Rationale for treating hepatitis C virus infection in patients with mild to moderate chronic kidney disease

Discovery and Development of Antiviral Therapies for Chronic Hepatitis C Virus Infection

At the beginning of this decade, an estimated 71 million people were living with chronic hepatitis C virus (HCV) infection worldwide. After the acute stage of HCV infection, 18-34% of individuals exhibit spontaneous clearance. However, the remaining 66-82% of infected individuals progress to chronic HCV infection and are at subsequent risk of progression to hepatic fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Chronic hepatitis C progression is generally slow during the first two decades of infection, but can be accelerated during this time in association with advancing age and cofactors, such as heavy alcohol intake and human immunodeficiency virus (HIV) co-infection. Since acute HCV infection is generally asymptomatic, HCV goes undiagnosed in a significant percentage of infected individuals. In 2014, direct-acting antiviral (DAA) therapy for chronic HCV was developed, which has increased the cure rates to nearly 100%. DAA therapy is among the best examples of success in the fight against viral infections. DAAs have transformed HCV management and have opened the door for the global eradication of HCV.

Hepatitis C Virus Epidemiology and the Impact of Interferon-Free Hepatitis C Virus Therapy

The public health impact of hepatitis C virus (HCV) infection has been realized only recently. Globally, 71 million people are living with HCV chronic infection. HCV prevalence is higher in some regions and countries, as well as in some subpopulations such as people who inject drugs, prisoners, or people living with HIV. In 2017, an estimated 580,000 people died from HCV, largely because of long-term complications of the disease. The advent of direct-acting antivirals (DAAs), which are highly effective in treating the infection and are well tolerated, led the World Health Organization (WHO) in 2016 to call for the elimination of HCV by 2030, which would be possible by meeting the numerical targets laid down by the organization. However, at present, only 12 countries are on track. Overall, only 20% of people with HCV have been diagnosed and only 7% of people diagnosed have initiated treatment, with major differences among countries. Underdiagnoses, a general lack of awareness, poor surveillance, and the prices of diagnostics and treatment remain major barriers to achieving the elimination goals. Comprehensive strategies, which include innovative models of care and the removal of reimbursement restrictions for treatment, are needed to overcome these public health and health system obstacles.

High rate of acute kidney injury in patients with chronic kidney disease and hepatitis C virus genotype 4 treated with direct-acting antiviral agents

BACKGROUND

Direct-acting antivirals (DAAs) have significantly improved the efficacy and safety of treating chronic hepatitis C (CHC), but their effectiveness and safety among patients with chronic kidney disease (CKD) remains poorly understood. Sofosbuvir/daclatasvir regimen is supposed to be used for patients with creatinine clearance more than 30 mL/min, while ombitasvir/paritaprevir/ritonavir regimen is used for patients with creatinine clearance less than 30 mL/min.

AIM

The aim of the study was to assess the safety and efficacy of DAAs among patients with CKD.

METHODS

Eighteen CKD stage 2-3b patients received sofosbuvir for 3 months. In addition, 42 CKD stage-4 patients received ritonavir-boosted paritaprevir plus ombitasvir for 3 months. Finally, ribavirin was added for 30 of them.

RESULTS

The patients'age was 49.2 ± 12 years. Baseline serum creatinine was 3.76 ± 1.67 mg/dL. Fifty patients were HCV genotype 4. A 3-month sustained viral response was achieved in 56 patients and 49 patients achieved a 6-month viral response. There were 11 relapsers. Acute kidney injury (AKI) upon CKD (AKI/CKD) occurred in 28 patients, of which 20 needed hemodialysis. Fifteen/28 recovered from AKI, whereas 13 were maintained on hemodialysis. In multivariate analysis, there were only two independent risk factors for developing AKI/CKD, i.e., being cirrhotic as defined by baseline abdominal ultrasound findings [odds ratio 4.15 (1.33-12.97); p = 0.013] and having had as DAA therapy OMV/PTV/RTV [odds ratio 7.35 (1.84-29.35); p = 0.001].

CONCLUSION

Treatment of HCV among stage 2, 3a, and 3b patients was achieved safely with a sofosbuvir-based regimen. We recommend that stage-4 patients wait until starting hemodialysis or transplantation.

Efficacy and safety of direct-acting antiviral agents for HCV in mild-to-moderate chronic kidney disease

BACKGROUND AND AIMS

The advent of direct-acting antiviral agents promises to change the management of hepatitis C virus infection (HCV) in patients with chronic kidney disease (CKD), a patient group in which the treatment of hepatitis C was historically challenging. We investigated the safety and efficacy of all-oral, interferon-free direct-acting antiviral agents for the treatment of hepatitis C in a 'real-world' cohort of patients with CKD.

METHODS

We performed an observational single-arm multi-centre study in a large (n=198) cohort of patients with stage 1-3 CKD who underwent antiviral therapy with DAAs for the treatment of HCV. The primary end-point was sustained virologic response (serum HCV RNA <15IU/mL, 12 weeks after treatment ended) (SVR12). We collected data on on-treatment adverse events (AEs), severe AEs, and laboratory abnormalities.

RESULTS

The average baseline eGFR (CKD-EPI equation) was 70.06±20.1mL/min/1.72m²; the most common genotype was HCV 1b (n=93, 51%). Advanced liver scarring was found in 58 (46%) patients by transient elastography. Five regimens were adopted: elbasvir/grazoprevir (n=5), glecaprevir/pibrentasvir (n=4), ritonavir-boosted paritaprevir/ombitasvir/dasabuvir (PrOD) regimen (n=40), simeprevir±daclatasvir (n=2), and sofosbuvir-based combinations (n=147). The SVR12 rate was 95.4% (95% CI, 93.8%; 96.8%). There were nine virological failures - eight being relapsers. Adverse events occurred in 30% (51/168) of patients, and were managed clinically without discontinuation of therapy or hospitalization. One of the most common AEs was anaemia (n=12), which required discontinuation or dose reduction of ribavirin in some cases (n=6); deterioration of kidney function occurred in three (1.7%).

CONCLUSIONS

All-oral, interferon-free therapy with DAAs for chronic HCV in mild-to-moderate CKD was effective and well-tolerated in a 'real-world' clinical setting. Studies are in progress to address whether sustained viral response translates into better survival in this population.

Managing hepatitis C therapy failures and chronic kidney disease

INTRODUCTION

Hepatitis C virus (HCV) infection leads to important morbidity and mortality through liver disease and extra-hepatic manifestations. Recent evidence suggests the role of HCV in developing chronic kidney disease (CKD); also, HCV adversely affects cardiovascular (CV) disease both in the general population and in patients with CKD. Areas covered: All-oral, interferon-free direct-acting antiviral agents (DAAs) are currently available; anti-HCV regimens based on DAAs are provided with high efficacy and safety and short treatment duration. However, some difficult-to-treat populations still exist including patients with CKD and those who failed previous DAA regimen. Expert commentary: Two DAAs regimens (elbasvir/grazoprevir and glecaprevir/pibrentasvir) are now recommended for the treatment of HCV in patients with advanced CKD, these combinations have shown great efficacy, according to two multicenter phase-3 trials (C-SURFER and EXPEDITION-4). These trials reported a minimal impact of baseline resistance-associated substitutions (RASs) on treatment outcomes. The sofosbuvir/velpatasvir/voxaliprevir combination has been recommended as the first-line option for DAAs failures, on the basis of the results given by two randomized clinical trials involving patients who had been previously received DAA-containing regimens (POLARIS 1-4 studies). It has been suggested that clinicians should consider RASs upon the introduction of DAA-based antiviral therapy.