New-onset hepatitis C virus-associated glomerulonephritis following sustained virologic response with direct-acting antiviral therapy

Abstract

Glomerulonephritis (GN) is an important extra-hepatic manifestation of infection with hepatitis C virus (HCV). HCV-associated GN occurs due to HCV-induced lymphoproliferation, leading to the generation of pathogenic immune complexes, including complexes containing cryoglobulins. The management of HCV-associated extra-hepatic disease is focused on viral eradication, with direct-acting antiviral agents leading to high rates of sustained virologic remission. There have been a few reports of relapsing cryoglobulinemic vasculitis after sustained virologic remission was achieved with interferon-based therapies. This report presents two cases of new-onset HCV-associated GN that occurred after sustained virologic response was achieved with direct-acting antiviral (DAA) therapy. .

Direct-Acting Antiviral Agents for HCV-Associated Glomerular Disease and the Current Evidence

“…disease has been noted by some authors in patients who achieved SVR with regimens based on DAAs [18][19][20]. Figure 2 shows purpuric manifestations in the lower limbs in a patient with HCV-related cryogobulinemic patient who received DAAs.…”

“…Finally, we suggest that serum creatinine and urinary abnormalities should be monitored with accuracy in all patients after antiviral treatment with DAAs. New-onset or relapsing glomerular disease has been noted by some authors in patients who achieved SVR with regimens based on DAAs [18][19][20]. Figure 2 shows purpuric manifestations in the lower limbs in a patient with HCV-related cryogobulinemic patient who received DAAs.…”

Persistent Hepatitis C Virus−Associated Cryoglobulinemic Glomerulonephritis in Patients Successfully Treated With Direct-Acting Antiviral Therapy

“…Others have previously reported that persistent (n = 6), recurrent (n = 1), and even de novo (n = 2) HCV-CryoGN can occur despite achievement of SVR. 21 , 22 , 23 HCV-CryoGN in the setting of SVR may be an indication for immunosuppressive therapy.…”

“…reported 2 patients with newly diagnosed HCV-CryoGN on kidney biopsy approximately 1 year after achieving SVR (1 patient with simeprevir and 1 patient with pegylated INF-α, ribavirin, and sofosbuvir). 22 Chowdhury and Tsen described a patient with recurrent HCV-CryoGN diagnosed approximately 2 months after achieving SVR with sofosbuvir and ribavirin. 23 We report herein 3 cases of biopsy-proven HCV-CryoGN diagnosed in patients who previously had achieved SVR with DAA therapy.…”

Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…The development or persistence of cryoglobulinemic vasculitis (with or without kidney involvement) after achieving sustained virologic response has been described. [64][65][66][67] Whether this presentation reflects continued B-cell production of pathogenic immune complexes requires further study.…”