A work group of the Kidney Disease: Improving Global Outcomes (KDIGO) organization has updated its 2018 guideline recommendations for treating hepatitis C in patients with chronic kidney disease (CKD). The updated guideline, which was published in Kidney International, provides additional recommendations for diagnosing and managing kidney diseases associated with hepatitis C.

The KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease notes that direct-acting antivirals effectively treat hepatitis C in patients of all CKD stages, including those on dialysis and kidney transplant recipients. No dose adjustment is needed.

Pangenotypic direct-acting antiviral regimens, including sofosbuvir-based regimens, and genotype-specific regimens are safe and effective for stage 4-5 CKD, including those on dialysis and receiving kidney transplant. If pangenotypic regimens are not available, determine the patient’s hepatitis C genotype and use the genotype-specific treatment. The full report lists direct-acting antiviral regimens with evidence of effectiveness for various CKD populations.

Protease inhibitors such as simeprevir, paritaprevir, and grazoprevir are contraindicated in patients with Child-Pugh B and C cirrhosis.

Direct-acting antiviral regimens can interact with immunosuppressive agents, such as calcineurin and mTOR inhibitors. The guideline suggests consulting http://www.hep-druginteractions.org before using these regimens in kidney transplant recipients.

Hepatitis B virus can reactivate during and after treatment with direct-acting antivirals, so the guideline recommends testing beforehand for serological markers, such as hepatitis B surface antigen, total core antibody, and antibody to hepatitis B surface antigen. If hepatitis B surface antigen is present, clinicians should assess the patient for hepatitis B therapy. If hepatitis B surface antigen is absent, but markers of prior hepatitis B infection (positive for total core antibody with or without antibody to hepatitis B surface antigen) are detected, clinicians should perform hepatitis B DNA testing if levels of liver function tests rise during direct-acting antiviral therapy.

In addition, kidney transplant candidates with hepatitis C should be screened for liver disease severity and portal hypertension. Results from this assessment will help guide the decision between kidney transplantation alone and simultaneous kidney-liver transplantation.

The guideline recommends administering direct-acting antiviral therapy to all kidney transplant candidates infected with hepatitis C. The decision to treat before or after transplantation should be guided by donor type (living vs deceased donor), wait-list times by donor type, center-specific policies, and the severity of liver fibrosis.

Living kidney donors should be screened for hepatitis C with immunoassay and undergo nucleic acid testing if seropositive. Kidneys from hepatitis C-infected donors can be offered to potential recipients who are positive or negative in accordance with national and regional laws. Research shows that kidney transplantation from hepatitis C-infected donors to uninfected recipients who are treated immediately or early with direct-acting antivirals leads to favorable outcomes. Education and informed consent are required.

Patients with hepatitis C presenting with immune-complex glomerulonephritis do not need a confirmatory kidney biopsy, according to the guideline. They should be treated with direct-acting antivirals. Clinicians should consider biopsy if kidney function or proteinuria worsens, and before immunosuppressive therapy.

Patients with cryoglobulinemic flare or rapidly progressive glomerulonephritis can be treated with both direct-acting antivirals and immunosuppressive agents, with or without plasma exchange. Rituximab is generally used as the first-line immunosuppressive treatment, although steroids should also be considered in rapidly progressive glomerulonephritis.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Martin P, Awan AA, Berenguer MC, et al. Executive Summary of the KDIGO 2022 clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease. Kidney Int. 2022 Dec;102(6):1228-1237. doi:10.1016/j.kint.2022.07.012

This article originally appeared on Renal and Urology News