Published online Jul 8, 2017. doi: 10.4254/wjh.v9.i19.833
Peer-review started: February 7, 2017
First decision: March 28, 2017
Revised: April 13, 2017
Accepted: May 3, 2017
Article in press: May 5, 2017
Published online: July 8, 2017
The prevalence of hepatitis C virus (HCV) infection amongst patients with chronic kidney disease (CKD) and end-stage renal disease exceeds that of the general population. In addition to predisposing to the development of cirrhosis and hepatocellular carcinoma, infection with HCV has been associated with extra-hepatic complications including CKD, proteinuria, glomerulonephritis, cryoglobulinemia, increased cardiovascular risk, insulin resistance, and lymphoma. With these associated morbidities, infection with HCV is not unexpectedly accompanied by an increase in mortality in the general population as well as in patients with kidney disease. Advances in the understanding of the HCV genome have resulted in the development of direct-acting antiviral agents that can achieve much higher sustained virologic response rates than previous interferon-based protocols. The direct acting antivirals have either primarily hepatic or renal metabolism and excretion pathways. This information is particularly relevant when considering treatment in patients with reduced kidney function. In this context, some of these agents are not recommended for use in patients with a glomerular filtration rate < 30 mL/min per 1.73 m2. There are now Food and Drug Administration approved direct acting antiviral agents for the treatment of patients with kidney disease and reduced function. These agents have been demonstrated to be effective with sustained viral response rates comparable to the general population with good safety profiles. A disease that was only recently considered to be very challenging to treat in patients with kidney dysfunction is now curable with these medications.
Core tip: Advances in the understanding of the molecular biology of hepatitis C virus (HCV) have ushered in a new era in treatment. Recent studies have shifted the focus to the more difficult-to-treat cohorts of patients. The presence of chronic kidney disease and end stage renal disease were exclusion criteria for the pivotal clinical direct-acting antiviral agents trials, creating a group of patients with a large unmet medical need. This review will update the reader on the use of the direct acting antiviral agents in the HCV-infected patient with kidney disease. Recommendations for the timing of therapy, choice of agents and management of the kidney transplant candidate will be presented.