Guideline Recommends Direct-acting Antivirals for HCV in People With Kidney Disease

By Will Boggs MD

September 25, 2019

NEW YORK (Reuters Health) - Patients with chronic kidney disease (CKD) should be screened for hepatitis C virus (HCV) infection, and infected individuals should be treated with direct-acting antiviral (DAA) therapy, according to the updated 2018 Kidney Disease: Improving Global Outcomes (KDIGO) clinical-practice guideline.

"The key thing that has changed since the original 2008 KDIGO guidelines on HCV in CKD is the development of DAA treatments, which have dramatically changed all aspects of HCV management," Dr. Craig E. Gordon of Tufts Medical Center, in Boston, told Reuters Health by email. "The existence of DAAs and their superb efficacy and safety in all CKD populations have impacted the majority of the guideline statements throughout the document."

Dr. Gordon and colleagues summarize 32 key recommendations (of the 66 recommendations included in the guideline) in a paper online September 24 in Annals of Internal Medicine.

The recommendation to screen all patients for HCV infection at the time of initial evaluation of CKD stems partly from the higher prevalence of HCV in these patients. And, Dr. Gordon said, "there is also provocative early evidence that HCV treatment in the CKD population may be associated with slower CKD progression to end-stage kidney disease (ESKD)."

According to the updated guideline, all CKD patients infected with HCV should be evaluated for antiviral therapy. This includes kidney-transplant recipients and candidates and patients with HCV-associated glomerular disease.

The timing of treatment of kidney-transplant candidates should be coordinated with the transplant center. Kidney donors should also be screened for HCV infection, and transplantation of kidneys from HCV-positive donors should be directed to HCV-positive recipients.

The choice of DAA-based regimen should be based on HCV genotype (and subtype), viral load, prior treatment history, drug-drug interactions, GFR, stage of hepatic fibrosis, liver transplant candidacy and comorbidities, the authors say.

Rituximab is recommended as the first-line immunosuppressive treatment for patients with HCV-associated glomerular disease, especially for those who do not respond to antiviral therapy. Interferon treatment should be avoided.

"The main message for physicians to take from the report is to recognize that the prevalence of HCV is significantly higher in CKD patients than the general population, and identifying HCV infection in this patient population can lead to opportunities to treat and cure the infection, in the hope of preventing HCV-related comorbidities later in life," Dr. Gordon said. "It is important to recognize that HCV is a major issue in CKD patients and requires greater attention from physicians of all specialties."

Dr. Meghan Elizabeth Sise of Massachusetts General Hospital, in Boston, who recently reported that DAA therapy slows kidney-function decline in renal patients with HCV infection, told Reuters Health by email, "What is extremely important to note is that the issue of timing of HCV treatment in dialysis patients will be a rapidly evolving question. In the last 6-12 months, a larger fraction of kidneys from HCV-infected donors are being used for HCV-uninfected recipients, because there is a rapidly increasing number of transplant centers that are developing research or clinical protocols to transplant HCV viremic kidneys into HCV-uninfected recipients."

"This will dramatically change the 'waiting-time advantage' that an HCV-infected patient might have previously experienced by being able to accept an HCV-infected donor kidney," said Dr. Sise, who was not involved in the guideline development. "Nephrologists will need to be aware of local transplant centers' practices and expectations."

"All patients with early and late stage chronic kidney disease or on dialysis should be screened for hepatitis C and referred for treatment," she concluded. "Interferon-free direct-acting antiviral therapies have been studied in patients with kidney disease, and there should be a safe, well-tolerated option for nearly all patients with kidney disease."

The complete version of the 2018 clinical practice guideline is available at https://kdigo.org/guidelines/hepatitis-c-in-ckd/.

SOURCE: https://bit.ly/2mhWDtg

Ann Intern Med 2019.

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