Chronic HCV in patients with renal disease

Hepatitis C virus infection remains prevalent in dialysis patients and renal transplant recipients. Treatment of HCV in patients with chronic kidney disease (CKD) is predicated on the premise that HCV is associated with decreased patient survival. All CKD patients with HCV should be evaluated for antiviral treatment and the decision to treat be based on potential benefits and risks of therapy (including life expectancy, candidacy for kidney transplantation, and comorbidities). There is good information supporting the antiviral treatment of HCV-infected renal transplant candidates; in these patients the goals of antiviral therapy include to avoid HCV-related extra-hepatic complications after RT (i.e., de novo glomerulonephritis, new onset diabetes after transplant, infections, and chronic allograft nephropathy). The summary estimate of sustained virological response (SVR) and drop-out rate to monotherapy with standard or pegylated interferon in dialysis patients, according to recent meta-analyses, is around 33–37 and 17–23% respectively. Recent data support the use of ribavirin in the dialysis setting, after implementation of some safety precautions. The summary estimate for sustained viral response in patients receiving IFN plus ribavirin was 56% (95% CI, 28–84). No data are available yet to confirm that achieving SVR translates into improved survival in the CKD population with HCV infection. However, successful antiviral therapy can improve other outcomes (e.g., liver histology). Pretransplant liver biopsy is crucial to determine the severity of hepatic injury and thereby to assess the prognosis of the patient. Antiviral therapy is virtually contraindicated after renal transplantation as the frequency of acute rejection induced by IFN is great (up to 50%). Kidney transplantation should be considered the treatment of choice for patients with CKD stage 5 and HCV. A risk related to the use of kidneys from HCV-positive donors cannot be excluded.