HCV in CKD: KDIGO updates guideline after a decade


  • Antara Ghosh
  • Medical news
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Takeaway

  • Kidney Disease: Improving Global Outcomes (KDIGO) has updated its initial HCV guideline in patients with chronic kidney disease (CKD), published in 2008.
  • With advance in evaluation and management, particularly advent of direct-acting antiviral (DAA) therapy, eradication of HCV from haemodialysis units is now completely feasible.
  • Haemodialysis population could be an excellent target for micro-elimination strategy, a first step towards the WHO’s goal of eliminating viral hepatitis as a public health problem by 2030.

Key recommendations

Detection and evaluation

  • Screen all patients for HCV infection at:
    • initial CKD evaluation (1C) using an immunoassay followed by nucleic acid testing (NAT) if necessary (1A);
    • initiation of in-centre haemodialysis or transfer from another dialysis facility (1A) using NAT alone or an immunoassay followed by NAT (1A) with follow-up every 6 months (1B);
    • evaluation for kidney transplantation (1A).
  • Repeat testing every 6 months using NAT for in-centre haemodialysis patients with resolved infection (1B).
  • Assess liver fibrosis in HCV-infected patients with CKD (1A):
    • initially non-invasive evaluation (1B);
    • assess portal hypertension in CKD patients with suspected advanced fibrosis (1A).
  • Screen kidney disease at the time of HCV infection diagnosis (1A).
  • CKD patients with HCV infection history, whether NAT-positive or not, should be screened and vaccinated against HAV and HBV and screened for HIV (1A).

Treatment 

  • Evaluate all patients for antiviral therapy (1A):
    • an interferon-free regimen is recommended (1A).
  • Regimen choice would be based on HCV genotype, viral load, prior treatment history, drug-drug interactions, glomerular filtration rate (GFR), hepatic fibrosis stage, kidney/liver transplant candidacy and co-morbidities (1A).
  • Any licensed DAA-based regimen is recommended for patients with GFR ≥30 mL/minute/1.73 m2 (1A).
  • Patients with GFR 2 should be treated with a ribavirin-free DAA-based regimen (1B/2D).
  • DAA-based regimen is recommended for kidney transplant recipients infected with HCV (1A):
    • avoid treatment with interferon (1A);
    • assess drug-drug interactions between DAA-based regimen and other concomitant medications, including immunosuppressive drugs (1A);
    • monitor calcineurin inhibitor levels during and after DAA treatment (1B).

Preventing HCV transmission in haemodialysis units

  • Adhere to standard infection control procedures (1A) with regular observational audits of infection control procedures (1C).
  • Haemodialysis centres should examine and track all HCV test results (1B):
    • if a dialysis-related new HCV case is identified, take aggressive measures for improved hand hygiene, glove use, injection safety and environmental cleaning and disinfection (1A).

HCV management before and after kidney transplantation

  • Evaluate liver disease severity and presence of portal hypertension in HCV-infected patients prior to acceptance for kidney transplantation (2D):
    • kidney transplantation is recommended for HCV-infected patients with compensated cirrhosis (1B);
    • combined liver-kidney transplantation (1B) and deferring HCV treatment until after transplantation (1D) is recommended for HCV-infected patients with decompensated cirrhosis.
  • Consider patients undergoing kidney transplantation for DAA therapy before/after transplantation (1A).
  • Screen all kidney donors for HCV with both immunoassay and NAT (1A).
  • Direct kidney transplantation from HCV NAT-positive donors to NAT-positive recipients (1A).
  • Use of all conventional current induction and maintenance immunosuppressive regimens is suggested (2C).
  • Patients with previous infection who achieved sustained virologic response before transplantation should be tested by NAT 3 months after transplantation (1D).
  • DAA regimen is recommended in patients with post-transplant HCV-associated glomerulonephritis (1D).

Diagnosis/management of HCV associated kidney diseases

  • Treat patients with HCV-associated glomerular disease for HCV (1A).
    • initially DAA treatment is recommended in patients showing stable kidney function and/or non-nephrotic proteinuria (1C);
    • immunosuppressive agents with/without plasma exchange in addition to DAA is recommended in patients with cryoglobulinemic flare, nephrotic syndrome or rapidly progressive kidney failure (1C);
    • immunosuppressive therapy (rituximab as the first-line) is recommended for patients with histologically active HCV-associated glomerular disease not responding to antiviral therapy (1B).

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