Hepatitis C virus (HCV) affects approximately 4 million Americans, and can trigger, share risk factors for, or result from CKD. Besides causing glomerulonephritis, HCV is associated with diabetes, a CKD precursor. End stage renal disease (ESRD) is a risk factor for HCV, transmitted via transfusions or transplantation in the era preceding its identification. The estimated HCV prevalence among U.S. CKD patients is 10 percent, several-fold higher than the general population, and is presumed to increase with CKD stage, with demographic variation. While acute infection is often subclinical, chronic HCV infection develops in most patients, leading to cirrhosis, hepatocellular carcinoma, and liver failure. Together with extrahepatic manifestations of glomerulonephritis and diabetes, these complications reduce HCV-positive CKD patient survival.
Standard antiviral therapy, until recently interferon-alpha (IFN) and ribavirin, achieved sustained response rates around 40 percent. Response rates are lower in patients infected with genotype 1, the most common HCV genotype among infected ESRD patients. Drug intolerance in CKD diminishes efficacy and IFN’s immunostimulatory properties increase transplant rejection risk.
The impact of HCV across the CKD spectrum, coupled with limited preexisting recommendations, was the impetus for these guidelines. The multinational Work Group comprised general and transplant nephrologists, hepatologists, pathologists, virologists, epidemiologists, and infection control specialists, all with expertise in HCV or its consequences (1).
Statements were graded as strong (high-quality evidence, intervention “should be performed”), moderate (moderate-low quality evidence, intervention “should be considered”), or weak (low or absent quality evidence, consensus-based recommendations, intervention “suggested”). Five topics were covered: 1) detection and evaluation of HCV, 2) treatment of HCV infection, 3) prevention of HCV transmission in hemodialysis units, 4) management of HCV-infected transplant patients, and 5) diagnosis and management of HCV-associated kidney diseases.
Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease. Kidney Int 2008; 109 (Suppl):S1–S99.