Background and Aims: Patients with chronic hepatitis C (CHC) and end-stage renal disease (ESRD) who are dialysisdependent form a unique group, in which safety, tolerability and efficacy of sofosbuvir (SOF)-based direct-acting antivirals (DAAs) need further evaluation. Methods: We performed a retrospective analysis of 14 patients with CHC and ESRD on dialysis who received 15 courses of SOF-based therapy. We evaluated dose escalation to standard-dose SOF in this proof-of-principle experience. Results: Sustained virological response (defined as undetectable viral load at 12 weeks, SVR-12) was achieved in 13 out of the 15 (86.7%) treatment courses. Seven (46.6%) patients received reduced half dose as conservative proof-of-principal to mitigate potential toxicity. In 13 out of 15 treatment courses, patients completed the designated treatment duration. One patient was treated twice and developed SVR-12 with the retreatment. One patient was lost to follow-up and counted as a non-responder. Premature discontinuations were not due to DAA-related adverse effects. There were no reports of severe adverse effects or drug interactions. Conclusion: We treated CHC patients with ESRD using dose escalation to standard-dose SOF in this proof-of-principle experience and achieved SVR rates comparable to general population. Citation of this article: Aggarwal A, Yoo ER, Perumpail RB, Cholankeril G, Kumari R, Daugherty TJ, et al. Sofosbuvir use in the setting of end-stage renal disease: a single center experience.

Multiple studies have shown a high prevalence of chronic hepatitis B (CHB) infection in the Philippines, not only in high-risk populations but also in the general population. The most recent national study estimated HBsAg seroprevalence to be 16.7%, corresponding to an estimated 7.3 million CHB adults. The factors underlying the high prevalence of CHB and its sequelae include the inadequate use of vaccination for prevention and the lack of treatment for many Filipinos. Because without medical monitoring and treatment of CHB the risk of progression to liver failure and death is 25-30%, the ultimate medical and societal costs will be very high if the Philippines fails to properly address hepatitis B infection. It will be very important to move forward with programs that can help to ensure universal vaccination of newborns, screening and vaccination nationwide, and monitoring and treatment for CHB persons. It will also be crucial to address transmission of HBV in the health-care setting (via contaminated needles and syringes and inadequately sterilized hospital equipment) and via injection drug use and tattooing. Because of the relatively low average per capita income and the lack of coverage by PhilHealth of outpatient visits and medications, there is an urgent need to move forward with a nationally supported program that includes education for both the general public and health-care workers on liver disease and screening for hepatitis viruses, followed by, as appropriate, vaccination or treatment, with expanded government coverage for these for all those who could not otherwise afford it.

INTRODUCTION: The estimated annual incidence of clearance of Hepatitis B surface antigen (HBsAg) is 1–2% in Asian populations. The spontaneous seroclearance of HBsAg in patients with chronic Hepatitis B infection in the Western world is seldomly reported. HBsAg loss is a relatively rare outcome in the natural history of chronic Hepatitis B. Aim of this study was to assess the incidence of spontaneous seroconversion of Hepatitis B surface antigen and the natural development of immunity to HBV virus as evidenced by development of Hepatitis B surface antibody (HBsAb) in a US-based outpatient population. METHODS: Electronic medical records from January 2010 to May 2019 at a large outpatient community-based Gastroenterology practice were retrospectively reviewed. Seroconversion of HBsAg and appearance of HBsAb were recorded. Serologic markers for Hepatitis B infection, AST, ALT, and alpha fetoprotein levels were also recorded. RESULTS: A total of 263 charts were reviewed. One hundred seventy nine (179/263; 68%) of these patients had a positive HBsAg upon referral. Fifty five had a history of Hep B treatment; 124 (124/179; 69%) were treatment-naïve. Forty six (46/179; 26%) had chronic active Hepatitis B, and seventy three (73/179; 40%) were lost to follow up. Five (5/179; 2.7%) patients seroconverted to negative HBsAg. Four of these patients subsequently developed immunity as evidenced by the appearance of HBsAb (4/179; 2.2%). Sixty seven (67/263; 25.5%) of all referred patients had immunity to Hepatitis B through natural infection. Thirteen (13/263; 4.9%) patients had incomplete serologies; 4 (4/263; 1.5%) patients were caught in the “window period” with both negative HBsAg and HBsAb. All four patients who had a documented loss of HBsAg were male, Asians (Filipino), aged 48-65 years. The average time from referral to HBsAg clearance was 8-9 years. None of the 4 patients had a positive Hepatitis delta agent, concomitant infection with Hepatitis C, or elevated AFP. CONCLUSION: Chronic HBV infection poses a significant socio-economic burden specially among immigrant communities from endemic geographic regions. Continued adherence to CDC guidelines for HBV screening should be encouraged among high risk patient populations. Further race/ethnicity and community based studies on the natural history of chronic HBV infection will further increase knowledge of disease prevention and cure.

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