- The 2018 Kidney Disease: Improving Global Outcomes (KDIGO) have been extensively updated to reflect major advances since the introduction of direct-acting antivirals (DAAs) for HCV in patients with chronic kidney disease (CKD).
- This synopsis focuses on 32 key recommendations, summarised here; please consult the complete publication for details.
- HCV screening should be conducted for all patients being evaluated for CKD.
- Patients should also be screened on evaluation for renal transplant; initiation of hemodialysis, peritoneal dialysis, or home dialysis; or transfer to a new dialysis facility or method.
- Nucleic acid testing can be used up front, or after a positive immunoassay.
- All HCV-infected patients with CKD should be evaluated for treatment with DAAs and tested for HBV.
- Interferon should be avoided.
- Choice of DAA regimen should be based on HCV genotype/subtype, viral load, prior treatment, drug interactions, renal function, fibrosis stage, comorbidities, and liver/kidney transplant candidacy.
- Any approved DAA regimen can be used with estimated glomerular filtration rate ≥30 mL/min/1.73 m2; ribavirin-free courses are recommended for lower levels of renal function.
Recommendations specific to kidney transplant recipients
- Pretreatment drug interaction assessment should also consider immunosuppressive therapy.
- Calcineurin inhibitor levels should be monitored during and after DAA therapy.
- Timing HCV treatment in kidney transplant candidates: willingness to accept an infected organ and postpone DAA therapy may shorten wait-list time, but patients with compensated cirrhosis should consider pretransplant DAA therapy to reduce fibrosis.
- HCV-infected living kidney donors should receive DAA therapy and be reevaluated on attainment of sustained virologic response.
- Patients with HCV-associated glomerular disease should receive DAA therapy. Those with cryoglobulinemic flare, nephrotic syndrome, or rapidly progressing renal failure should receive immunosuppressive therapy (rituximab recommended)±plasma exchange.