Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2015; 21(2): 408-422
Published online Jan 14, 2015. doi: 10.3748/wjg.v21.i2.408
Management of hepatitis C in patients with chronic kidney disease
Roberto J Carvalho-Filho, Ana Cristina CA Feldner, Antonio Eduardo B Silva, Maria Lucia G Ferraz
Roberto J Carvalho-Filho, Ana Cristina CA Feldner, Antonio Eduardo B Silva, Maria Lucia G Ferraz, Division of Gastroenterology, Hepatology Section, Federal University of Sao Paulo, Sao Paulo, SP 04023-900, Brazil
Author contributions: Carvalho-Filho RJ, Feldner ACCA, Silva AEB and Ferraz MLG designed and performed the research, analyzed the data, and wrote the paper; all authors revised and approved the final version.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Roberto J Carvalho-Filho, MD, Division of Gastroenterology, Hepatology Section, Federal University of Sao Paulo, Rua Botucatu 740, Sao Paulo, SP 04023-900, Brazil.
Telephone: +55-11-55764050 Fax: +55-11-55729532
Received: July 1, 2014
Peer-review started: July 1, 2014
First decision: July 21, 2014
Revised: September 7, 2014
Accepted: December 8, 2014
Article in press: December 8, 2014
Published online: January 14, 2015

Hepatitis C virus (HCV) infection is highly prevalent among chronic kidney disease (CKD) subjects under hemodialysis and in kidney transplantation (KT) recipients, being an important cause of morbidity and mortality in these patients. The vast majority of HCV chronic infections in the hemodialysis setting are currently attributable to nosocomial transmission. Acute and chronic hepatitis C exhibits distinct clinical and laboratorial features, which can impact on management and treatment decisions. In hemodialysis subjects, acute infections are usually asymptomatic and anicteric; since spontaneous viral clearance is very uncommon in this context, acute infections should be treated as soon as possible. In KT recipients, the occurrence of acute hepatitis C can have a more severe course, with a rapid progression of liver fibrosis. In these patients, it is recommended to use pegylated interferon (PEG-IFN) in combination with ribavirin, with doses adjusted according to estimated glomerular filtration rate. There is no evidence suggesting that chronic hepatitis C exhibits a more aggressive course in CKD subjects under conservative management. In these subjects, indication of treatment with PEG-IFN plus ribavirin relies on the CKD stage, rate of progression of renal dysfunction and the possibility of a preemptive transplant. HCV infection has been associated with both liver disease-related deaths and cardiovascular mortality in hemodialysis patients. Among those individuals, low HCV viral loads and the phenomenon of intermittent HCV viremia are often observed, and sequential HCV RNA monitoring is needed. Despite the poor tolerability and suboptimal efficacy of antiviral therapy in CKD patients, many patients can achieve sustained virological response, which improve patient and graft outcomes. Hepatitis C eradication before KT theoretically improves survival and reduces the occurrence of chronic graft nephropathy, de novo glomerulonephritis and post-transplant diabetes mellitus.

Keywords: Hepatitis C virus, Chronic kidney disease, End-stage renal disease, Conservative management, Hemodialysis, Kidney transplantation, Diagnosis, Therapy

Core tip: In this review, we discuss the most recent and relevant literature regarding diagnostic aspects, clinical features, outcomes and therapy of chronic hepatitis C in subjects with chronic kidney disease, in the context of conservative management, hemodialysis, and kidney transplantation. In addition, antiviral regimens are summarized and treatment algorithms are proposed.