patient and graft survival after kidney transplantation. In the pre‐direct‐acting antiviral (DAA) era, treatment of HCV infection was associated with low response rates, poor tolerance, and increased risk of allograft rejection. However, DAAs have revolutionized HCV treatment. The aims of this study were to determine the impact of DAA on the sustained virologic response (SVR), renal function, and calcineurin inhibitor (CNI) levels and assess the tolerability to treatment in kidney transplant recipients with HCV infection in Qatar.

Methods

This retrospective study included the medical records of all kidney transplant recipients with confirmed HCV infection before January 1, 2020. All data were obtained from the patients’ electronic medical records; these included patient demographics; virologic responses to treatment; serum creatinine levels during treatment; urine protein to creatinine ratios and CNI levels before, during, and after treatment; and side effects related to DAA therapy.

Results

A total of 27 kidney transplant recipients with HCV were identified, 23 of whom received DAA therapy. The length of treatment ranged from 12 to 24 weeks, and 52% of patients had HCV genotype 1 infection. The median log10 HCV RNA was 6.6 copies per milliliter. None of the patients had liver cirrhosis, and all of them achieved SVR. There was no statistically significant difference in the glomerular filtration rate before, during, and after treatment. Most patients had stable CNI trough levels during treatment and did not require dose adjustment.

Conclusions

HCV infection was successfully eradicated by DAA therapy in kidney transplant recipients, with a 100% SVR rate. Moreover, DAA therapy was well‐tolerated, and kidney function remained stable without an increased risk of rejection. These results are expected to drive the eradication of hepatitis C from the entire country.

The combination of sofosbuvir and daclatasvir is effective and safe in treating patients with hepatitis C and severe renal impairment

BACKGROUND AND AIM

Many of the treatment regimens available for hepatitis C include sofosbuvir. Unfortunately, sofosbuvir has not been recommended for use in patients with severe renal impairment leaving these group of patients with very few options. Nevertheless, there are many reports in which these patients have been treated with sofosbuvir-containing regiments without important adverse events. This study aims at determining the safety and effectiveness of a sofosbuvir-based treatment in patients with severe renal impairment, including those on hemodialysis.

METHOD

We enrolled subjects with hepatitis C and estimated glomerular filtration rate under ml/min/1.73m² from 13 centers in Iran. Patients were treated for 12 weeks with a single daily pill containing 400-mg sofosbuvir and 60-mg daclatasvir. Patients with cirrhosis were treated for 24 weeks. Response to treatment was evaluated 12 weeks after end of treatment (sustained viral response [SVR]). ClinicalTrials.gov identifier: NCT03063879.

RESULTS

A total of 103 patients were enrolled from 13 centers. Seventy-five patients were on hemodialysis. Thirty-nine had cirrhosis and eight were decompensated. Fifty-three were Genotype 1, and 27 Genotype 3. Twenty-seven patients had history of previous failed interferon-based treatment. Three patients died in which cause of death was not related to treatment. Six patients were lost to follow-up. The remaining 94 patients all achieved SVR. No adverse events leading to discontinuation of medicine was observed.

CONCLUSIONS

The combination of sofosbuvir and daclatasvir is an effective and safe treatment for patients infected with all genotypes of hepatitis C who have severe renal impairment, including patients on hemodialysis.

Mortality in Hepatitis C-Positive Patients Treated with Peritoneal Dialysis

Objective

The published mortality data for patients with hepatitis C virus (HCV) infection and being treated with peritoneal dialysis (PD) are not available. The aim of this study was to determine the mortality of HCV patients undergoing PD.

Methods

We retrospectively reviewed 538 PD patients in our hospital from 1996 to 2005. Of these patients, 75 (13.9%) were anti-HCV positive at the beginning of PD. We used Kaplan–Meier analysis to compare mortality between patients with and patients without HCV infection. The association between HCV infection and mortality was analyzed using multivariate Cox regression with adjustment for age, gender, residual renal function, and cardiovascular disease.

Results

A total of 157 patients (39 HCV positive, 118 HCV negative) died during the 10-year follow-up period. The mortality rate (52%, 39/75) of HCV-positive patients was significantly higher than that of HCV-negative patients (25.5%, 118/463; p < 0.001). Cardiovascular mortality was 57.6% (68/118) among HCV-negative patients and 56.4% (22/39) among HCV-positive patients. Kaplan–Meier estimate showed that patients with HCV infection had higher mortality than those without ( p < 0.001, log-rank). The result of Cox regression suggested that chronic HCV infection, independent of diabetes, was associated with 10-year mortality. The adjusted hazard ratios (HRs) of HCV infection and diabetes for mortality were 2.195 (95% CI: 1.486 – 3.243, p < 0.001) and 2.242 (95% CI: 1.533 – 3.277, p < 0.001).

Conclusion

Our results show that the HCV-positive PD patients had a higher 10-year mortality rate than the HCV-negative PD patients. The association between HCV infection and mortality was independent of diabetes. Cardiovascular mortality, infection, and arrhythmia were the leading causes of death among the PD patients with HCV infection.

Hepatitis C virus and mortality among patients on dialysis: A systematic review and meta-analysis

BACKGROUND AND RATIONALE

The role of hepatitis C virus (HCV) as an independent risk factor for death in dialysis population is unclear.

DESIGN

A systematic review of the published medical literature was performed to evaluate the impact of positive anti-HCV serologic status on all-cause and disease-specific mortality in patients on regular dialysis. The risk of all-cause, cardiovascular and liver disease-related mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies.

RESULTS

Twenty-three observational studies (n = 574,081 patients on long-term dialysis) were identified. Pooling of study results demonstrated that HCV positive status was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted death risk (all-cause mortality) with HCV was 1.26 (95% CI: 1.18; 1.34) (P < 0.0001). Between-study heterogeneity was found (Q value 52.8, P = 0.001). The overall estimate for adjusted death risk (liver disease-related mortality) was 5.05 (95% CI: 2.53; 10.0) (P < 0.0001); heterogeneity statistics, Q value 8.2, P = 0.04. The overall estimate for adjusted death risk (cardiovascular mortality) was 1.18 (95% CI: 1.085; 1.29) (P < 0.0001) (no heterogeneity). Meta-regression showed that the effect of HCV on all-cause mortality was more evident in those studies provided with a greater size (P = 0.0001), a higher prevalence of diabetics (P = 0.0005) and HCV-infected individuals (P = 0.001).

CONCLUSIONS

An association between HCV positive serologic status and increased risk of either liver or cardiovascular disease-related mortality exists among dialysis patients.

The efficacy and safety of glecaprevir plus pibrentasvir in 141 patients with severe renal impairment: a prospective, multicenter study

BACKGROUND

Patients with chronic hepatitis C are often complicated by chronic kidney disease (CKD).

AIM

To evaluate the efficacy, safety and pharmacokinetics of glecaprevir/pibrentasvir in patients with severe renal impairment.

METHODS

In a prospective, multicentre study involving 35 medical institutions, 832 genotype 1-3 patients were treated with glecaprevir/pibrentasvir. The efficacy and safety of glecaprevir/pibrentasvir were analysed for patients with CKD stage 4 or 5. Multivariate analysis was performed to identify the factors associated with the most frequently observed adverse event. In patients undergoing haemodialysis, a pharmacokinetic study was conducted to investigate the dialysability of the drugs: plasma samples were obtained from the arterial and venous sides of a dialyser to serially measure drug concentrations.

RESULTS

The subjects comprised 141 patients (32 with CKD stage 4 and 109 with CKD stage 5), of whom 100 were undergoing haemodialysis. All but one stage 5 CKD patients undergoing haemodialysis achieved sustained virologic response (99.3%). Adverse events were observed in 39.7% of subjects: pruritus was the most frequent (30.5%), and was significantly associated with haemodialysis. In the pharmacokinetic study, no arterial-venous differences in the plasma concentrations of glecaprevir/pibrentasvir were detected during the haemodialysis sessions.

CONCLUSIONS

Glecaprevir/pibrentasvir was highly effective and safe in chronic hepatitis C patients with severe renal impairment. Haemodialysis was associated with increased incidence of pruritus, which was the most frequent adverse event, but had little or no influence on the drug concentrations, which indicated that their dialysability is very low and that no dose modification is required in patients undergoing haemodialysis. (UMIN registration no. 000032073).

Efficacy of ombitasvir/paritaprevir/ritonavir/ribavirin in management of HCV genotype 4 and end-stage kidney disease

BACKGROUND

Till now, pooled data about the safety and efficacy of different direct-acting antiviral (DAAs) regimens in different renal situations are still under evaluation.

AIM

To evaluate a real-life experience of the efficacy and safety of ombitasvir/paritaprevir/ritonavir plus ribavirin (OBV/PTV/r plus RIB) in patients with end-stage kidney disease (ESKD).

PATIENTS AND METHODS

Between January 2017 and January 2018, an open-label multicenter prospective study was designed to enroll all consecutive patients with proven CHC genotype 4 infections and concomitant ESKD based on estimated glomerular filtration rate (eGFR) with (HD group) or without hemodialysis (non-HD group). Patients were given a co-formula of OBV/PTV/r (25/150/100 mg) once-daily plus RIB was given for 12 weeks. Sustained virologic response (SVR 12) was the primary endpoint.

RESULTS

A total of 110 patients were enrolled. An overall SVR 12 was reported in 104 (94.5%) patients, and treatment failure were reported in 6 patients [2 patients (1.8%) were relapsed, and 4 patients (3.6%) patients were non-responders]. SVR12 was 96% in HD and 91.4% in non-HD patients (P = 0.286). There were no reported serious adverse events. Anemia was reported in 66.6% (n = 50) in HD group and in 31.4% (n = 11) in non-HD group.

CONCLUSION

Although it is still challenging, achievement of SVR12 in patients with chronic HCV and concomitant end-stage kidney disease in the era of DAAs became possible with a 12 weeks course of a co-formula of ombitasvir/paritaprevir /ritonavir plus ribavirin. CLINICALTRIALS.

GOV ID

NCT03341988.

Mortality and Kidney Transplantation Outcomes Among Hepatitis C Virus-Seropositive Maintenance Dialysis Patients: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Hepatitis C virus (HCV) infection is common among maintenance dialysis patients. Few studies have examined both dialysis survival and transplantation outcomes for HCV-seropositive patients because registry data sets lack information for HCV serostatus.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adult long-term dialysis patients treated by a US national dialysis provider between January 1, 2004, and December 31, 2014.

EXPOSURE

HCV antibody serostatus obtained as part of clinical data from a national dialysis provider.

OUTCOMES

Mortality on dialysis therapy, entry onto the kidney transplant waiting list, kidney transplantation, and estimated survival benefit from kidney transplantation versus remaining on the waitlist.

ANALYTICAL APPROACH

After linking clinical data with data from the Organ Procurement and Transplantation Network, Cox and cause-specific hazards regression were implemented to estimate the associations between HCV seropositivity and mortality, as well as entry onto the kidney transplant waitlist. Cox regression was also used to estimate the survival benefit from transplantation versus dialysis among HCV-seropositive individuals.

RESULTS

Among 442,171 dialysis patients, 31,624 (7.2%) were HCV seropositive. HCV seropositivity was associated with a small elevation in the rate of death (adjusted HR [aHR], 1.09; 95% CI, 1.07-1.11) and a substantially lower rate of entry onto the kidney transplant waitlist (subdistribution HR [sHR], 0.67; 95% CI, 0.61-0.74). Once wait-listed, the kidney transplantation rate was not different for HCV-seropositive (sHR 1.10; 95% CI, 0.96-1.27) versus HCV-seronegative patients. HCV-seropositive patients lived longer with transplantation (aHR at 3 years, 0.42; 95% CI, 0.27-0.63). Receiving an HCV-seropositive donor kidney provided a survival advantage at the 2-year posttransplantation time point compared to remaining on dialysis therapy waiting for an HCV-negative kidney.

LIMITATIONS

No data for HCV viral load or liver biopsy.

CONCLUSIONS

HCV-seropositive patients experience reduced access to the kidney transplantation waitlist despite deriving a substantial survival benefit from transplantation. HCV-seropositive patients should consider foregoing HCV treatment while accepting kidneys from HCV-infected donors to facilitate transplantation and prolong survival.

Hepatitis C virus-infected kidney waitlist patients: Treat now or treat later?

Currently many but not all centers transplant hepatitis C virus (HCV) viremic positive (+) donor kidneys into HCV+ recipients. Directed donation of HCV+ organs reduces the wait time to transplantation for HCV+ patients. Direct-acting antiviral (DAA) therapy can cure HCV in virtually all who are infected. Some have suggested that treatment of HCV+ waitlisted patients be deferred with the hope that earlier transplantation will provide better outcomes than early DAA therapy. However, there are not enough organs to guarantee prompt transplantation for the current waitlist of infected candidates. A Markov medical decision analysis model was created to compare the overall outcomes of delayed DAA therapy (Option 1) to immediate DAA therapy (Option 2) in waitlisted HCV+ patients. Option 1 patients were modeled to be transplanted 1 year earlier, with a higher cumulative transplant incidence (54% at 5 years post-listing vs 45% for Option 2). Despite this, Option 2 provided 0.43 (95% confidence interval [CI] 0.38-0.49) more life years than Option 1. However, Option 1 was preferred for regions with much greater access to HCV+ organs or in patients with very low HCV+-associated mortality. The best option from an individual patient's perspective will differ by region and candidate.

Eradication of HCV in Renal Transplant Recipients and Its Effects on Quality of Life

Background

The use of direct antiviral agents (DAA) has radically modified the course of HCV hepatitis in renal patients. Aim of this study was to assess the effects of HCV eradication on quality of life (QOL) in renal transplant recipients (RTR), measured by CLDQ and SF-36.

Methods

Sixteen RTR with well preserved GFR (mean: 60.3±19.3 ml/min) and chronic HCV infection with moderate liver stiffness (9.3±1.7 kPa) were given a sofosbuvir-based regimen for 12 weeks and had a 1 year follow-up.

Results

At end of treatment (EOT) a complete viral clearance was observed in all the patients, with normalization of most laboratory data and a consistent reduction in liver stiffness. All these parameters remained stable after 1 year, as well as renal function and proteinuria. Questionnaire data showed consistent amelioration in different “emotional” domains at EOT, which persisted after 1 year and were associated with a globally improved QOL, although there was no change in most of the “physical” domains in both questionnaires. One patient under ribavirin developed an acute anemia and withdrew from the study, but no further adverse episode was observed throughout the study.

Conclusions

Our data, while confirming the efficacy of oral DAA, show that HCV infection represents a heavy psychological burden in renal transplant recipients, greatly alleviated by viral eradication, which determines a significant improvement in QOL that represents an important outcome in management of all transplant recipients. This trial is registered with ISRCTN97560076.

Sofosbuvir-based antiviral therapy in hepatitis C virus patients with severe renal failure

Background

Chronic hepatitis C virus (HCV) infection is the most common chronic liver disease in patients with end-stage renal disease (ESRD). Over the last few years, second-generation direct-acting antivirals have been revolutionary in the treatment of hepatitis C, and sofosbuvir (SOF) is the backbone of most modern treatment strategies. Since SOF is eliminated through the kidney, the aim of this multicentre retrospective study was to assess its antiviral efficacy and safety in HCV-infected patients with severe renal failure [including haemodialysis (HD) patients].

Methods

Fifty patients (36 males, mean age ± standard deviation 60.5 ± 7.5 years) with chronic HCV infection (G1: 28/56%, cirrhosis: 27/54%) and severe renal failure [i.e. MDRD estimated glomerular filtration rate (eGFR) <35 mL/min], including 35 on HD, were enrolled. Antiviral treatment consisted of SOF/ribavirin (RBV) (n = 7), SOF/RBV/pegylated interferon (n = 2), SOF/daclatasvir ± RBV (n = 30) or SOF/simeprevir ± RBV (n = 11) for 12 or 24 weeks. A reduced dose of SOF (400 mg three times a week or 400 mg every other day) was given to all HD patients. Initial dose of RBV (n = 12) ranged from 400 to 4200 mg/week.

Results

On an intent-to-treat-based analysis, sustained virological response rate was 86% at 12 weeks. During therapy, haemoglobin levels were not significantly modified, but recombinant erythropoietin (rEPO) dose significantly increased in patients treated with RBV. Two patients (4%) required blood transfusion. No patient had treatment discontinuation due to side effects. Dose of RBV was reduced in two patients (16.7%) during antiviral therapy. Dose of SOF was reduced in two non-HD patients because of side effects. In non-HD patients, median eGFR was not significantly modified during treatment.

Conclusions

Our results strongly suggest that SOF-based antiviral therapy, with a reduced dose of SOF, is safe and effective for the treatment of HCV patients with ESRD, including HD patients.

Real-world use of elbasvir-grazoprevir in patients with chronic hepatitis C: retrospective analyses from the TRIO network

BACKGROUND

Elbasvir-grazoprevir is indicated for chronic hepatitis C virus (HCV) genotypes 1 and 4.

AIM

To evaluate the utilization and outcomes of chronic HCV patients treated with elbasvir-grazoprevir in the United States.

METHODS

We conducted a retrospective cohort study of adults treated with elbasvir-grazoprevir with or without ribavirin for chronic HCV genotypes 1 or 4 infection. Data were collected from healthcare providers and specialty pharmacies through Innervation Platform, a proprietary, cloud-based disease management program from Trio Health. The primary endpoint was per protocol sustained virological response 12 weeks post-treatment (SVR12).

RESULTS

Among 470 patients treated in 2016, 95% had HCV genotype 1 infection, 80% (373/468) were HCV treatment naïve and 70% (327/468) had non-cirrhotic disease. Almost 3 quarters (73%) of patients received care in community practices. The majority (89%) of patients received elbasvir-grazoprevir for 12 weeks. Per protocol SVR12 rates were 99% (396/402) for HCV genotype 1 and 95% (21/22) for HCV genotype 4. Among patients with Stage 4 or 5 chronic kidney diseases, 99% (113/114) achieved SVR12. In univariate analyses, variables significantly associated with per protocol SVR12 for the entire sample were therapy duration (P = 0.001), treatment experience (P = 0.016), and cirrhosis status (P = 0.001). However, among HCV genotype 1 patients, no variables were significant. Intent-to-treat SVR12 rates were 89% (396/447) for HCV genotype 1 and 91% (21/23) for HCV genotype 4.

CONCLUSION

Elbasvir-grazoprevir is highly effective, and in this 2016 cohort, its use was predominantly in patients with HCV genotype 1 and as a 12-week therapy without ribavirin.

Efficacy and safety of ombitasvir/paritaprevir/ritonavir in dialysis patients with genotype 1b chronic hepatitis C

AIM

From a pharmacokinetic viewpoint, the use of ombitasvir/paritaprevir/ritonavir, one of the standards of care for genotype 1b chronic hepatitis C in Japan, could be possible in patients with impaired renal function. The aim of this study was to assess the efficacy and safety of this combination that have not yet been addressed in patients undergoing dialysis.

METHODS

A retrospective, multicenter study evaluated the outcome of 12-week ombitasvir (non-structural protein [NS]5A inhibitor)/paritaprevir (NS3/4A protease inhibitor)/ritonavir combination therapy for dialysis patients. The primary end-point was sustained virologic response 12 weeks after therapy (SVR12).

RESULTS

The subjects were 31 patients with a median age of 64 years (range, 49-85 years), including 10 cirrhotic patients. All of the 31 patients had an estimated glomerular filtration rate level <15 mL/min/1.73 m² , defined as end-stage renal disease (ESRD). Pre-existing resistance-associated substitutions at position L31 and Y93 of the NS5A region were detected in 0% and 3.6% (1/28), respectively. The rates of rapid virologic response, end-of-treatment response, and SVR12 were 93.5% (29/31), 100% (31/31), and 96.8% (30/31), respectively. The incidence of adverse events was 35.5% (11/31). Of the 11 patients, one discontinued the treatment due to erythema multiforme and thereafter relapsed. The most frequent adverse event was pruritus (6.5%; 2/31).

CONCLUSIONS

The present study suggests that ombitasvir/paritaprevir/ritonavir combination therapy is effective and safe for genotype 1b chronic hepatitis C patients undergoing dialysis due to ESRD.

When and how can nephrologists treat hepatitis C virus infection in dialysis patients?

Hepatitis C virus (HCV) infection, a major cause of end-stage liver disease, is a common comorbidity in patients on dialysis and causes increased morbidity and mortality. Historically HCV has been extremely difficult to cure with interferon and ribavirin-based therapies, which are also associated with significant side effects, and few dialysis patients ever received HCV treatment. However, in the last 4 years, interferon-free direct-acting antiviral therapies have been approved, and several combinations have been studied in dialysis patients. A recently approved, pan-genotypic, direct-acting antiviral regimen, glecaprevir and pibrentasvir, may simplify prescribing. The simplicity of these new therapies, with few side effects, makes it possible for nephrologists to treat HCV infection in their patients on dialysis. We review the workflow and motivation behind nephrology-led management of HCV infection. We highlight the importance of identifying which patients need referral to a hepatologist or HCV specialist prior to treatment and which can be managed by their nephrologist. Nephrologist involvement would lead to improved access to treatment and ensure that appropriate patients are referred for HCV treatment. In this paper, we review the background of HCV infection, its effect on dialysis patients, and impact on kidney transplantation. In addition, we outline the therapy options for each genotype of HCV, and we discuss the benefits and barriers to nephrology-led HCV treatment.

Ledipasvir/sofosbuvir is effective and well tolerated in postkidney transplant patients with chronic hepatitis C virus

Patients with end-stage renal diseases on hemodialysis have a high prevalence of hepatitis C infection (HCV). In most patients, treatment for HCV is delayed until postrenal transplant. We assessed the effectiveness and tolerance of ledipasvir/sofosbuvir (LDV/SOF) in 32 postkidney transplant patients infected with HCV. The group was composed predominantly of treatment-naïve (75%) African American (68.75%) males (75%) infected with genotype 1a (62.5%). Most patients received a deceased donor kidney graft (78.1%). A 96% sustained viral response (SVR) was reported (27/28 patients). One patient relapsed. One patient with baseline graft dysfunction developed borderline rejection. No graft loss was reported. Six HIV-coinfected patients were included in our analysis. Five of these patients achieved SVR 12. There were four deaths, and one of the deaths was in the HIV group. None of the deaths were attributed to therapy. Coinfected patients tolerated therapy well with no serious adverse events. Serum creatinine remained stable at baseline, end of therapy, and last follow-up, (1.351±.50 mg/dL; 1.406±.63 mg/dL; 1.290±.39 mg/dL, respectively). In postkidney transplant patients with HCV infection with or without coinfection with HIV, a combination of LDV/SOF was well tolerated and effective.

Mortality, Hospitalization, and Quality of Life among Patients with Hepatitis C Infection on Hemodialysis

BACKGROUND AND OBJECTIVES

Hepatitis C virus (HCV) infection is widely prevalent among patients on hemodialysis (HD), but very rarely treated. The aim of our study is to evaluate the burdens of HCV suffered by patients on HD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Dialysis Outcomes and Practice Patterns Study is an international, prospective, cohort study of patients on HD. We reviewed the HCV status of 76,689 adults enrolled between 1996 and 2015. We compared HCV-positive (HCV+) with HCV-negative (HCV-) patients for risk of mortality, hospitalization, decline in hemoglobin concentration <8.5 g/dl, and red blood cell transfusion. We also compared health-related quality of life scores using the Kidney Disease Quality of Life instrument and the Center for Epidemiologic Studies Short Depression Scale. We adjusted for age, sex, race, years on dialysis, 14 comorbid conditions (including hepatitis B infection), and serum albumin, phosphorus, and creatinine concentrations.

RESULTS

A total of 7.5% of patients were HCV+ at enrollment. Serum concentrations of alanine aminotransferase and aspartate aminotransferase were not markedly elevated in HCV+ patients on HD; the mean concentrations were only 22.6 and 21.8 U/L, respectively. Median follow-up was 1.4 years. Case-mix adjusted hazard ratios (95% confidence intervals) for HCV+ versus HCV- patients were 1.12 (1.05 to 1.20) for all-cause mortality, 5.90 (3.67 to 9.50) for hepatic-related mortality, 1.09 (1.04 to 1.13) for all-cause hospitalization, and 4.40 (3.14 to 6.15) for hepatic-related hospitalization. Quality of life measures indicated significantly worse scores for physical function, pain, vitality, mental health, depression, pruritus, and anorexia among HCV+ patients. The adjusted hazard ratio for transfusion was 1.36 (95% CI, 1.20 to 1.55) and incidence of hemoglobin concentration <8.5 g/dl was 1.12 (95% CI, 1.03 to 1.21). Only 1.5% of HCV+ patients received antiviral medication.

CONCLUSIONS

HCV infection among patients on HD is associated with higher risk of death, hospitalization, and anemic complications, and worse quality of life scores. Internationally, HCV infection is almost never treated in patients on HD. Our data provide a rationale for more frequent treatment of HCV in this population.

Pharmacokinetics, efficacy and safety of daclatasvir plus asunaprevir in dialysis patients with chronic hepatitis C: pilot study

The aim of this study was to evaluate the pharmacokinetic profile of daclatasvir (DCV) and asunaprevir (ASV) dual therapy in haemodialysis patients infected with hepatitis C virus (HCV). Eighteen haemodialysis patients and 54 patients with normal renal function were treated with DCV and ASV dual therapy for 24 weeks. We evaluated the pharmacokinetic profiles of DCV and ASV and examined the rate of sustained virological response 12 weeks after the end of treatment (SVR₁₂ ) and incidence of adverse events during treatment of haemodialysis patients infected with chronic HCV genotype 1 infection. To adjust for potential differences in baseline characteristics between haemodialysis patients and patients with normal renal function, we used propensity scores case-control matching methods. Area under the plasma concentration time curve from 0 to 6 h (AUC_{0-6 h} ) of DCV was slightly lower in haemodialysis patients than in patients with normal renal function (P > 0.6). AUC_{0-6 h} of ASV was significantly lower in haemodialysis patients (P = 0.012). SVR₁₂ rates were 100% (18/18) for haemodialysis and 96.2% (52/54) for patients with normal renal function. Changes in mean log₁₀ HCV RNA levels and viral response were higher in haemodialysis patients compared to patients with normal renal function. No discontinuations due to adverse events occurred. In conclusion, DCV and ASV dual therapy for HCV infection is effective and safe with similar results in haemodialysis patients compared to patients with normal renal function.

Safety and efficacy of dual direct-acting antiviral therapy (daclatasvir and asunaprevir) for chronic hepatitis C virus genotype 1 infection in patients on hemodialysis

BACKGROUND

Hepatitis C virus (HCV) infection is a major comorbidity in patients receiving hemodialysis. Interferon-based antiviral therapy to eradicate HCV is less effective in patients receiving hemodialysis than patients without renal dysfunction. Recently reported combination therapy with two oral direct-acting antiviral drugs, daclatasvir and asunaprevir, both of which are metabolized in the liver and excreted into the bile ducts, reportedly showed a high rate of HCV eradication. We evaluated the safety and efficacy of this therapy in patients receiving hemodialysis.

METHODS

The safety and viral responses were compared among patients infected with HCV genotype 1, between 28 patients receiving hemodialysis, and propensity score-matched 56 patients without renal dysfunction.

RESULTS

The reduction in serum HCV RNA levels 1 day after the start of therapy was significantly larger (p = 0.0329) and the disappearance of serum HCV RNA occurred significantly earlier (p = 0.0017) in patients receiving hemodialysis than those without renal dysfunction. The rates of sustained virologic response, i.e., the eradication of HCV, were comparable between two groups; the rate of SVR12 was 100 % in patients receiving hemodialysis and 94.6 % in patients without renal dysfunction. No adverse constitutional events were observed in either of the groups. The elevation of serum alanine aminotransferase levels, a known adverse effect of these drugs, was observed in comparable rate of patients between the two groups.

CONCLUSIONS

The therapy with daclatasvir and asunaprevir has high antiviral efficacy in patients receiving hemodialysis with a comparable safety profile to patients without renal dysfunction.

Novel Hepatitis C Treatment and the Impact on Kidney Transplantation

With a worldwide prevalence of 6% to 40% among patients with end-stage renal disease, hepatitis C virus (HCV) infection is a significant cause of comorbidity in kidney transplant candidates and recipients alike. Hepatitis C infection negatively impacts patient and allograft outcomes, predisposes to progressive liver disease and increases the risks of glomerular disease as well as new onset diabetes after transplantation. Treatment options until now have revolved around interferon, limited in efficacy, restricted to pretransplant administration because of concerns related to allograft dysfunction and immune stimulation, and fraught with high rates of intolerance. Direct-acting antivirals therapies are now emerging, providing the opportunity to effectively cure chronic HCV infection and to reduce the burden of hepatic and extrahepatic complications of HCV that are observed in kidney recipients, thereby offering hope of improved patient outcomes. Against a description of the major outcomes and risks that HCV+ kidney candidates and recipients encounter, and a summary of the pertinent studies of interferon-based therapies in this population, this review discusses the potential role for emerging direct-acting antivirals, proposing treatment algorithms that should be considered in the management of these complex patients. Conundrums relating to the new treatment, including the potential impact on the utilization of kidneys from HCV-infected donors, are presented.

Interventions for dialysis patients with hepatitis C virus (HCV) infection

BACKGROUND

Hepatitis C virus (HCV) infection is common in chronic kidney disease (CKD) patients on dialysis, causes chronic liver disease, increases mortality and impacts kidney transplant outcomes. Sustained response to the preferred treatment with standard or pegylated (PEG) interferon is seen in 39% with side effects necessitating treatment discontinuation in 20%. We collated evidence for treatment response and harms of interventions for HCV infection in dialysis.

OBJECTIVES

We aimed to look at the benefits and harms of various interventions for HCV infection in CKD patients on HD or peritoneal dialysis, specifically on mortality, disease relapse, response to treatment, treatment discontinuation, time to recovery, quality of life, cost effectiveness,adverse effects, and other outcomes. We aimed to study comparisons of available interventions with a placebo or control group, combinations of interventions with placebo or control group, interventions with each other singly and in combination, available standard interventions with newer treatment modalities.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 24 March 2015 through contact with the Trials' Search Co-ordinator. We also checked references of reviews, studies and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs, first period of randomised cross-over studies on interventions for HCV in CKD on dialysis were considered.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration and also collected adverse effects data listed in included RCTs.

MAIN RESULTS

Ten RCTs (361 participants) met our inclusion criteria. Five RCTs (152 participants, 134 analysed) with low to moderate quality of evidence compared standard recombinant interferon with placebo or control. There was no significant difference for mortality (5 studies (134 participants): RR 0.89, 95% CI 0.06 to 13.23), relapses (1 study (36 participants): RR 0.72, 95% CI 0.28 to 1.88), sustained virological response (4 studies (98 participants): RR 3.25, 95% CI 0.81 to 13.07), treatment discontinuation (4 studies (116 participants): RR 4.59, 95% CI 0.49 to 42.69) and number with adverse events (5 studies (143 participants): RR 3.56, 95% CI 0.98 to 13.01). End of treatment response was significantly more for standard interferon (5 studies (132 participants): RR 8.62, 95% CI 3.03 to 24.55). There was overall low to unclear risk of bias and no significant heterogeneity.One RCT (50 participants) with moderate quality of evidence compared PEG interferon and standard interferon. There was no significant difference in mortality (RR 0.33, 95% CI 0.01 to 7.81), relapses (RR 0.72, 95% CI 0.41 to 1.25), sustained virological response (RR 2.40, 95% CI 0.99 to 5.81), treatment discontinuation (RR 0.11, 95% CI 0.01 to 1.96) and number with major adverse events (RR 0.11, 95% CI 0.01 to 1.96). End of treatment response was significantly more for PEG interferon (RR 1.53, 95% CI 1.09 to 2.15). There was overall low risk of bias.Two RCTs (97 participants) with moderate quality of evidence compared two doses of two different preparations of PEG interferon. Subgroup analysis comparing high and low doses of PEG interferon alpha-2a (135 µg/week versus 90 µg/week) and PEG interferon alpha-2b (1 µg/kg versus 0.5 µg/kg body weight/week) found no significant difference in mortality (2 studies (97 participants): RR 4.30, 95% CI 0.76 to 24.33), relapses (1 study (81 participants): RR 1.11, 95% CI 0.45 to 2.77), end of treatment response (2 studies (97 participants): RR 1.42, 95% CI 0.51 to 3.90), sustained virological response (2 studies (97 participants): RR 1.19, 95% CI 0.68 to 2.07), treatment discontinuation (2 studies (97 participants): RR 1.20, 95% CI 0.63 to 2.28), patients with adverse events (2 studies (97 participants): RR 1.05, 95% CI 0.61 to 1.83) or serious adverse events (2 studies (97 participants): RR 1.24, 95% CI 0.72 to 2.14). Both had overall low risk of bias and no significant subgroup differences.Two RCTs (62 participants) with moderate quality of evidence compared standard or PEG interferon alone or in combination with ribavirin. The only reported outcome in both was treatment discontinuation which was significantly more with ribavirin in the one study (RR 0.34, 95% CI 0.14 to 0.84) and pooled 7/10 in the second.No RCTs had data on time to recovery, cost-effectiveness, quality of life, and other outcomes and in peritoneal dialysis.

AUTHORS' CONCLUSIONS

Our review demonstrated that in CKD patients on haemodialysis with HCV infection treatment with standard interferon brings about an end of treatment but not a sustained virological response and is relatively well tolerated. PEG interferon is more effective than standard interferon for end of treatment response but not for sustained response; both were equally tolerated. Increasing doses of PEG interferon did not improve responses but high and low doses are equally tolerated. Addition of ribavirin results in more treatment discontinuation.

Differential Effect of Viral Hepatitis Infection on Mortality among Korean Maintenance Dialysis Patients: A Prospective Multicenter Cohort Study

The role of infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in terms of survival among dialysis patients remains incompletely understood. In the present multicenter prospective cohort study, we investigated the prevalences of HBV and HCV infection among 3,321 patients receiving maintenance dialysis in Korea, and assessed the impacts of these infections on survival. All included patients underwent hepatitis B antigen (HBsAg) and HCV antibody (Ab) testing, which revealed that 236 patients (7.1%) were HBsAg-positive, and 123 patients (3.7%) were HCV Ab-positive. HBsAg-positive and HCV Ab-positive patients were matched to hepatitis virus-negative patients using a propensity score at a ratio of 1:2. The prevalences of HBV and HCV infection did not significantly differ according to dialysis modality. Linear-by-linear association analysis revealed that hepatitis B prevalence significantly increased with increasing dialysis vintage (p = 0.001), and hepatitis C prevalence tended to be higher with increasing dialysis vintage (p = 0.074). We compared the survival of HBsAg-positive and HCV Ab-positive patients to that of hepatitis virus-negative patients. After propensity score matching, cumulative survival did not differ between HBsAg-positive and HBsAg-negative patients (p = 0.37), while HCV Ab-positive patients showed significantly lower survival than HCV Ab-negative patients (p = 0.03). The main conclusions of the present study are that HBV infection prevalence increased with longer dialysis vintage, and that both HBV and HCV infections were most prevalent among patients with the longest dialysis vintage. Additionally, HCV infection among maintenance dialysis patients is associated with an increased risk of mortality.

Hepatitis C virus resistance to interferon therapy: an alarming situation

Hepatitis C virus is presently a major public health problem across the globe. The main objective in treating hepatitis C virus (HCV) infection is to achieve a sustained virological response (SVR). Interferon-α (IFN-α) and pegylated interferon (PegIFN) in combination with Ribavirin (RBV) are the choice of treatment nowadays against chronic hepatitis C. There are several mechanisms evolved by the hepatitis C virus that facilitate the persistence of virus and further lead the patient’s status as non responder. Various factors involved in patient’s lack ofresponse to the therapy include: (1) viral factors, (2) host factors, (3) molecular mechanisms related to the lack of response and (4) social factors. Herein we have made an attempt to summarize all the related predictors of drug resistance in one article so that the future polices can be planned to overcome this obstacle and potential therapies can be designed by considering these factors.

Histological features of chronic hepatitis C in haemodialysis patients

BACKGROUND & AIMS

HCV infection in haemodialysis (HD) patients is still a matter of investigation. The aim of this study was to determine the histology of chronic hepatitis C (CHC) in HCV-infected HD patients within the context of a comparative analysis including non-uraemic patients with CHC. The relative importance of virological, demographic and clinical parameters on disease manifestation was examined.

METHODS

Sixty-one consecutive liver biopsies from HD patients and 326 from non-uraemic patients with chronic HCV infection were comparatively evaluated.

RESULTS

Haemodialysis patients with CHC were older than control subjects (P = 0.031), showing a similar HCV genotype distribution (P = 0.328) and lower viral load (P = 0.001). CHC in HD patients was significantly milder according to stage (P = 0.033), grade and its parameters (periportal activity, portal inflammation and lobular activity) (P < 0.001). The frequency of lymphoid aggregates (10.2% vs. 50%, P < 0.001), bile duct lesions (1.7% vs. 22.1%, P < 0.001) and extent of steatosis (P = 0.022) in HD group was significantly reduced. Multivariate analysis showed that non-uraemic patients had 2.3 times higher risk of developing steatosis independently of genotype distribution and age. In HD group, genotype 3, longer HD duration and age at infection were significantly associated with steatosis, while older age at infection correlated with advanced fibrosis.

CONCLUSIONS

Chronic hepatitis C in HD patients is usually very mild, losing its diagnostic histological features while patient's age and age at infection retain their prognostic significance. The weak inflammatory response, probably because of immunocompromised status and low viral load, may present a beneficial factor in the natural course of the disease.

Hepatitis C virus infection in end-stage renal disease and kidney transplantation

Liver disease secondary to chronic hepatitis C virus (HCV) infection is an important cause of morbidity and mortality in patients with end-stage renal disease (ESRD) on renal replacement therapy and after kidney transplantation (KT). Hemodialytic treatment (HD) for ESRD constitutes a risk factor for bloodborne infections because of prolonged vascular access and the potential for exposure to infected patients and contaminated equipment. Evaluation of HCV-positive/ESRD and HCV-positive/KT patients is warranted to determine the stage of disease and the appropriateness of antiviral therapy, despite such treatment is challenging especially due to tolerability issues. Antiviral treatment with interferon (IFN) is contraindicated after transplantation due to the risk of rejection, and therefore, treatment is recommended before KT. Newer treatment strategies of direct-acting antiviral agents in combination are revolutionizing HCV therapy, as a result of encouraging outcomes streaming from recent studies which report increased sustained viral response, low or no resistance, and good safety profiles, including preservation of renal function. KT has been demonstrated to yield better outcomes with respect to remaining on HD although survival after KT is penalized by the presence of HCV infection with respect to HCV-negative transplant recipients. Therefore, an appropriate, comprehensive, easily applicable set of clinical practice management guidelines is necessary in both ESRD and KT patients with HCV infection and HCV-related liver disease.

Hepatitis C virus and kidney disease

Hepatitis C virus (HCV) is the most frequently observed viral infection in patients with kidney disease. HCV can cause glomerular disease, which can lead to end-stage renal disease that requires dialysis and/or kidney transplantation. It is recommended to test HCV patients once a year for proteinuria, microscopic hematuria and estimated glomerular filtration rate. Membranoproliferative glomerulonephritis is the most common glomerular disease induced by HCV. Over the past few decades, the prevalence of HCV infection has decreased among dialysis and kidney transplant patients. However, survival is significantly lower in HCV-positive than in HCV-negative dialysis patients whereas survival is significantly better in HCV-positive kidney transplant patients compared with HCV-positive dialysis patients. Thus, dialysis patients without a sustained virological response after anti-HCV therapy should be proposed for kidney transplantation. Recurrence or de novo occurrence of glomerular disease is responsible for the lower kidney allograft survival in HCV-positive compared with HCV-negative kidney transplant patients. Dialysis and kidney transplantation do not appear to negatively affect progression of liver fibrosis in the majority of patients. The available data also suggest that occult HCV infection does not exist in dialysis and kidney transplant patients.

Hepatitis C treatment in patients with kidney disease

Hepatitis C virus (HCV) remains the most common cause of liver damage in patients with kidney disease, including those on long-term dialysis. The natural history of HCV in patients on regular dialysis is not fully elucidated, but an adverse effect of HCV on survival has been noted; a novel meta-analysis of observational studies (14 studies including 145,608 unique patients) showed that the summary estimate for adjusted relative risk (all-cause mortality) was 1.35 with a 95% confidence interval of 1.25-1.47. The adjusted RR for liver disease-related death and cardiovascular mortality among maintenance dialysis patients was 3.82 (95% CI, 1.92-7.61) and 1.26 (95% CI, 1.10-1.45), respectively. It has been recommended that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and comorbidities. A pooled analysis including 494 dialysis patients on monotherapy with conventional interferon reported a summary estimate for sustained viral response and dropout rate of 39% (95% CI, 32-46) and 19% (95% CI, 13-26), respectively. All renal transplant candidates (dialysis dependent or not) with HCV should be assessed for antiviral treatment given the increased risk of progressive liver disease with immunosuppressive therapy, the increased life expectancy compared to other HCV-positive patients on dialysis, and the inability to receive interferon after transplant. Current guidelines support monotherapy with standard interferon in these patients, but modern antiviral approaches (that is, dual therapy with peg-IFN plus ribavirin) in a well-controlled setting may be an appropriate alternative.

Survival advantage of kidney transplantation over dialysis in patients with hepatitis C: a systematic review and meta-analysis

BACKGROUND

The clinical outcomes of hepatitis C infection in kidney transplantation and maintenance dialysis patients remain controversial. Here, we conducted a systematic review and meta-analysis that aimed at comparing 5-year mortality rates between waiting list and kidney transplantation patients with hepatitis C infections.

METHODS

We searched Medline, EMBASE, and Scopus databases published since inception to June 2011 and found nine studies with 1734 patients who were eligible for pooling. Eligible studies were cohort studies that analyzed adult end-stage renal disease patients with hepatitis C virus infection and compared death rates between waiting list and kidney transplantation. The crude risk ratio of death along with its 95% confidence interval was estimated for each study. Data were independently extracted by two reviewers.

RESULTS

The pooled risk ratio of death at 5 years by using a random-effect model was 2.19 (95% confidence interval, 1.50-3.20), which significantly favored the kidney transplantation when compared with the waiting list. There was evidence of heterogeneity of death rates across studies (χ(2) = 22.6; df = 8; P = 0.004). From the metaregression model, age and male gender could be the source of heterogeneity or variation of treatment effects. A major cause of death in the waiting list was cardiovascular diseases, whereas infection was a major cause in the transplant group. There was no evidence of publication bias suggested by an Egger test.

CONCLUSIONS

This systematic review suggested that hepatitis C virus-infected patients who remain on dialysis are at higher risk of death when compared with those who received kidney transplantations.

Hepatitis C infection is very rarely treated among hemodialysis patients

BACKGROUND

Hepatitis C virus (HCV) infection is associated with increased mortality among hemodialysis (HD) patients. Guidelines from Kidney Disease: Improving Global Outcomes recommend that infected HD patients awaiting renal transplantation be treated for HCV and that clinicians decide whether to treat other infected patients on a case-by-case basis. We evaluated the extent and outcome of HCV therapy among HD patients.

METHODS

The Dialysis Outcomes and Practice Patterns Study is an observational study; 49,762 HD patients in 12 nations enrolled between 1996 and 2011. We reviewed HCV status, use of interferon or ribavirin, and survival over a median 1.4 years per study phase.

RESULTS

4,735 patients (9.5%) were HCV+. Only 48 (1.0%) of the 4,589 HCV+ patients with prescription data were receiving antiviral medication. Among the subset of 617 HCV+ patients also known to be on a waiting list for renal transplantation, only 3.7% were receiving treatment. After restricting to HCV+ patients with overlapping propensity for antiviral treatment, 4 (9.5%) of 42 treated patients and 638 (21.0%) of 3,037 untreated patients died. The hazard ratio for adjusted mortality comparing treated patients with untreated patients was 0.47 (95% CI, 0.17-1.26).

CONCLUSIONS

HD patients with hepatitis C infection very rarely receive antiviral therapy. Increased intervention might prolong survival for some patients and in particular might improve the prospects for those awaiting renal transplantation.

Hepatitis C virus infection and dialysis: 2012 update

Hepatitis C virus infection is still common among dialysis patients, but the natural history of HCV in this group is not completely understood. Recent evidence has been accumulated showing that anti-HCV positive serologic status is significantly associated with lower survival in dialysis population; an increased risk of liver and cardiovascular disease-related mortality compared with anti-HCV negative subjects has been found. According to a novel meta-analysis (fourteen studies including 145,608 unique patients), the adjusted RR for liver disease-related death and cardiovascular mortality was 3.82 (95% CI, 1.92; 7.61) and 1.26 (95% CI, 1.10; 1.45), respectively. It has been suggested that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and co-morbidities. According to recent guidelines, the antiviral treatment of choice in HCV-infected patients on dialysis is mono-therapy but fresh data suggest the use of modern antiviral approaches (i.e., pegylated interferon plus ribavirin). The summary estimate for sustained viral response and drop-out rate was 56% (95% CI, 28-84) and 25% (95% CI, 10-40) in a pooled analysis including 151 dialysis patients on combination antiviral therapy (conventional or pegylated interferon plus ribavirin).

Hepatitis C virus core antigen test in monitoring of dialysis patients

Hepatitis C virus infection is a persistent worldwide public health concern. The prevalence of HCV infection is much higher in patients on chronic haemodialysis (HD) than in the general population. HCV infection can detrimentally affect patients throughout the spectrum of chronic kidney disease. Despite the control of blood products, hepatitis C virus transmission is still being observed among patients undergoing dialysis. Detection systems for serum HCV antibodies are insensitive in the acute phase because of the long serological window. Direct detection of HCV depends on PCR test but this test is not suitable for routine screening. Recent studies have highlighted the importance of HCV core antigen detection as an alternative to PCR. Few studies exist about the efficacy of HCV core antigen test in dialysis population. We studied the utility of HCV core antigen test in routine monitoring of virological status of dialysis patients. We screened 92 patients on long-term dialysis both by PCR HCV-RNA and HCV core antigen test. The sensitivity of HCVcAg test was 90%, the specificity 100%, the positive predictive power 100%, the negative predictive power 97%, and the accuracy 97%. We think serological detection of HCV core antigen may be an alternative to NAT techniques for routine monitoring of patients on chronic dialysis.

Incidence of hepatitis C virus infection in patients on hemodialysis: a systematic review and meta-analysis

Hepatitis C virus infection is a perennial concern for hemodialysis units because the prevalence of hepatitis C is significantly higher there than in the general population. Through a systematic review and meta-analysis, we aim to assess the incidence rate of hepatitis C virus infection in hemodialysis units and explore its potential risk factors. Five electronic databases were used to search articles from 1990 to 2012, including PubMed, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang. A random-effects analysis was used to estimate the overall incidence rate of hepatitis C virus infection. A subgroup analysis and meta-regression analysis were conducted to explore factors associated with heterogeneity between studies. Twenty-two eligible articles were found, including 23 incidence rate estimates. The overall incidence rate of hepatitis C virus infection was 1.47 per 100 patient-years (95% confidence interval [CI] 1.14 to 1.80). In the subgroup analysis, the pooled incidence rate was 4.44 (CI 2.65, 6.23) per 100 patient-years in the developing world and 0.99 (CI 0.66, 1.29) per 100 patient-years in the developed world. [Correction added on 2 November 2012, after first online publication: Pooled incidence rate in the developed world has been changed.] In addition, in hemodialysis units with higher prevalence, the incidence rate of hepatitis C virus infection also tended to be higher. Meta-regression analysis showed that the country's development level and initial HCV prevalence combined could explain 67.91% of the observed heterogeneity. The incidence rate of hepatitis C virus infection among patients on hemodialysis was significantly high. Efforts should be taken to control hepatitis C virus infection in hemodialysis units, especially in developing countries.

Impact of hepatitis C on survival in dialysis patients: a link with cardiovascular mortality?

Recent evidence has been accumulated showing that anti-HCV-positive serologic status is significantly associated with lower survival in dialysis populations, but the mechanisms underlying this negative relationship are still unclear. The aim of this study was to conduct a systematic review of the published medical literature concerning the impact of hepatitis C virus (HCV) infection on all-cause and disease-specific mortality of patients on regular dialysis. The relative risk of all-cause, cardiovascular and liver disease-related mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random effect pooled estimates for mortality with HCV across the published studies. We identified fourteen observational studies involving 145 608 unique patients on long-term dialysis. Pooling of study results demonstrated that anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (all-cause mortality) was 1.35 with a 95% confidence interval (CI) of 1.25-1.47. Stratified analysis showed that the adjusted RR for liver disease-related death was 3.82 (95% CI, 1.92; 7.61); heterogeneity statistics, R(i) = 0.58 (P-value by Q-test = 0.087). The adjusted RR for cardiovascular mortality was 1.26 (95% CI, 1.10; 1.45); no heterogeneity was found (NS). This meta-analysis of observational studies indicates that anti-HCV-positive patients on dialysis have an increased risk of either liver or cardiovascular disease-related mortality compared with anti-HCV-negative patients. Further studies are in progress to understand better the link between HCV and cardiovascular risk among patients on maintenance dialysis.

Virological responses of pegylated interferon alpha-2a treatment in hemodialysis patients infected with hepatitis C

BACKGROUND

Hepatitis C is the most frequently encountered hepatic disease in dialysis patients. Data related to pegylated interferon alfa-2a (Peg-IFN-α-2a) use in hemodialysis patients with hepatitis C virus (HCV) are limited. The aim of this study was to evaluate the efficacy of Peg-IFN-α-2a among these patients.

METHODS

Forty-one IFN-naive hemodialysis patients infected by HCV were assessed. All patients had positive anti-HCV antibody and positive HCV-RNA. Peg-IFN-α-2a 135 mcg/week was given for 48 weeks. Biochemical and virological responses were evaluated at treatment weeks 12, 24, 48, and 72.

RESULTS

Thirty-eight of the 41 patients who completed the treatment enrolled in the study. Mean age of the 38 patients was 38.1 (range 23-65) years, and the study group was predominantly male (65.8 %). There was no statistically significant difference in mean age, gender, mean duration of hemodialysis, HCV infection, patient numbers with normal alanine aminotransferase (ALT) values and mean ALT, platelet, and HCV-RNA values between patients who achieved sustained virological response (SVR) and those who did not. Only the Knodell histology activity index correlated with SVR (P = 0.048). Biochemical and virological response rates at the 12th week (early response) were 94.7 % and 60.5 %, respectively. The 34 (89.5 %) patients achieved biochemical response at the end of therapy (48th week); 24 (63.2 %) remained HCV-RNA negative. At the 72nd week, biochemical and virological response rates were 84.2 % and 50 %, respectively.

DISCUSSION

According to results of this study, patients achieved good sustained viral and biochemical response rates with Peg-IFN-α-2a treatment. Histology activity index may be a predictor for SVR; but large randomized controlled trials are needed. Weekly 135 mcg dose of Peg-IFN-α-2a for 48 weeks is an effective treatment in HCV-infected hemodialysis patients.

Association of HCV core antigen seropositivity with long-term mortality in patients on regular hemodialysis

Anti-hepatitis C virus (HCV) antibody seropositivity is independently associated with poor prognosis in hemodialysis (HD) patients. However, anti-HCV antibody cannot distinguish between patients with active infection and those who have recovered from infection. We therefore aimed in this study to examine the association of HCV core antigen (HCVcAg) seropositivity with mortality in HD patients. We first measured serum HCVcAg using an immunoradiometric assay and anti-HCV antibody in 405 patients on regular HD, and followed them for 104 months. There were 82 patients (20.2%) who had been positive for anti-HCV antibodies; 57 (69.5%) of these were positive for HCVcAg. During the follow-up, 29 patients were excluded, so we tested the association of HCVcAg seropositivity with all-cause, cardiovascular (CV) and non-CV mortalities in 376 patients. A total of 209 patients (55.6%) had expired during the observational period, 92 out of them due to CV causes. After adjusting for comorbid parameters, HCVcAg was independently associated with overall mortality (HR 1.61, 95% CI 1.05–2.47, p < 0.05). HCV infection was significantly related to liver disease-related mortality. Past HCV infection also contributed to CV mortality (HR 2.63, 95% CI 1.27–5.45, p < 0.01). In contrast, anti-HCV antibody and HCVcAg seropositivities did not associate with infectious disease-related and cancer-related (expect for hepatocellular carcinoma) mortality. It follows from these findings that HCVcAg serology is associated with all-cause and CV mortality in HD patients.

Kinetics of hepatitis C virus load and hemodialysis: is there any influence of the reuse of dialysis membrane on HCV viremia?

BACKGROUND

Patients with chronic kidney disease (CKD) on regular hemodialysis are at increased risk of acquiring hepatitis C virus (HCV). Although controversial, a distinct dynamic of the HCV load has been reported in this group - a lower HCV viremia compared to non-uremic patients. The reasons for this remain unclear, but the host immune response related to the hemodialysis procedure and the reuse of dialysis membranes are the most investigated factors.

METHODS

We analyzed the kinetics of HCV RNA viremia in 21 hemodialysis patients infected with genotype 1, through a highly sensitive quantitative method (real-time polymerase chain reaction), immediately before and at the end of the first use and the last reuse of the cellulose diacetate dialysis membrane.

RESULTS

Initial HCV load did not correlate with demographic or biochemical parameters, but higher HCV viremia was associated with a longer time on hemodialysis (r = 0.44, p = 0.04). Although not significant, HCV RNA decreased in 11/21 (52.3%) patients after the first dialysis session (median 279,000 vs 176,000 IU/ml, p = 0.91). However, a significant increase in HCV RNA viremia was observed in 17/21 (80.9%) patients after the tenth session (median 187,000 vs 342,000 IU/ml, p = 0.009).

CONCLUSIONS

Except for the first session of hemodialysis, we did not confirm a decrease in HCV viremia related to the time on hemodialysis or with the reuse of the dialysis membrane. Factors other than the reuse of the dialysis membrane might be involved in the multifaceted kinetics of HCV RNA in CKD patients on hemodialysis.

Seropositivity for anti-HCV core antigen is independently associated with increased all-cause, cardiovascular, and liver disease-related mortality in hemodialysis patients

Background

It is not known whether chronic or past hepatitis C virus (HCV) infection contributes to the high mortality rate in hemodialysis patients.

Methods

This prospective study of 1077 adult hemodialysis patients without hepatitis B virus infection used Poisson regression analysis to estimate crude and sex- and age-adjusted rates (per 1000 patient-years) of all-cause, cardiovascular, infectious disease-related and liver disease-related mortality in patients negative for HCV antibody (group A), patients positive for HCV antibody and negative for anti-HCV core antigen (group B), and patients positive for anti-HCV core antigen (group C). The relative risks (RRs) for each cause of death in group B vs group C as compared with those in group A were also estimated by Poisson regression analysis after multivariate adjustment.

Results

A total of 407 patients died during the 5-year observation period. The sex- and age-adjusted mortality rate was 71.9 in group A, 80.4 in group B, and 156 in group C. The RRs (95% CI) for death in group B vs group C were 1.23 (0.72 to 2.12) vs 1.60 (1.13 to 2.28) for all-cause death, 0.75 (0.28 to 2.02) vs 1.64 (0.98 to 2.73) for cardiovascular death, 1.64 (0.65 to 4.15) vs 1.58 (0.81 to 3.07) for infectious disease-related death, and 15.3 (1.26 to 186) vs 28.8 (3.75 to 221) for liver disease-related death, respectively.

Conclusions

Anti-HCV core antigen seropositivity independently contributes to elevated risks of all-cause and cause-specific death. Chronic HCV infection, but not past HCV infection, is a risk for death among hemodialysis patients.

Effect of dialysis modality on survival of hepatitis C-infected ESRF patients

BACKGROUND AND OBJECTIVES

Hepatitis C virus (HCV) infection is associated with increased mortality and morbidity in end-stage renal failure (ESRF) patients. Despite a lower incidence and risk of transmission of HCV infection with peritoneal dialysis (PD), the optimal dialysis modality for HCV-infected ESRF patients is not known. The aim of this study was to evaluate the impact of dialysis modality on the survival of HCV-infected ESRF patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study included all adult incident ESRF patients in Australia and New Zealand who commenced dialysis between January 1, 1994, and December 31, 2008, and were HCV antibody-positive at the time of dialysis commencement. Time to all-cause mortality was compared between hemodialysis (HD) and PD according to modality assignment at day 90, using Cox proportional hazards model analysis.

RESULTS

A total of 424 HCV-infected ESRF patients commenced dialysis during the study period and survived for at least 90 days (PD n = 134; HD n = 290). Mortality rates were comparable between PD and HD in the first year (10.7 versus 13.8 deaths per 100 patient-years, respectively; adjusted hazard ratio [HR] 0.65, 95% CI 0.34 to 1.26) and thereafter (20 versus 15.9 deaths per 100 patient-years, respectively; HR 1.27, 95% CI 0.86 to 1.88).

CONCLUSIONS

The survival of HCV-infected ESRF patients is comparable between PD and HD.

Chronic hepatitis C

The goal of antiviral therapy for patients with chronic hepatitis C virus (HCV) infection is to attain a sustained virologic response (SVR), which is defined as undetectable serum HCV-RNA levels at 6 months after the cessation of treatment. Major improvements in antiviral therapy for chronic hepatitis C have occurred in the past decade. The addition of ribavirin to interferon-alfa therapy and the introduction of pegylated interferon (PEG-IFN) have substantially improved SVR rates in patients with chronic hepatitis C. The optimization of HCV therapy with PEG-IFN and ribavirin continues to evolve. Studies are ongoing that use viral kinetics to tailor therapy to an individual's antiviral response and determine the ideal length of treatment to maximize the chance of SVR. Improved SVR can be achieved with new specific inhibitors that target the HCV NS3/4A protease and the NS5B polymerase. Several long-term follow-up studies have shown that SVR, when achieved, is associated with a very low risk of virologic relapse. Furthermore, antiviral therapy can reduce the morbidity and mortality rates associated with chronic hepatitis C by reducing fibrosis progression, the incidence of cirrhosis, and hepatocellular carcinoma.

Effect of kidney transplantation on outcomes among patients with hepatitis C

The long-term outcome of kidney transplantation in patients infected with hepatitis C virus (HCV) and end stage renal disease (ESRD) is not well described. We retrospectively identified 230 HCV-infected patients using enzyme immunoassay and nucleic acid testing obtained during the transplant evaluation. Of 207 patients who had a liver biopsy before transplant, 44 underwent 51 follow-up liver biopsies at approximately 5-year intervals either while on the waitlist for a kidney or after kidney transplantation. Advanced fibrosis was present in 10% of patients biopsied, identifying a population that may warrant consideration for combined liver-kidney transplantation. Kidney transplantation does not seem to accelerate liver injury; 77% of kidney recipients who underwent follow-up biopsies showed stable or improved liver histology. There was a higher risk for death during the first 6 months after transplant, but undergoing transplantation conferred a long-term survival advantage over remaining on the waitlist, which was evident by 6 months after transplant (HR, 0.32; 95% CI, 0.17 to 0.62). Furthermore, the risk for death resulting from infection was significantly higher during the first 6 months after transplant (HR, 26.6; 95% CI, 5.01 to 141.3), whereas there was an early (≤6 months) and sustained decrease in the risk for cardiovascular death (HR, 0.20; 95% CI, 0.08 to 0.47). In summary, these data suggest the importance of liver biopsy before transplant and show that kidney transplantation confers a long-term survival benefit among HCV-infected patients with ESRD compared with remaining on the waitlist. Nevertheless, the higher incidence of early infection-related deaths after transplant calls for further study to determine the optimal immunosuppressive protocol.

Treatment of hepatitis C virus infection in patients with end-stage renal disease

Hepatitis C virus (HCV) infection is a major health problem in patients with end-stage renal disease (ESRD). The incidence of acute HCV infection during maintenance dialysis is much higher than that in the general population because of the risk of nosocomial transmission. Following acute HCV infection, most patients develop chronic HCV infection, and a significant proportion develop chronic hepatitis, cirrhosis, and even hepatocellular carcinoma. Overall, chronic hepatitis C patients on hemodialysis bear an increased risk of liver-related morbidity and mortality, either during dialysis or after renal transplantation. Interferon (IFN) therapy is modestly effective for the treatment of HCV infection in ESRD patients. Conventional or pegylated IFN monotherapy has been used to treat acute hepatitis C in ESRD patients with excellent safety and efficacy. Regarding chronic hepatitis C, approximately one-third of patients can achieve a sustained virological response (SVR) after conventional or pegylated IFN monotherapy. The combination of low-dose ribavirin and conventional or pegylated IFN has further improved the SVR rate in treatment-naïve or retreated ESRD patients in clinical trials. Similar to the treatment of patients with normal renal function, baseline and on-treatment HCV virokinetics are useful to guide optimized therapy in ESRD patients. Of particular note, IFN-based therapy is not recommended at the post-renal transplantation stage because of the low SVR rate and risk of acute graft rejection. In conclusion, ESRD patients with HCV infection should be encouraged to receive antiviral therapy, and those who achieve an SVR usually have long-term, durable, virological, biochemical, and histological responses.