The impact of hepatitis C virus infection on survival in dialysis patients: meta‐analysis of observational studies

Abstract

The impact of hepatitis C virus (HCV) infection on mortality of patients receiving regular dialysis remains unclear. The assessment of the natural history of HCV in dialysis population is difficult because of the low progression of HCV-related liver disease over time and the reduced life expectancy in patients with end-stage renal disease. The aim of the study was to conduct a systematic review of the published medical literature concerning the impact of HCV infection on the survival of patients undergoing maintenance dialysis. The relative risk of mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies. We identified seven studies involving 11 589 unique patients on maintenance dialysis; two (29%) were case-control studies. Pooling of study results demonstrated that presence of anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (aRR) (all-cause mortality) was 1.34 with a 95% confidence interval (CI) of 1.13-1.59. Heterogeneity statistics, R(i) = 0.48 (P-value by Q-test = 0.13). In a sensitivity analysis including only (n = 5) cohort studies, the pooled aRR was 1.38 (95% CI, 1.20-1.59); heterogeneity statistics R(i) = 0.46. As a cause of death, hepatocellular carcinoma and liver cirrhosis were significantly more frequent among anti-HCV-positive than -negative dialysis patients. Our meta-analysis indicates that anti-HCV-positive patients on dialysis have an increased risk of mortality compared with HCV-negative patients. The excess risk of death in HCV-positive patients may be at least partially attributed to chronic liver disease with its attendant complications.

Indian National Association for Study of the Liver (INASL) Guidance for Antiviral Therapy Against HCV Infection: Update 2016

“…144,145 In CH-C patients with ESRD, altered drug pharmacokinetics, increased susceptibility to drug-related toxicity, the requirement for renal transplantation, and a modified course of disease make their treatment difficult. Some of the other issues, which are peculiar to this population of patients, include normal or minimal elevation of transaminases, GT-1 predominance, inaccurate noninvasive assessment of hepatic fibrosis especially with transient elastography, and higher complication rate after liver biopsy.…”

Occult Hepatitis C Virus Infection in Hemodialysis

“…This link between occult HCV and mortality (odds ratio 3.84) was much stronger than that observed between "classic" hepatitis C and survival in dialysis populations (adjusted relative risk 1.34). 3 It is difficult to explain these conflicting results, because a comparative study 11 of nonuremic patients suggested occult HCV is a mild disease with less liver damage than "classic" chronic hepatitis C, and the percentage of HCV-infected hepatocytes seems significantly lower in patients with "occult" HCV. No liver biopsy information on occult HCV in dialysis patients was provided.…”

“…Damage to the endothelium impairs its capacity to control complement activation allowing the alternative pathway to proceed uninhibited. 1 There is evidence that the membrane attack complex, 2 C3a, 3 and C5a all may contribute to this phase of injury; however, it has proved more difficult to demonstrate a role for complement activation during acute rejection.…”

“…1,2 HCV infection has a detrimental effect on survival in patients on maintenance dialysis 3 and after renal transplantation. In a recent meta-analysis of observational studies, 3 incorporating 11,589 unique patients on maintenance dialysis, the summary estimate for adjusted relative risk for all-cause mortality was 1.34 (95% confidence interval 1.13 to 1.59). The excess risk for death in HCV-positive patients was partially attributed to chronic liver disease with its attendant complications, particularly hepatocellular carcinoma and liver cirrhosis.…”

Sofosbuvir‐based regimens for the treatment of chronic hepatitis C in severe renal dysfunction

“…In the United States, the prevalence of HCV in patients receiving hemodialysis ranges from 5% to 13% depending on the region evaluated 1. End‐stage renal disease is associated with an increased risk for all‐cause and liver‐related mortality compared to the general population 2, 3…”