Hepatitis C virus infection in kidney transplantation-changing paradigms with novel agents

Age-modified risk factors for mortality of non-elderly adult kidney transplant recipients: a retrospective database analysis

PURPOSE

We aimed to investigate the role of the recipient's age strata in modifying the associations between risk factors and mortality in non-elderly adult kidney transplant (KT) recipients (KTR).

METHODS

We stratified 108,695 adult KTRs between 2000 and 2016 with conditional 1-year survival after KT into cohorts based on age at transplant: 18-49 years and 50-64 years. We excluded KTRs aged < 18 years or > / = 65 years. KTRs were observed for 5 years during the 2nd through 6th years post-KT for the outcome, all-cause mortality.

RESULTS

Increasing recipient age strata (18-49-year-old and 50-64-year-old) correlated with decreasing 6-year post-KT survival rates conditional on 1-year survival (79% and 57%, respectively, p < 0.0001). Middle adult age stratum was associated with a higher risk of all-cause mortality than young adult age stratum in KTRs of Hispanic/Latino and other races [HR = 1.23, 95% CI = 1.04-1.45 and HR = 1.51, 95% CI = 1.16-1.97, respectively] and with a primary native renal diagnosis of hypertension or glomerulonephritis [HR = 1.32, 95% CI = 1.12-1.55 and HR = 1.29, 95% CI = 1.10-151, respectively]. When compared with the young adult age stratum, the middle adult age stratum had a mitigating effect on the higher risk of mortality associated with sirolimus-mycophenolate or sirolimus-tacrolimus than the standard calcineurin inhibitor-mycophenolate regimen [HR = 0.75, 95% CI = 0.57-0.99 and HR = 0.71, 95% CI = 0.57-0.89, respectively].

CONCLUSION

Among adult non-elderly KTRs, the age strata, 18-49 years, and 50-64 years, have varying modifying effects on the strength and direction of associations between some specific risk factors and all-cause mortality.

Impact of antiviral therapy with Direct Acting Antiviral Agents (DAAs) on kidney disease in patients with chronic hepatitis C

Hepatitis C virus and chronic kidney disease are major public health issues all over the world and controversy persists regarding the role of hepatitis C as a risk factor for the development of chronic kidney disease in the adult general population. Numerous studies found a relationship between positive anti-HCV antibody serologic prevalence and increased frequency of incidence, prevalence and accelerated progression of CKD over time. However, this has not been universally accepted. One method to analyze the relationship between anti-HCV status and CKD is to evaluate the impact of anti-HCV antiviral therapy on the risk of CKD in the general population. The availability of safe and effective drugs (direct-acting antiviral agents) for HCV eradication support this approach. Novel data support the notion that sustained viral response with anti-HCV regimens leads to improvement of hepatic and extra-hepatic outcomes. A systematic review with metaanalysis of clinical observational studies was recently performed on this point. Fifteen studies were retrieved (n=356, 285 patients); a relationship between sustained viral response and lower rate of kidney disease was noted- the summary estimate for adjusted risk of kidney disease was 2.5 (95% CI, 1.41; 4.41) (P=0.0016). An association between anti-HCV therapy and reduced risk of kidney disease after comparison of treated vs. untreated cohorts was observed, the summary estimate for adjusted HR was 0.44 (95% CI, 0.25; 0.63) (P=0.0001). Several biologic mechanisms have been cited to explain the detrimental role of HCV on kidney disease in the general population, and a direct and indirect activity of HCV on atherogenesis at kidney level has been mentioned. Clinical and experimental studies are under way.

Summary of the 2018 Kidney Disease Improving Global Outcomes (KDIGO) Guideline on hepatitis C in chronic kidney disease

KDIGO recently updated its clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD). The management of HCV in patients with CKD has dramatically shifted over the past 10 years with the development of direct-acting antiviral (DAA) agents and subsequent demonstration of their efficacy in CKD populations. The opportunity to cure HCV with DAA treatment has impacted all aspects of the KDIGO guideline on HCV in CKD including: (a) HCV diagnosis in CKD populations; (b) HCV treatment in CKD populations; (c) preventing HCV transmission in HD units; (d) management of HCV before and after kidney transplantation; and (e) management of HCV-associated glomerular disease. This review summarizes and discusses the major recommendations, along with the implication of the guideline on clinical practice.