Updates guidelines on HCV in patients with kidney disease

Takeaway

• 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. 

Screening recommendations

• 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.

Treatment recommendations

• 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.

Other recommendations

• 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.