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Fabrizi F, Donato FM, Messa P. Association Between Hepatitis C Virus and Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Ann Hepatol 2019; 17:364-391. [PMID: 29735788 DOI: 10.5604/01.3001.0011.7382] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM The role of hepatitis C virus infection as a risk factor for the development and progression of chronic kidney disease in the general population remains unclear. MATERIAL AND METHODS A systematic review of the published medical literature was performed to assess whether positive anti-HCV serologic status is associated with higher frequency of chronic kidney disease in the adult general population. We used a random-effects model to generate a summary estimate of the relative risk of chronic kidney disease (defined by lowered glomerular filtration rate or detectable proteinuria) with HCV across the published studies. Meta-regression and stratified analysis were also carried out. RESULTS Forty studies were eligible (n = 4,072,867 patients), and separate meta-analyses were conducted according to the outcome. Pooling results of longitudinal studies (n = 15 studies, n = 2,299,134 unique patients) demonstrated an association between positive anti-HCV serologic status and increased incidence of CKD, the summary estimate for adjusted HR with HCV across the surveys, 1.54 (95% CI, 1.26; 1.87) (P < 0.001). Between-study heterogeneity was observed (Q value by Chi-squared [χ2] test 500.3, P < 0.0001). The risk of chronic kidney disease related to HCV, in the subset of surveys from Asia was 1.45 (1.27; 1.65) (P < 0.001) (no heterogeneity). According to our meta-regression, ageing (P < 0.0001) and duration of follow-up (P < 0.0001) increased the risk of chronic kidney disease among HCV-positive subjects. We observed a relationship between anti-HCV positive serologic status and frequency of proteinuria, adjusted effect estimate of proteinuria with HCV among surveys was 1.633 (95% CI, 1,29; 2.05) (P < 0.001) (n = 10 studies; 315,404 unique patients). However, between-studies heterogeneity was noted (P value by Q test < 0.0001). CONCLUSION An association between HCV infection and increased risk of chronic kidney disease in the general population exists. The mechanisms underlying such association are currently under active investigation.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Francesca M Donato
- Division of Gastroenterology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Piergiorgio Messa
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
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Younossi ZM, Henry L, P Ong J, Tanaka A, Eguchi Y, Mizokami M, Lim YS, Dan YY, Yu ML, Stepanova M. Systematic review with meta-analysis: extrahepatic manifestations in chronic hepatitis C virus-infected patients in East Asia. Aliment Pharmacol Ther 2019; 49:644-653. [PMID: 30761562 DOI: 10.1111/apt.15131] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/21/2018] [Accepted: 12/16/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although the prevalence of extrahepatic manifestations of chronic hepatitis C virus (HCV) infection has been reported from Western countries, their prevalence in East Asian countries is not well known. AIM To perform a systematic review to quantify the prevalence of selected extrahepatic manifestations of HCV among patients from East Asia. METHODS Medline, CINAHL, EMBASE, Cochrane and country-specific databases were reviewed according to standard guidelines for meta-analyses. Only articles with patients from East Asian countries were included. RESULTS After review, 34 articles were selected (Japan = 9; China = 5, Korea = 3, Taiwan = 16, multiple countries = 1) with 646 228 subjects, 66 436 with HCV. Mean age for HCV-infected patients was 56 years (range 41-72 years), 50% were male (range 26%-73%). The pooled prevalence of type 2 diabetes in East Asian HCV patients was 19.0% (95% confidence interval 15.6%-22.9%) (n = 19 studies) with an increased risk when compared to non-HCV: odds ratio (OR) 1.58 (1.28-1.94). The prevalence of chronic kidney disease in HCV was 9.2% (5.0%-16.2%) (n = 7 studies), also with a significantly increased risk: OR=1.98 (1.41-2.77). Pooled prevalence of cardiovascular disease in HCV was 8.6% (3.5%-19.9%) (n = 6 studies), also with an increased risk: OR = 1.55 (1.21-1.98). The prevalence of lichen planus in HCV was 8.9% (3.6%-20.6%) (n = 6 studies) while the prevalence of rheumatoid arthritis was 4.5% (0.6%-25.7%) (n = 4 studies). CONCLUSIONS These data show increased risk of developing extrahepatic manifestations in East Asian patients with HCV. Both hepatic and extrahepatic manifestations of the infection should be used to accurately determine the total burden of the disease in the region.
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Zhang H, Xu H, Wu R, Yu G, Sun H, Lv J, Wang X, Chi X, Gao X, Kong F, Zhang M, Hang L, Jiang J, Pan Y, Niu J. Association of Hepatitis C and B Virus Infection with CKD and Impact of Hepatitis C Treatment on CKD. Sci Rep 2019; 9:1910. [PMID: 30760762 PMCID: PMC6374358 DOI: 10.1038/s41598-018-36437-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023] Open
Abstract
Hepatitis C virus (HCV) infection greatly increases the risk of nephropathy. In this observational study, we aimed to explore the relationship between viral hepatitis infection and chronic kidney disease (CKD), identify risk factors, and determine the effect of antiviral treatment on CKD in Chinese patients with chronic HCV infection. A total of 2,435 study subjects were enrolled and divided into four groups: the HCV infection, HBV infection, HBV and HCV co-infection, and uninfected control groups. Of these, 207 patients with chronic hepatitis C (CHC) were given standard dual therapy [subcutaneous injection of recombinant interferon (IFN)-α2b and oral ribavirin (RBV)] for 48 weeks. We found that the prevalence of CKD gradually increased with age in all groups and was significantly increased in patients 60 years or older. Multivariate logistic regression analyses showed that persistent HCV infection was significantly associated with CKD [odds ratio (OR), 1.33; 95% confidence interval (CI), 1.06–1.66; P = 0.013], whereas there was no significant link between CKD and spontaneous HCV clearance (OR, 1.23; 95% CI, 0.79–1.90; P = 0.364), HBV infection (OR, 0.73; 95% CI, 0.44–1.19; P = 0.201), or HBV/HCV co-infection (OR, 1.40; 95% CI, 0.81–2.40; P = 0.234). Notably, after anti-HCV therapy, the serum creatinine concentration was significantly decreased (76.0, 75.5–79.4 μmol/L) from the pretreatment level (95.0, 93.0–97.2 μmol/L), both in patients who showed an end of treatment virological response (ETVR) and those who did not (P < 0.001). Also, in both the ETVR and non-ETVR groups, the percentages of patients with an estimated glomerular filtration rate (eGFR) ≥90 ml/min/1.73 m2 increased significantly (P < 0.001), whereas the percentages of those with an eGFR <60 ml/min/1.73 m2 significantly decreased (P < 0.001). In conclusion, persistent HCV infection was independently associated with CKD, and antiviral treatment with IFN plus RBV can improve renal function and reverse CKD in HCV-infected patients.
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Affiliation(s)
- Hui Zhang
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Department of Hepatology, Jiangsu Taizhou People's Hospital, Taizhou, 225300, China
| | - Hongqin Xu
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China
| | - Ruihong Wu
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China
| | - Ge Yu
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Haibo Sun
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Juan Lv
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Xiaomei Wang
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China
| | - Xiumei Chi
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China
| | - Xiuzhu Gao
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China
| | - Fei Kong
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Mingyuan Zhang
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Lei Hang
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China
| | - Jing Jiang
- Department of Clinical Epidemiology, The First Hospital, Jilin University, No. 71 Xinmin Street, Changchun, 130021, China
| | - Yu Pan
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China.
| | - Junqi Niu
- Department of Hepatology, The First Hospital of Jilin University, Jilin University, Changchun, 130021, China. .,Jilin Province Key Laboratory of Infectious Diseases, Laboratory of Molecular Virology, Changchun, 130021, China.
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Henson JB, Sise ME. The association of hepatitis C infection with the onset of CKD and progression into ESRD. Semin Dial 2018; 32:108-118. [PMID: 30496620 DOI: 10.1111/sdi.12759] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hepatitis C virus (HCV) infection is not only an important cause of chronic liver disease, but extrahepatic manifestations are common and include chronic kidney disease (CKD). HCV is classically associated with cryoglobulinemic glomerulonephritis in the context of mixed cryoglobulinemia syndrome, but other glomerular diseases also occur and may be significantly under-recognized. HCV may cause glomerular disease by immune complex deposition; however, other potential mechanisms by which HCV promotes CKD include a direct cytopathic effect of the virus on renal tissue, and by its association with accelerated atherosclerosis, insulin resistance, and chronic inflammation. Epidemiologic studies show HCV infection confers an increased risk of incident CKD and accelerates progression of CKD to end-stage renal disease (ESRD) in the general population, as well as subpopulations including diabetic patients, those coinfected with human immunodeficiency virus (HIV), and kidney transplant recipients. Patients with CKD and HCV infection experience inferior clinical outcomes, including poorer quality of life and an increased risk of mortality. Treatment with interferon-based regimens is associated with decreased risk of incident CKD and ESRD, though prior studies are limited by the small number of patients with HCV and CKD who underwent treatment. With the advent of new, well-tolerated direct-acting antiviral combinations that are not cleared by the kidneys, it is possible to treat all genotypes of HCV infection in patients with CKD and ESRD. More data on the effect of direct-acting antivirals on CKD incidence and progression are necessary. However, there is every expectation that with improved access to HCV treatment, the burden of CKD in patients with HCV could significantly decline.
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Affiliation(s)
- Jacqueline B Henson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the major causes of chronic liver disease. HBV and HCV affect nearly 7% of the world's population. Extra-hepatic complications and particularly renal failure have different mechanisms and manifestations. The underlying mechanism, although differing for each disease, mainly involves the immune system and antibody deposits in the kidney, which can lead to tissue damage. Areas covered: We do not cover in this review hepatorenal syndrome. We report on the renal complications of viral hepatitis (HBV, HCV, hepatitis E), autoimmune hepatitis, cirrhosis, and Wilson's disease. The most frequent renal disorders are those related to HBV, and HCV due to their high prevalence worldwide. Expert commentary: Thanks to generalization of vaccination against HBV, prevalence of HBV-related liver diseases will decrease, and thereby its associated renal involvement such as polyarteritis nodosa (an exceptional condition), and glomerulonephritis such as membranous nephropathy. Thanks to direct acting antiviral agents HCV infection will be cured within the next decade. However, HCV-related cryoglobulinemia with or without renal involvement might evolve on its own after the patient has eliminated HCV, necessitating then rituximab therapy. Conversely, orofecal-transmitted hepatitis viruses such as hepatitis A and hepatitis E are still very prevalent in developing countries; however, they are rarely associated with renal manifestations.
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Affiliation(s)
- Johan Noble
- a Service de Néphrologie, Hémodialyse , Aphérèses et Transplantation rénale , Grenoble-Alpes , France.,b Université Joseph Fourier , Grenoble-Alpes , France
| | - Thomas Jouve
- a Service de Néphrologie, Hémodialyse , Aphérèses et Transplantation rénale , Grenoble-Alpes , France.,b Université Joseph Fourier , Grenoble-Alpes , France
| | - Paolo Malvezzi
- a Service de Néphrologie, Hémodialyse , Aphérèses et Transplantation rénale , Grenoble-Alpes , France.,b Université Joseph Fourier , Grenoble-Alpes , France
| | - Lionel Rostaing
- a Service de Néphrologie, Hémodialyse , Aphérèses et Transplantation rénale , Grenoble-Alpes , France.,b Université Joseph Fourier , Grenoble-Alpes , France
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Shuster DL, Menon RM, Ding B, Khatri A, Li H, Cohen E, Jewett M, Cohen DE, Zha J. Effects of chronic kidney disease stage 4, end-stage renal disease, or dialysis on the plasma concentrations of ombitasvir, paritaprevir, ritonavir, and dasabuvir in patients with chronic HCV infection: pharmacokinetic analysis of the phase 3 RUBY-I and RUBY-II trials. Eur J Clin Pharmacol 2018; 75:207-216. [PMID: 30291369 DOI: 10.1007/s00228-018-2566-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/25/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE To characterize the pharmacokinetics of ombitasvir, paritaprevir, ritonavir, dasabuvir, and ribavirin in hepatitis C virus (HCV)-infected patients with chronic kidney disease stage 4 (CKD4) or end-stage renal disease (ESRD), including those on dialysis, in the open-label phase 3 RUBY-I and RUBY-II studies. METHODS Patients (n = 18 CKD4, n = 68 ESRD) received ombitasvir/paritaprevir/ritonavir 25/150/100 mg once daily ± dasabuvir 250 mg twice daily ± ribavirin 200 mg once daily for 12 or 24 weeks. Intensive pharmacokinetic samples were collected from ten patients; sparse samples were collected from all patients. Arterial and venous samples were collected from three patients during hemodialysis. Area under the plasma concentration-time curve (AUC) was estimated using noncompartmental analyses for intensive data, and steady-state trough concentrations (Ctrough) were obtained from the sparse data. Pharmacokinetic results from RUBY-I and RUBY-II were compared empirically to historical data. RESULTS The AUC values of ombitasvir, paritaprevir, ritonavir, and dasabuvir were comparable between CKD4 and ESRD patients and were within the range of values observed in historical studies; dialysis had no effect on drug exposures. Ribavirin was extracted during hemodialysis but had similar exposures on dialysis and non-dialysis days. Individual steady-state Ctrough values for each drug overlapped between CKD4 and ESRD patients, and values in both groups were similar to historical values. CONCLUSION Plasma concentrations of ombitasvir, paritaprevir, ritonavir, and dasabuvir were not altered by renal impairment or dialysis, suggesting these agents can be administered to HCV-infected CKD4 or ESRD patients, including those on dialysis, without dose adjustment. TRIAL REGISTRATION Clinicaltrials.gov identifiers: NCT02207088 (RUBY-I) and NCT02487199 (RUBY-II).
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Affiliation(s)
- Diana L Shuster
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Rajeev M Menon
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Bifeng Ding
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Amit Khatri
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Hong Li
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Eric Cohen
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Melissa Jewett
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Daniel E Cohen
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Jiuhong Zha
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA.
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KDIGO 2018 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease. Kidney Int Suppl (2011) 2018; 8:91-165. [PMID: 30675443 PMCID: PMC6336217 DOI: 10.1016/j.kisu.2018.06.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Wigneswaran J, Van Wyck D, Pegues D, Gholam P, Nissenson AR. Hepatitis C virus infection in patients with end-stage renal disease. Hemodial Int 2018; 22:297-307. [DOI: 10.1111/hdi.12672] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/27/2018] [Indexed: 12/22/2022]
Affiliation(s)
| | | | - David Pegues
- Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Pierre Gholam
- Liver Center of Excellence; University Hospitals of Cleveland; Cleveland Ohio USA
| | - Allen R. Nissenson
- DaVita, Inc.; Denver Colorado USA
- David Geffen School of Medicine; University of California; Los Angeles California USA
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Kim SM, Song IH. Hepatitis C virus infection in chronic kidney disease: paradigm shift in management. Korean J Intern Med 2018; 33:670-678. [PMID: 29961309 PMCID: PMC6030406 DOI: 10.3904/kjim.2018.202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/17/2018] [Indexed: 12/14/2022] Open
Abstract
Hepatitis C virus (HCV) infection in chronic kidney disease (CKD) is associated with increased liver-related morbidity and mortality rates, accelerated progression to end-stage renal disease, and risk of cardiovascular events. CKD patients with HCV infection require antiviral therapy. Pegylated interferon (peg-IFN) plus ribavirin was the standard of care for HCV-infected CKD patients before the introduction of first-generation direct-acting antiviral (DAA) oral anti-HCV agents. Peg-IFN-based treatment has a low virologic response rate and poor compliance, resulting in a high dropout rate. Recently, several clinical trials of all-DAA combination regimens have reported excellent antiviral efficacy and few adverse drug reactions in HCV-infected patients with CKD. These positive results have revolutionized the treatment of chronic HCV infection in this population. In this review, we address the impact of chronic HCV infection in CKD patients, and discuss their management using next-generation DAAs.
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Affiliation(s)
- So Mi Kim
- Division of Nephrology, Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
| | - Il Han Song
- Division of Hepatology, Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
- Correspondence to Il Han Song, M.D. Division of Hepatology, Department of Internal Medicine, Dankook University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea Tel: +82-41-5503924 Fax: +82-41-5563256 E-mail:
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Medeiros T, Rosário NF, Saraiva GN, Andrade TG, Silva AA, Almeida JR. Renal safety after one year of sofosbuvir-based therapy for chronic hepatitis C: A Brazilian "real-life" study. J Clin Pharm Ther 2018; 43:707-713. [PMID: 29737025 DOI: 10.1111/jcpt.12697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/28/2018] [Indexed: 01/12/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Sofosbuvir(SOF)-based regimens have been administrated with excellent efficacy in chronic hepatitis C. Few uncontrolled ("real-life") studies consider the assessment of renal function when evaluating their post-treatment outcomes. This study aims to evaluate renal biomarkers in a "real-life" experience with chronic hepatitis C patients treated with SOF therapy in a long-term follow-up. METHODS Serum and urinary biomarkers were analysed before, at the end of therapy (EoT), after 12 weeks (sustained virological response-SVR) and one year (1y) post-treatment. Patients were categorized according to baseline glomerular filtration rate (GFR-cut-off 45 mL/min/1.73 m2 ). RESULTS Ninety-four patients with a mean age of 59.9 ± 8.5 years were included; 98.9% of patients reached SVR. Significant improvement in renal biomarkers was observed in patients with GFR ≥45 mL/min/1.73 m2 , as indicated by a progressive increase in mean GFR values until 1y. No evidence of tubular dysfunction was identified. Patients with baseline GFR <45 mL/min/1.73 m2 did not experience alterations in renal biomarkers; however, a mean change of +10.7 in GFR values was observed. We noticed significant upper stage transition in the CKD classification, and 58.7% of patients achieved G1 stage at 1y (P < .0001). WHAT IS NEW AND CONCLUSION In a "real-life experience" of a Brazilian centre, SOF therapy appears to guarantee renal safety for patients with chronic hepatitis C followed until one year after treatment.
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Affiliation(s)
- T Medeiros
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - N F Rosário
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - G N Saraiva
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - T G Andrade
- Centro de Referência de Tratamento em Hepatites/HUAP, Serviço de Gastroenterologia, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - A A Silva
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil.,Departamento de Patologia, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - J R Almeida
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas, Departamento de Medicina Clínica, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
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