Treatment of hepatitis C infection in patients with renal disease

Hepatitis C infected hemodialysis and renal transplant patients with elevated α-glutathione S-transferase have increased risk for liver damage

Patients on hemodialysis (HD) and renal transplant recipients (RT) have a high prevalence of HCV infection. Theaimof our study was to determine the prevalence of HCV-RNA in the anti-HCV positive patients and to compare the biochemical parameters of PCR(+) and PCR(−) subgroups.Methods:The 525 sera were screened for anti-HCV. HCV-RNA was detected by polymerase chain reaction (PCR) and liver enzymes [SGOT, SGPT, GGT,α-glutathione S-transferase (GST)] were measured.Results:Active viraemia was found only in 187 of 289 (65%) seropositive HD patients in contrast to 53 of 53 (100%) of seropositive RT patients. Significantly increased (p<0.05) GST values (9.9 μg/l) were found in the PCR(+) subgroups compared to GST levels (2.7 μg/l) of the PCR(−) subgroups. Elevated GST concentration was found in 80% (208/251) of PCR(+) patients. The measured enzymes were not elevated in HCV infected patients. Six percent of HD and 11% of RT patients were screened before seroconversion. Diagnostic sensitivity (80%) and specificity (79%) of GST were calculated as good for early liver damage caused by HCV. In contrast, the sensitivity of the measurement of other liver enzymes were very weak (SGOT: 8%; SGPT: 10%; GGT: 42%).Conclusion:The significantly higher viraemia of the RT subgroup could be related to the immunosuppressive therapy. Increased GST level may be a useful indicator of tissue damage during HCV infection. If HCV infection is suspected, PCR and GST measurement should be performed, even if anti-HCV result is negative.

Increased prevalence of reduced estimated glomerular filtration rate in chronic hepatitis C patients

BACKGROUND

To investigate the prevalence and severity of reduced estimated glomerular filtration rate (eGFR) in patients with chronic hepatitis C (CHC).

METHODS

Medical record review of 831 consecutive CHC patients seen in our clinic between July 2000 and August 2003; eGFR was estimated using the abbreviated Modification of Diet in Renal Disease (aMDRD) equation. The stage of kidney disease was determined based on eGFR expressed in milliliters per minute per 1.73 m(2): stage 1 (signs of kidney damage but normal or elevated (eGFR >or= 90), stage 2 (eGFR 60-89), stage 3 (30-59), stage 4 (eGFR 15-29), stage 5 (eGFR < 15 or dialysis-dependent).

RESULTS

A total of 522 patients had available data with using the aMDRD equation, 51% had abnormal eGFR (stage 1, 4.6%; stage 2, 36.4%; stage 3 or 4, 6.1%; stage 5, 3.8%). Of 190 patients with stage 2 kidney disease, 189 patients (99.5%) had normal serum creatinine and only one patient (0.5%) had elevated creatinine concentrations (>1.4 mg/dl). Of the 32 patients with stage 3 or 4 disease, 20 (62.5%) had a normal serum creatinine concentration. Of 349 patients without diseases known to cause renal insufficiency, 38% had stage 2-4 renal disease. In a subset of these patients, 95/522 (18%) the measured creatinine clearance showed good correlation with their aMDRD (R = 0.47, (p < 0.0001).

CONCLUSIONS

In CHC patients, a normal serum creatinine concentration does not assure normal kidney function. Estimation of eGFR with the aMDRD equation is a more accurate method of identifying patients with chronic kidney disease and reduced eGFR. Therefore, CHC patients should be screened more rigorously for chronic kidney disease because of the high prevalence of reduced eGFR. Lastly, in all CHC patients, the aMDRD eGFR should be used in each encounter with these patients when assessing their renal function irrespective of their serum creatinine.

Hepatitis C and renal transplantation: a review on historical aspects and current issues

Chronic liver disease has a significant impact on the survival of renal transplant recipients with an incidence rate of 4-38%. Approximately, 8-28% of renal transplant recipients die due to chronic liver disease. Hepatitis C seems to be the leading cause of chronic liver disease in kidney recipients. Hepatitis C virus (HCV) infection has a wide range of prevalence (2.6-66%) among renal transplant recipients living in different countries with great genotype diversity in different parts of the world. Nowadays, antiviral drugs are used for the management of hepatitis C. Because of graft-threatening effects of some antiviral drugs used in HCV-infected renal transplant recipients, we specifically focused on HCV treatment after renal transplantation. Treatment of post-renal transplantation chronic liver disease with INF and ribavirin remains controversial. Anecdotal reports on post-renal transplantation hepatitis C demonstrate encouraging findings. This review summarises the most current information on diagnosis, treatment, prognosis, complications as well as the new aspects of treatment in HCV-infected renal transplant recipients. HCV belongs to the family of Flaviviridae, genus Hepacivirus.

Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach

Hepatitis C Virus is associated with a wide series of extrahepatic manifestations. Based on available data the link between the virus and some of these extrahepatic diseases is only suggested and needs further confirmation. Hepatitis C Virus-related lymphoproliferative disorders, whose prototype is mixed cryoglobulinaemia, represent the most closely related extrahepatic manifestations of Hepatitis C Virus. Other Hepatitis C Virus-associated disorders include nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, porphyria cutanea tarda, lichen planus, diabetes, chronic polyarthritis, cardiopathy and atherosclerosis. A pathogenetic link between Hepatitis C Virus and some extrahepatic manifestations was confirmed by their responsiveness to antiviral therapy, which is now deemed the first therapeutic option to consider. By contrast, there are diseases where treatment with interferon was ineffective or dangerous. The aim of the present paper is to outline the most recent evidence concerning extrahepatic disorders that are possibly associated with Hepatitis C Virus infection. Special emphasis will be given to discussion of the most appropriate clinical approaches to be adopted in order to diagnose, treat (possibly prevent) and follow-up extrahepathic diseases in patients with Hepatitis C Virus infection.

Hepatitis C is a predictor of poorer renal survival in diabetic patients

OBJECTIVE

Hepatitis C virus (HCV) is highly prevalent in the U.S. and worsens renal survival in some kidney diseases. We examined the effects of HCV on renal survival in diabetic patients with renal disease.

RESEARCH DESIGN AND METHODS

HCV and diabetes status were noted in patients seen in our nephrology clinic in 2001 and 2002. Charts of diabetic patients were reviewed for demographics, blood pressure, renal function, medicines, the presence of HCV, and other factors at the initial visit and over follow-up. The effect of HCV on renal survival was determined by Cox proportional hazards, using end-stage renal disease (ESRD) as an end point.

RESULTS

Of 1,127 patients, prevalence rates for HCV were higher in African Americans than non-African Americans (8.09 vs. 3.93%, respectively, P = 0.06), with African-American men having the highest prevalence rates (12.7%). The charts of 312 diabetic patients were reviewed. Over 80% were African American, as were 23 of 24 patients with HCV. Compared with non-HCV patients, HCV patients were younger, had higher diastolic blood pressure, and had lower BMI. HCV patients had significantly worse cumulative renal survival by Kaplan-Meier. On Cox proportional hazards analysis, HCV was a significant predictor of reaching ESRD independent of initial renal function, proteinuria, blood pressure, sex, race, presence of diabetic nephropathy, age, or duration of diabetes (odds ratio 3.49, 95% CI 1.27-9.57, P = 0.015).

CONCLUSIONS

HCV is common in African Americans with diabetes and renal disease and is an independent risk factor for renal survival in this population. Prospective studies are necessary to confirm these observations.

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.

Infections associated with uremia and dialysis

Patients with chronic renal failure are predisposed to infections. Infections in end-stage renal disease patients are caused by immunosuppressive effects of uremia. Patients with renal failure on dialysis have impaired host defenses and may develop infections related to vascular access. This article reviews the infectious complications related to chronic renal failure in dialysis.

Gastrointestinal and hepatic disorders in end-stage renal disease and renal transplant recipients

Gastrointestinal and hepatic disorders are commonly associated with end-stage renal disease, hemodialysis, and renal transplantation. Recent studies indicate that the prevalence of dyspepsia, ulcer disease, and Helicobacter pylori gastritis is not significantly different from the general population. Bleeding from angiodysplasia, however, is more common in chronic renal failure, as is gastroparesis. The prevalence of chronic hepatitis B has been dramatically reduced among hemodialysis patients since the advent of universal precautions. Response rates to hepatitis B vaccine in noninfected patients, however, are lower in these individuals. Chronic hepatitis C is found in 20% to 25% of HD patients worldwide and accounts for approximately 1% of all infected individuals. Levels of alanine aminotransferase and aspartase aminotransferase are often within normal limits but may be elevated compared with a patient's preinfection levels. Dialysis has been shown to reduce the level of hepatitis C virus viremia. Treatment is similar to non-renal failure patients, although interferon is generally not used in renal transplant recipients owing to concerns of graft failure.