- Kidney Disease: Improving Global Outcomes (KDIGO) guidelines have shifted with the advent of highly effective direct-acting antivirals (DAAs) for HCV in patients with chronic kidney disease (CKD).
- HCV screening recommended at CKD diagnosis, on initiation of dialysis, before transplant, and every 6 months during in-center hemodialysis.
- HCV treatment in CKD:
- Interferon-free regimen preferred.
- Consider HCV genotype/subtype, viral load, treatment history, drug interactions, renal function, hepatic fibrosis stage, kidney/liver transplant candidacy, and comorbidities.
- Patients with estimated glomerular filtration rate 2 should receive ribavirin-free DAA-based therapy.
- Test for comorbid HBV.
- Managing HCV before/after kidney transplant (KT):
- Evaluate KT candidates for liver disease severity and portal hypertension. Consider combined liver/kidney transplant in settings of decompensated cirrhosis, with subsequent antiviral therapy.
- KT recipients should receive a DAA-based regimen while considering drug interactions with immunosuppressive therapy. Monitor calcineurin inhibitor levels during/after treatment.
- Base antiviral timing (before vs after KT) on donor type, wait-list times, HCV genotype, and fibrosis severity.
- Managing HCV-associated glomerular disease: perform kidney biopsy.
- Use DAAs in presence of stable kidney function and/or non-nephrotic proteinuria.
- Add-on immunosuppression recommended for cryoglobulinemic flare, nephrotic syndrome, or rapidly progressive kidney failure.
- Add rituximab in patients with histologically active glomerular disease who do not respond to antivirals.