Treatment of Hepatitis C Virus Infection in Patients with End-stage Renal Disease

Chen-Hua Liu; Jia-Horng Kao

Disclosures

J Gastroenterol Hepatol. 2011;26(2):228-239. 

In This Article

Abstract and Introduction

Abstract

Hepatitis C virus (HCV) infection is a major health problem in patients with end-stage renal disease (ESRD). The incidence of acute HCV infection during maintenance dialysis is much higher than that in the general population because of the risk of nosocomial transmission. Following acute HCV infection, most patients develop chronic HCV infection, and a significant proportion develop chronic hepatitis, cirrhosis, and even hepatocellular carcinoma. Overall, chronic hepatitis C patients on hemodialysis bear an increased risk of liver-related morbidity and mortality, either during dialysis or after renal transplantation. Interferon (IFN) therapy is modestly effective for the treatment of HCV infection in ESRD patients. Conventional or pegylated IFN monotherapy has been used to treat acute hepatitis C in ESRD patients with excellent safety and efficacy. Regarding chronic hepatitis C, approximately one-third of patients can achieve a sustained virological response (SVR) after conventional or pegylated IFN monotherapy. The combination of low-dose ribavirin and conventional or pegylated IFN has further improved the SVR rate in treatment-naïve or retreated ESRD patients in clinical trials. Similar to the treatment of patients with normal renal function, baseline and on-treatment HCV virokinetics are useful to guide optimized therapy in ESRD patients. Of particular note, IFN-based therapy is not recommended at the post-renal transplantation stage because of the low SVR rate and risk of acute graft rejection. In conclusion, ESRD patients with HCV infection should be encouraged to receive antiviral therapy, and those who achieve an SVR usually have long-term, durable, virological, biochemical, and histological responses.

Introduction

Despite the introduction of blood-product screening, the increased use of erythropoietin, as well as the adoption of universal precautions and strict infection controls, hepatitis C virus (HCV) infection still remains a major health problem in patients with end-stage renal disease (ESRD). The annual incidence of HCV infection in these patients ranges from 0.2% to 6.2%, which is approximately 100–1000 times higher than that in the general population (Table 1).[1–19] After exposure to HCV, there is a mean incubation period of 8 weeks before the onset of symptoms. Although some patients might present with fatigue, anorexia, or abdominal discomfort during acute HCV infection, most are asymptomatic, with mild-to-moderate, elevated serum alanine aminotransferase (ALT) levels. ALT values range from two to 20 times the upper limit of normal (ULN).[4,20,21] The diagnosis of acute HCV infection in patients with ESRD is confirmed by the detection of serum HCV-RNA and the documentation of anti-HCV seroconversion.

Without effective medical interventions, 65–92% of ESRD patients with acute hepatitis C become chronically infected.[2,4,20,21] Therefore, the high, acute HCV infection and chronicity rates after acute infection contribute to the high prevalence of HCV infection in ESRD patients. The reported prevalence rates of chronic HCV infection among ESRD patients ranges from 3.4%to 80% with great geographic variation (Table 1).[2,7,10–12,22–36] The higher incidence and prevalence rates of HCV infection among ESRD patients suggest the possible routes of nosocomial transmission, such as contamination of the hands of staff members, sharing items between patients, dialyzer reuse, and contamination of dialysis machines.[37–41] ESRD patients with chronic HCV infection usually have an apparent indolent clinical course with only mildly-elevated serum ALT levels.

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