HCV in CKD patients

  • Editorial
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Despite a constant decline, Hepatitis C virus (HCV) infection remains around 4-fold more prevalent in patients with chronic kidney disease (CKD), especially in dialysis and kidney transplant (KT) patients, than in the general population (1). HCV may be a cause of the renal impairment (via cryoglobulinemic vasculitis and indirectly via chronic inflammation inducing vascular damage and diabetes)(2) but may be also a consequence of the CKD (nosocomial transmission in the dialysis or transplantation setting). These reciprocal interplays impact the prognosis of CKD patients with a higher morbidity (cardio-vascular, faster progression of diabetes and of renal failure) and mortality (3). That is why any HCV-infected patient has to be evaluated for the kidney function and that all patients with CKD and HCV infection should be considered for treatment by direct acting anti-virals (DAAs), prioritizing those with symptomatic cryoglobulinemic vasculitis, extensive liver fibrosis and patients with stage 4-5 CKD. Hepatic as well as extra-hepatic complications, including the risk of end-stage renal disease, are decreased by the sustained virologic response (SVR) associated with the antiviral treatment: SVR reduces the mortality of patients with CKD (4). The new pangenotypic oral drugs extend to late CKD and kidney transplant recipients the possibility to cure HCV in >95% of cases, with a fair tolerance. The long-term renal safety of DAAs needs a prospective re-appraisal but SVR appears to improve the renal function in CKD stage 3 patients. The very recent recommendations of the KDIGO (5) indicate how to improve the screening of HCV, how to reduce the risk of re-infection in dialysis, how to perform the diagnosis and the treatment of HCV-infected patients with CKD and their times in the history of the patients. If DAA treatment should be considered in any patient, it may be delayed in dialysis patients until after transplantation in those whose waiting time is markedly reduced by accepting an HCV-positive organ. The elimination of HCV (6) now appears at hand in the nephrology field (EASL/ERA initiative), but an improvement in awareness of physicians and in access to care (DAA treatment) of patients has to be coupled with reinforced hygienic precautions to prevent reinfections in hemodialysis units.