Stakeholders Update HCV Management Guidelines for Chronic Kidney Disease Patients

Paul Martin, MD

With the advent of new treatments, an international taskforce has updated 2008 guidelines for the prevention, diagnosis, treatment, and management of hepatitis C virus (HCV) infections in adult chronic kidney disease (CKD) populations.

The team, led by Michel Jaboul, MD, of Université Catholique de Louvain and Paul Martin, MD of the University of Miami, recently published The Kidney Disease: Improving Global Outcomes (KDIGO) 2018 clinical practice guideline with 66 new recommendations that include more widespread use of direct-acting antivirals (DAAs) instead of interferon drugs to treat infections for this population.

The recommendations were ultimately split into 5 different categories—the detection and evaluation of HCV in CKD, treatment of HCV infection in patients with CKD, prevention of HCV transmission in hemodialysis units, management of HCV-infected patients before and after kidney transplantation, and diagnosis and management of kidney diseases associated with HCV infection.

“We are optimistic that the current KDIGO guideline will increase attention on the intersection between HCV and CKD and spur future investigation into new directions to improve the care of this patient population,” the authors wrote.

The recommendations include screening all CKD patients for HCV infection at the time of their initial evaluation and using an immunoassay followed by nucleic acid testing if the immunoassay is positive.

They also recommend screening all patients for infection upon initiation of hemodialysis and at the time of evaluation for kidney transplantation.

The team reccomends evaluating patients for antiviral therapy, an interferon-free regimen, and a choice of specific regimen based on the HCV genotype, viral load, prior treatment history, drug-drug interactions, glomerular filtration rate, stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities.

There was also particular focus paid to DAAs in the guideline due to a 90-100% sustained virologic response with few adverse events.

“We recommend that patients with GFR ≥30 mL/min/1.73 m² (CKD G1—G3b) be treated with any licensed direct-acting antiviral (DAA)-based regimen,” the authors wrote. “Patients with GFR <30 mL/min/1.73 m² (CKD G4—G5D) should be treated with a ribavirin-free DAA-based regimen.”

They also recommend patients with cryoglobulinemic flare, nephrotic syndrome, or rapidly progressive kidney failure be treated, in addition to DAA treatment, with immunosuppressive agents with or without plasma-exchange and immunosuppressive therapy for patients with histologically active-associated glomerular disease who do not respond to antiviral therapy, especially those with cryoglobulinemic kidney disease.

The overall goal of the guideline is to inform the management of HCV infection, including the use of DAAs in adults with chronic kidney disease. The target audience is nephrologists, transplant physicians, hepatologists, infectious disease specialists, primary care physicians, and other practitioners caring for HCV infected adults suffering from chronic kidney disease.

HCV infection is more common in the CKD population than it is in the general population, where about 5% of patients receiving incident dialysis have HCV-positive results on enzyme-linked immunosorbent assays. Just 1% of the general US population is HCV positive.

In addition, approximately 10% of patients in the hemodialysis population in the recent Dialysis Outcomes and Practice Patterns Study (DOPPS) tested positive for HCV.

“The high HCV prevalence occurs as a result of the high prevalence of HCV on initiation of dialysis as well as nosocomial transmission within hemodialysis units,” the authors wrote. “Testing for HCV before the start of in-center hemodialysis (including a transition from another dialysis method) and upon transfer between hemodialysis facilities provides the opportunity to identify patients potentially exposed to HCV at the previous facility.”

The study, “Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C Virus Infection in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2018 Clinical Practice Guideline,” was published online in the Annals of Internal Medicine.