Treatment of chronic viral hepatitis in patients with renal disease

Patients with ESRD remain at increased risk for HCV/HBV-related liver disease. The recent availability of effective antiviral agents offers new options in the management of chronic hepatitis in infected dialysis and RT recipients. Randomized trials, however, are warranted to clarify the efficacy of IFN plus ribavirin in the management of HCV-related liver disease in patients with ESRD. Lamivudine has been an important addition to the management of HBV-infected RT candidates, lessening the risk of hepatic decompensation. Still, larger scale clinical trials are necessary. Adefovir also required further evaluation in this population. In both HBV- and HCV- infected patients with ESRD, liver biopsy remains an important part of the evaluation of severity of liver disease given the frequent absence of elevated aminotransferases despite chronic viral hepatitis in the population. Identification of HCV's role in GN in native and transplanted kidneys also provides another important rationale for antiviral therapy in patients with renal disease and viral hepatitis. Use of IFN after renal transplantation for HCV infected recipients is precluded by the high frequency of impairment of the graft. IFN can lead to excellent results in selected patients on dialysis with long term remission durable even after RT. Absorption and distribution of PEG IFN are similar in patients with stable chronic renal impairment and individuals with normal renal function; studies are underway to evaluate the efficacy of PEG IFNs in individuals with HCV infection and renal insufficiency. Preliminary data encourage cautious ribavirin use in conjunction with IFN therapy in dialysis populations. There is no standard effective therapy for mixed cryoglobulinemic glomerulonephritis, although IFN-alpha, with or without ribavirin, has been used successfully. Alternative therapeutic options are also under evaluation.