Management of Hepatitis C in Patients with Chronic Kidney Disease

Abstract

Chronic kidney disease represents a global health problem. Chronic hepatitis C virus (HCV) infection is prevalent in patients with end stage renal disease (ESRD) on hemodialysis (HD) and in renal transplant recipients with significant impact on morbidity and mortality. Furthermore, HCV can cause various forms of glomerulopathy with the predominant type being cryglobulinemia associated membranoproliferative glomerulonephritis. Liver enzymes are traditionally used as markers of liver injury; however, there is wide variation in aminotransferase levels in patients with ESRD. Therefore, diagnosis of chronic hepatitis C (CHC) in patients with ESRD is based on HCV antibody testing and further confirmation with polymerase chain reaction testing. Current standard therapy for CHC is composed of pegylated interferon and ribavirin. However, this combination is challenging in patients with ESRD due to its tolerability. We describe in this review relevant issues in epidemiology, diagnosis and management of CHC in ESRD, HD and renal transplant recipients.

Management of patients with hepatitis C infection and renal disease

“…It is known that serum ALT levels in patients with ESRD are lower than in the general population, so it should not be used to screen for liver diseases [23][24][25] . This is possibly due to suppression of ALT synthesis in hepatocytes, defective release of ALT into the blood stream, or accelerated clearance in patients with chronic renal insufficiency [24,26] .…”

“…The lower cutoff ALT level (≥ 27 U/L) was proposed for patients with ESRD to increase sensitivity (to 50%) and specificity (to 100%) for detecting HCV viremia [23] . In addition, there is a weak correlation between ALT levels and liver disease activity in patients with ESRD, especially those on dialysis [25] .…”

“…The second generation EIA (EIA-2) assay was frequently associated with false negative results in patients with ESRD on dialysis, with a reported rate of 2.6%-7% [27,28] . The third generation EIA (EIA-3) testing provided excellent accuracy, with 0.26% falsenegative rate, and is the preferred screening tool in this setting [3,25,29] . PCR-based molecular diagnostics are required to confirm viremia, viral load, and genotype to guide management decisions.…”

“…Notably, HCV-RNA level is transiently decreased during hemodialysis and gradually returns to baseline level within 48 h [3] . This may be explained by several mechanisms, such as interference with PCR technique by heparin used during dialysis, adsorption of HCV onto the dialysis membrane, destruction of HCV particles by the hydraulic pressure, escape of HCV into the dialysate, or increased plasma IFN levels during the dialysis [3,25] . Therefore, it is recommended to determine HCV-RNA level before hemodialysis to avoid the possibility of underestimation [3] .…”

Chronic kidney disease, spirituality and religiosity: a systematic overview with the list of eligible studies

“…1 It is a condition in which the kidneys damage leads to a loss of their physiological functions (filtering blood, regulating the pressure, maintaining acids and bases homeostasis, regulating fluids and electrolytes). Thus, wastes are not properly removed, their level tends to increase and this leads to other complex health problems and comorbidities, including above all complications such as cardiovascular disease (CVD), 4 hypertension, 5 anemia, 6 malnourishment (in particular, protein-energy malnutrition, or PEM), 7 endocrinological disorders (impaired balance of electrolytes, erythropoietin deficiency, secondary hyperparathiroidism, hyperinsulinism, growth hormone impairment, sexual dysfunctions), 8 bone diseases (osteoporosis, osteomalacia, osteitis fibrosa, osteodistrophy, adynamic bone and other bone abnormalities that are included in the complex clinical syndrome termed as renal bone disease, or renal osteodistrophy, or CKD-mineral and bone disorder), 9 infections (especially, hepatitis C), 10 cancer, 11 and mental disorders like dementia and cognitive impairment. [12][13][14] People with early CKD tend not to feel any kind of symptom and the only ways to detect CKD as earlier as possible are through a blood test to estimate kidney function, and a urine test to quantitatively assess the entity of kidney damage.…”