Treating Hepatitis C Infection in Patients With Chronic Kidney Disease: Our Options Have Improved Greatly

Chronic hepatitis C infection (HCV) is a common problem in patients with kidney disease (Corouge M. et al. Liver Int (2016); 36:28–33, Fabrizi F. et al. Int. J. Artif. Organs (2017); 0). In the past, treatment of hepatitis C infection was very difficult due to poor efficacy, significant side effects, and the multiple comorbidities that affect patients with advanced kidney disease (Pockros PJ et al. Gastroenterology (2016); 150:1590–1598). Significant recent advances in oral interferon-free treatment regimens allow patients with hepatitis C to be treated effectively with minimal side effects. For patients with genotype 1a, 1b, or 4, there are several recommended oral regimens that achieve virologic cure in greater than 95% of patients, even in patients with severe or end-stage renal disease. For other genotypes, specifically 2, 3, 5, and 6, treatment with direct acting antiviral (DAA) agents that are used in patients with normal renal clearance has significant potential for side effects and is not recommended. Patients who are waiting for a kidney transplant or who have received a kidney transplant and have estimated eGFR greater than 30 ml/min can be treated with multiple regimens in an attempt to cure their hepatitis C (Fabrizi F. et al. Int. J. Artif. Organs (2017); 0). Patients with kidney-related complications due to their chronic hepatitis C infection can also be treated with a significant chance of resolution of the complication (Corouge M. et al. Liver Int (2016); 36:28–33, Kamar N. et al. Clin. Nephrol (2008); 69:149–160). The timing of HCV treatment and kidney transplant depends on the individual transplant centers protocol and the patient’s position on the waiting list for a kidney (Fabrizi F Clin. Liver Dis 2005; 9: 503, viii). USA transplant centers in order to reduce the time on the waiting list have decided to offer HCV-infected patients a kidney from an HCV-positive donor. Treatment of the HCV is then done early after recovery from the transplant surgery. Due to significant advances in developing oral direct acting antiviral agents, we now have safe and effective oral regimens to treat HCV-infected patients with renal disease, including those on hemodialysis, waiting for a kidney transplant, or after a renal transplant. The purpose of this review is to summarize the currently recommended treatment regimens and provide clinicians with guidance in terms of the efficacy and safety of the new direct acting antiviral agents (DAAs) in treating HCV-infected patients who have advanced kidney disease.