Renal manifestations of hepatitis C virus infection. Extrahepatic complications often are silent--and thus overlooked

Lupus-like glomerulonephritis: an autoimmune complication of hepatitis C infection

Lupus-like glomerulnephritis in patients with negative lupus serologies and no extra-renal manifestations of lupus can create a diagnostic dilemma. We describe a 53-year-old gentleman with chronic hepatitis C virus (HCV) infection who presented with dialysis-requiring renal failure, renal histologic findings of "full-house" immunofluorescence label and tubuloreticular inclusions on electronic microscopy, but no extra-renal or laboratory signs of systemic lupus erythematosis. Attempted treatment with cyclophosphamide and corticosteroids was limited by cyclophosphamide hypersensitivity. The patient remained dialysis-dependent over 18 months of observation and did not develop extra-renal clinical or biological manifestations of lupus. Mimics of seronegative lupus with isolated renal involvement can include HCV-related autoimmunity. Treatment of acute glomerulonephritis may be similar initially, but other concerns in patients with HCV infection include excluding cryoglobulinemia, the potential impact of immunosuppression therapy on liver disease and consideration of subsequent use of antiviral therapy. Given the increasing prevalence of HCV globally, the recognition of extra-hepatic autoimmune manifestations of HCV infection will likely increase.

Long-term outcomes after treatment with interferon and ribavirin in HCV patients

Hepatitis C is a leading indication for transplantation and a common cause of liver-related death worldwide. Treatment for hepatitis C has evolved from interferon therapy alone, which yielded relatively poor response rates compared with the currently recommended and more effective combination of pegylated interferon and ribavirin. Factors such as hepatitis C viral genotype, pretreatment viral load, race, renal function, degree of hepatic fibrosis, and comorbid conditions such as HIV coinfection have clinical importance in that they influence viral kinetics, which play a large role in determining a sustained response to therapy or virologic "cure." However, the goal of therapy is to reduce liver-related morbidity and mortality by decreasing rates of progression or improvement of fibrosis, reducing risk of hepatocellular carcinoma, improving posttransplant graft and patient survival, and resolving or improving some of the extrahepatic manifestations of hepatitis C. Studies generally infer long-term success from the more tangible goal of sustained viral suppression; however, increasing data suggest that effective therapy does result in decreased morbidity and mortality. Given the heterogeneity of patients who are infected with hepatitis C, treatment decisions should be specifically tailored to each individual patient on the basis of their predisposing conditions and anticipated clinical outcomes.

Renal hepatitis C in the absence of detectable serum or hepatic virus

We report an apparently unique case where hepatitis C virus (HCV) RNA was identified in renal tissue from a patient with membranoproliferative glomerulonephritis and treated chronic hepatitis C, despite the absence of detectable virus in the serum or liver (COBAS Amplicor qualitative assay, lower limit of detection 50 IU/ml). The implications of this finding are discussed, with particular reference to current concepts regarding 'occult' hepatitis C infection.

Histological characterization of HCV-associated glomerulopathy in Egyptian patients

BACKGROUND

HCV infection in Egypt has reached epidemic proportion, it is associated with many extra hepatic manifestations. Glomerulonephritis (GN) is one of the most serious ending in renal failure in some cases. Detection of viral genome or particles within the kidneys of HCV-infected patients proved to be difficult. Histological characterization of renal lesions still represents a major challenge. The aim of our work was to describe the histological patterns of HCV-associated nephropathy.

METHODS

Fifty patients--out of 233 presented to Mansoura Urology and Nephrology clinic with manifestations of glomerular disease were screened for HCV antibodies by 3rd generation ELISA test-, those proved positive for HCV antibodies were confirmed by PCR for HCV RNA and were thoroughly investigated regarding clinical, biochemical, histological criteria's of HCV-associated nephropathy. Kidney and liver biopsies were examined by LM and electron microscopy.

RESULTS

Histological study of renal biopsies revealed membranoproliferative (MPGN) type 1 to be the commonest lesion encountered (54), followed by focal segmental glomerulosclerosis (FSGS) (24), mesangioproliferative GN (18), membranous nephropathy (MN) (4) in that order. Electron microscopic examinations of renal biopsies were successful in identifying HCV-like particles in frozen renal tissue.

CONCLUSION

HCV-associated glomeruloapthy is a distinct category of glomerulonephritis, by LM it has some peculiar features, we were successful in localization of HCV particles in renal tissues by EM.

Relationship between Hepatitis C and Chronic Kidney Disease: Results from the Third National Health and Nutrition Examination Survey

Previous research supports an association between hepatitis C virus (HCV) infection and glomerulonephritis. However, little is known about the association between HCV and chronic kidney disease. The cross-sectional association between prevalent hepatitis C seropositivity and albuminuria and estimated GFR (eGFR), respectively, was examined among 15,029 participants in the Third National Health and Nutrition Examination Survey (NHANES III). In the multivariate analysis, we noted an age-dependent association between HCV seropositivity and albuminuria (adjusted odds ratios and 95% confidence intervals 0.83, 0.39 to 1.75 for ages 20 to 39; 1.84, 1.00 to 3.37 for ages 40 to 59; 2.47, 1.27 to 4.80 for > or =60 yr of age). There was no significant association observed for hepatitis C seropositivity and low eGFR (<60 ml/min per 1.73 m(2); adjusted odds ratios and 95% confidence interval for all ages 0.89, 0.49 to 1.62). Among a representative sample of the US population, hepatitis C is independently associated with albuminuria among adults over the age of 40; however, it does not seem to be significantly associated with a low eGFR in this population-based cross-sectional analysis.

Renal dysfunction in liver cirrhosis

Liver cirrhosis is an escalating health problem attributed to numerous causes, including an increase in alcohol consumption, morbid obesity and chronic viral hepatitis. The circulatory disturbances seen in advanced cirrhosis lead to the development of ascites, which often lead to progressive renal impairment or the development of hepatorenal syndrome. Furthermore, cirrhotic patients commonly experience clinical situations that predispose them to the development of pre-renal failure, such as dehydration, hypovolaemia, septic shock, or exposure to nephrotoxic drugs. This article provides an overview of the main causes of acute renal failure in liver cirrhosis and describes the current medical and nursing management.

Extrahepatic manifestations of hepatitis C

Hepatitis C affects approximately 170 million people worldwide. Extrahepatic manifestations of chronic hepatitis C infection are clinically evident in nearly 40% of patients. Much research has been done over the last decade to better understand their incidence, clinical presentation, mechanism of disease, and the role of antiviral therapy in their treatment. Of the commonly reported manifestations, cryoglobulinemia, membranoproliferative glomerulonephritis, and porphyria cutanea tarda remain the best understood manifestations. More recently, the association of insulin resistance and diabetes mellitus with chronic hepatitis C has been demonstrated. This paper serves to review the growing body of literature detailing the extrahepatic manifestations of chronic hepatitis C.

HCV associated glomerulopathy in Egyptian patients: clinicopathological analysis

BACKGROUND

Hepatitis C virus (HCV) infection in Egypt has reached an epidemic proportion and is associated with many extra hepatic manifestations; Glomerulonephritis (GN) is one of the most consequences of HCV infection often resulting in end stage renal disease in some cases. Detection of viral genome or particles within the kidney biopsies from HCV-infected patients has proven to be difficult. Histological characterization of renal lesions still represents a major challenge. The aim of our work was to describe the histological pattern of HCV-associated nephropathy.

METHODS

Fifty Patients--out of 233--presented to Mansoura Urology and Nephrology clinic with manifestations of glomerular disease were screened for HCV antibodies by a 3rd generation ELISA test. Those tested positive for HCV antibodies were confirmed by PCR for HCV-RNA and subjected to more detailed clinical, biochemical and histological study. Kidney biopsies and in appropriate cases liver biopsies were examined by LM and electron microscopy (EM).

RESULTS

Histological study of renal biopsies revealed membranoproliferative (MPGN) type 1 to be the most common lesion encountered (54%), followed by focal segmental glomerulosclerosis (FSGS) (24%), mesangioproliferative GN (18%), membranous nephropathy (MN) (4%) in that order. EM examinations of renal biopsies were successful in identifying HCV like particles in frozen renal tissue.

CONCLUSION

HCV-associated glomerulopathy is a distinct category of glomerulonephritis. Results of LM showed some peculiar features. In addition, we were successful in location and detection of HCV particles in renal tissues by EM.

Hepatitis C virus-related extra-hepatic disease--aetiopathogenesis and management

Summary Hepatitis C virus infection is often associated with extra-hepatic manifestations, secondary to the elicitation of autoimmune reactions, generalized deposition of immune complexes and lymphoproliferative disorders. The most clearly established associations are those linking chronic hepatitis C with mixed cryoglobulinaemia (and the related glomerulonephritis and cutaneous vasculitis), as well as with the presence of autoantibodies. Less well-documented disorders include non-Hodgkin's lymphoma, thrombocytopenia, sialadenitis, thyroid disease, lichen planus, porphyria cutanea tarda, rheumatoid disorders and neurological disorders. Extra-hepatic manifestations are most frequent in patients of female sex, advanced age, long-lasting infection and cirrhosis. Optimal treatment strategies should be based on the predominant manifestation of the disease. In the case of autoimmune disorders not clearly attributable to the viral infection, corticosteroids may be the most effective option. Interferon-alpha alone or in combination with ribavirin may be indicated for those disorders related to immune complex deposition, such as mixed cryoglobulinaemia, although relapses of extra-hepatic signs often occur on discontinuation of treatment. In some cases, interferon-alpha may induce or exacerbate some extra-hepatic manifestations.