Antiviral Therapy for HCV-Associated Cryoglobulinemic Glomerulonephritis: Case Report and Review of the Literature

Abstract

We describe the case of a 51-year-old woman with HCV-associated cryoglobulinemic glomerulonephritis (GN). She presented mild deterioration of kidney function, non-nephrotic proteinuria, and active urinary sediment. Kidney biopsy showed features of membranoproliferative changes with some sclerosis. Sustained viral response (SVR) was obtained by 6 months of antiviral therapy (peg-IFN-α2a plus ribavirin). SVR was linked with improvement of kidney function and remission of proteinuria. Clinical and virological remission persists over a 25-month follow-up. This case report emphasizes efficacy and safety of antiviral treatment of HCV-associated glomerulonephritis – preliminary but encouraging results exist. We identified by systematic review of the literature 9 studies (156 unique patients); the pooled estimate of frequency of sustained virological response after IFN-based therapy was 0.49 (95% confidence interval, CI: 0.21, 0.77; p < 0.0005; random effects model). Heterogeneity was found (I² = 98.9%, p < 0.0001). Two possible regimens should be considered for the treatment of HCV-associated cryoglobulinemic GN according to the clinical presentation. Immunosuppressive therapy is recommended for HCV-related kidney disease having aggressive course, and recent evidence supports rituximab (RTX) use with a reduced exposure to corticosteroids. We identified six studies (66 unique patients) on RTX therapy for HCV-associated kidney disease; at the end of RTX therapy, the pooled estimate of the mean decrease in proteinuria was 1.4 g/24 h (95% CI: 0.75, 2.05, p < 0.001); The p test for heterogeneity gave a value of 0.94 (I² = 0). Several questions related to RTX use remain. HCV-induced GN is uncommon among CKD patients of developed countries, and this clearly hampers prospective controlled clinical trials aimed to evaluate efficacy and safety of antiviral or immunosuppressive therapy in this population.

Membranous nephropathy associated with hepatitis C virus infection treated with corticosteroids and Ledipasvir-Sofosbuvir: a case report and review of literature

“…By literature review, we found two case reports of patients with HCV-associated glomerulonephritis, presented with deterioration of kidney function and proteinuria. [17, 18] Treatment with INF-2a (one plus ribavirin) resulted in sustained virological response with a clinical remission of proteinuria as well as stabilization of renal function. Thus, we suggest that anti-virus therapy could ameliorate proteinuria in patients with HCV related glomerulonephritis.…”

A Case of Cryoglobulinemic Membranoproliferative Glomerulonephritis Induced by Hepatitis C Virus

“…However, especially when splenoma is present, as in our case, treatment with IFN alone might not be able to inhibit memory B cells. The complete remission rate of chronic HCV infection with IFN therapy is about 30% 31 . New therapeutic agents, such as protease inhibitors and polymerase inhibitors, have recently been developed and are expected to have beneficial effects 32 34 .…”

“…The possibility has also been suggested that IFN aggravates primary glomerular diseases 31,35,36 . Previous reports indicate that in many cases of IFN-induced glomerulonephritis, remission was achieved by discontinuation of IFN therapy and appropriate treatment 35 .…”

Managing refractory cryoglobulinemic vasculitis: challenges and solutions

“…Severe adverse effects (fulminant hepatitis in HCV liver cirrhosis, serious infections, and sepsis) were rarely noticed when applied for primary glomerulonephritis treatment 26,38,41,42. Respiratory infections were slightly more frequent, as well as cytopenias, when rituximab was applied along with antiviral drugs 32,33,43. In some patients with HCV-related CryoVas, severe systemic reactions after administration of rituximab have been noticed 37,44.…”