Chronic hepatitis C treatment complicated by kidney disease

Key Points

People with CKD may be more at risk for complications with antiviral treatment. "Ribavirin can cause hemolysis in patients with more advanced CKD and lead to serious anemia," said David Roth, MD, William W. Anderson professor of nephrology and director of clinical services for the division of nephrology and hypertension at the University of Miami. "In addition, there is a black-box warning against the use of ribavirin in patients with GFR < 50 ml/min/1.73m2." He added that if ribavirin is used in patients with more advanced stages of CKD, it should be administered with extreme caution, and at much lower doses.

As for interferon, dose adjustments of the drug are recommended for patients with more advanced states of CKD, Roth said. He also pointed out that interferon is not recommended for use in the post-kidney-transplant recipients because of the risk of triggering rejection of the transplant.

One difference, he said, is that the guidelines recommend treating transplant candidates with milder HCV-caused liver damage than would prompt treatment in patients who do not have CKD. Lack of data seems to be an ongoing theme when it comes to treating HCV in people with CKD. "Unfortunately, all of the trials done on treatment of HCV specifically excluded patients with kidney disease, so the data available on this issue are very limited," Roth said.

There is evidence that HCV-infected dialysis and transplant patients have worse outcomes than those not infected with HCV. However, Roth said, "There is no good long-term data demonstrating that treatment of HCV in the CKD population will have an impact on patient outcomes."

While it may be ideal to wait for more appropriate clinical trials before establishing global guidelines for HCV treatment, it's simply not practical. According to the KDIGO foundation, about 170 million people around the world are infected with HCV, and approximately 3.2 million of them are Americans. Improper or nonexistent screening for HCV, as well as inappropriate sanitary precautions during hemodialysis, have contributed to the spread of HCV. A substantial portion of KDIGO's new guidelines address proper screening and prevention techniques for HCV in CKD patients.

Treating HCV-infected patients with CKD is complicated and risky, and the lack of available data only contributes to the difficulty in managing these patients. Until KDIGO published its guidelines in April, there were no global recommendations for treating people with both HCV and CKD.

JILLENE MAGILL-LEWIS is a writer based in the Seattle area.