Chronic viral hepatitis and chronic kidney disease

Effect of Entecavir, Tenofovir Disoproxil Fumarate, and Tenofovir Alafenamideantiviral Therapy on Renal Function in Chronic Hepatitis B Patients: A Real-World Retrospective Study

Background

Entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide(TAF) are first-line nucleos(t)ide analogs (NUCs) with chronic hepatitis B (CHB). This study aimed to assess the renal safety profile in NUC-experienced CHB patients who received ETV, TDF or TAF therapy.

Methods

This retrospective observational cohort study investigated factors related to renal function in 154 patients with NUC-experienced CHB who received ETV, TDF, and TAF therapy for 48 weeks. Changes in UREA, uric acid (UA), creatinine (Cr), and estimated glomerular filtration rate (eGFR) were analyzed using a one-way analysis of variance. A linear mixed-effects model for repeated measures was used to evaluate the correlation between baseline information and eGFR changes 48 weeks following treatment initiation. The model considered sex, baseline age, viral load, aminotransferases, renal function, and treatment group as fixed effects, and incorporated random effects for individual subjects.

Results

There were no significant differences in UA or Cr levels during therapy over time. The eGFR level was elevated in ETV-treated patients (117.5 ± 16.65 mL/min/1.7m2 vs 109.8 ± 15.69 mL/min/1.7m2, P=0.027), whereas it did not change significantly in TDF- (123.6 ± 28.54 mL/min/1.7m2 vs 115.5 ± 20.44 mL/min/1.7m2, P=0.070) and TAF-treated (121.6 ± 23.44 mL/min/1.7m2 vs 113.4 ± 16.90 mL/min/1.7m2, P=0.053) patients. Younger patients (<30 years) and those with higher HBV DNA (> 7 log10IU/mL) and lower alanine aminotransferase levels (<5 × upper limit of normal) showed a significant improvement in eGFR elevation during NUCs therapy. The linear mixed-effects model showed that the baseline HBV DNA level was an important positive predictor of eGFR elevation at 48 weeks following treatment initiation (estimate was 1.437 and 2.449, P<0.001).

Conclusion

In real-life experience, ETV, TDF, and TAF therapy may not be associated with eGFR changes in NUC-experienced CHB patients without baseline renal impairment.

Dynamic changes in liver stiffness measurements using transient elastography in hemodialysis patients

Background and Aim

The impact of fluid status changes on liver stiffness measurements (LSM) using transient elastography (TE) in dialysis patients remains unclear. This study aimed to evaluate LSM variations during hemodialysis (HD) and analyze contributing factors.

Materials and Methods

A cross-sectional study was conducted on dialysis patients at a tertiary care hospital. TE and bioelectrical impedance analysis were performed at four time points: before dialysis, immediately after, the first day after, and the second day after dialysis. LSM values were compared across these time points.

Results

Seventy patients were enrolled, with two cases showing consistently extremely elevated LSM values exceeding 20 kPa, considered outliers. The mean LSM values were 7.6±7.0 kPa before dialysis, 6.12±2.94 kPa immediately after, 6.64±5.27 kPa on the first day, and 6.94±5.12 kPa on the second day after dialysis. The mean pre-HD LSM was significantly higher than immediately after and on the first day after dialysis, with mean differences of 1.54 kPa (95% CI 0.22-2.86, p=0.02) and 1.02 kPa (95% CI 0.15-1.9, p=0.02), respectively. The ultrafiltration volume positively correlated with the LSM difference pre- and post-HD (r=0.315, p=0.008). Patients with residual fluid overload had significantly higher post-HD LSM compared to euvolemic patients (p=0.003).

Conclusion

LSM values significantly decreased after dialysis and remained lower for up to 24 hours. Transient elastography should preferably be performed within 24 hours post-dialysis when the patient is in a euvolemic state.

Role of Metformin in Preventing New-Onset Chronic Kidney Disease in Patients with Type 2 Diabetes Mellitus

Background: Recent evidence supports the protective role of metformin on kidney function in patients with type 2 diabetes mellitus. However, its potential to prevent new-onset chronic kidney disease (CKD) in patients with type 2 diabetes mellitus with normal renal function remains unclear. Therefore, this study aimed to investigate whether metformin could prevent the development of new-onset CKD in such patients. Methods: This retrospective, observational, multicenter cohort study included 316,693 patients with type 2 diabetes mellitus. After matching using the inverse probability of treatment weighting, 9109 metformin users and 1221 nonusers were analyzed. The primary outcomes were an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2, urinary albumin-to-creatinine ratio of ≥30 mg/g, and a composite outcome defined as new-onset CKD. Results: The multivariable Cox survival model showed that metformin users had significantly better renal outcomes, with a notably lower risk of sustained eGFR of <60 mL/min/1.73 m2 (hazard ratio (HR), 0.71; 95% confidence interval (CI), 0.56-0.90) and new CKD onset (HR, 0.78; 95% CI, 0.65-0.94). Conclusions: Metformin plays a key role in delaying renal events in individuals with type 2 diabetes mellitus and in those with initially normal renal function.

Switching from combination therapy with entecavir hydrate plus tenofovir alafenamide fumarate to tenofovir alafenamide fumarate monotherapy in patients with chronic hepatitis B based on nucleotide sequences of hepatitis B virus pregenome RNA

AIM

Patients with chronic hepatitis B virus (HBV) infection experiencing viral breakthrough (BTH) or partial response (PR) during lamivudine (LAM) or entecavir hydrate (ETV) administration often took ETV plus tenofovir alafenamide fumarate (TAF) due to the emergence of a drug-resistance mutation. However, in patients lacking drug-resistance mutation against TAF, sufficient antiviral effects may be achievable with TAF monotherapy. We assessed the drug-resistance profile through nucleotide sequences of HBV pregenome RNA, and subsequently changed to TAF monotherapy from ETV plus TAF.

METHODS

This prospective study included 25 patients with serum HBV-DNA below 20 IU/mL under ETV plus TAF administration. Pregenome RNA nucleotide sequences of HBV in the sera were analyzed using direct sequencing and deep sequencing. ETV was discontinued in patients without rtA194T and rtS106C + rtH126Y + rtD134E + rtL269I quadruple mutations in direct sequencing.

RESULTS

LAM-PR, LAM-BTH, ETV-PR, and ETV-BTH were observed in 1, 16, 7, and 1 patient(s), respectively. Pregenome RNA nucleotide sequences were analyzable in 20 patients. Among the 12 patients classified as LAM-BTH, six patients showed rtL180M + rtM204V/I in direct sequencing, and one patient showed minor clones containing rtL180M + rtM204V + A194T in deep sequencing at a frequency of 0.3%. In the six patients classified as ETV-PR, one patient harbored rtM204I. No clones showing rtS106C + rtH126Y + rtD134E + rtL269I quadruple mutation were detected in deep sequencing. Subsequently, ETV was discontinued, and serum HBV-DNA remained undetectable up to 48 weeks in all patients.

CONCLUSION

Patients receiving ETV plus TAF due to partial response or BTH during initial LAM or ETV administration were able to safely transition to TAF monotherapy based on nucleotide sequences of HBV pregenome RNA in the sera.

Management of hepatitis B and C in special population

Chronic viral hepatitis is one of the leading causes of cirrhosis worldwide. Chronic hepatitis B is more common in the Asia-Pacific region due to the larger population and lower screening availability. Hepatitis C predominates in the west due to injection drug abuse. The discovery of (oral) direct-acting antiviral agents (DAAs) has changed the landscape of chronic hepatitis C (CHC) management. Nucleos(t)ide analogs (NUCs) have also changed the approach to the treatment of chronic hepatitis B (CHB). Oral NUCs and DAAs have excellent efficacy and patient acceptance as well as a lower risk of resistance. However, certain populations have no robust data and safety and efficacy of such oral drugs is still evolving. In this review, we provide an overview of the management of CHB and CHC in special populations, such as those with chronic kidney disease, pregnant women, healthcare workers, and those undergoing chemo- or immunosuppressive therapy.

Health Care Resource Use and Cost Burden of Chronic Kidney Disease in Patients With Chronic Liver Disease: A Real-World Claims Analysis

Chronic Liver Disease (CLD) is associated with an increased risk of chronic kidney disease (CKD). However, the health care burden of CKD in the CLD spectrum is unknown. We aimed to evaluate the health care use and cost burdens associated with CKD in patients with CLD in the United States by using real-world claims data. We analyzed data from the Truven Health MarketScan Commercial Claims database from 2010 to 2015. A total of 19,664 patients with CLD with or without comorbid CKD were identified using International Classification of Diseases, Ninth Revision, codes and matched 1:1 by sociodemographic characteristics and comorbidities using propensity scores. Total and service-specific unadjusted and adjusted health care parameters were analyzed for the 12 months following an index date selected at random to capture whole disease burdens. In CLD, comorbid CKD was associated with a higher annual number of claims per person (CKD vs. no CKD, 69 vs. 55) and higher total annual median health care costs (CKD vs. no CKD, $21,397 vs. $16,995). A subanalysis stratified by CKD category showed that health care use and cost burden in CLD increased with disease stage, with a peak 12-month median cost difference of $77,859 in patients on dialysis. The adjusted per person annual health care cost was higher for CKD cases compared to controls ($35,793 vs. $24,048, respectively; P < 0.0001). Stratified by the type of CLD, the highest between-group adjusted cost differences were for cirrhosis, viral hepatitis, hemochromatosis, and nonalcoholic fatty liver disease. Conclusion: CKD is a cost multiplier in CLD. The CKD health care burden in liver disease differs by the type of CLD. Improved CKD screening and proactive treatment interventions for at-risk patients can limit the excess burden associated with CKD in patients with CLD.

Evaluation of hepatic and kidney dysfunction among newly diagnosed HIV patients with viral hepatitis infection in Cape Coast, Ghana

OBJECTIVE

HIV positive individuals infected with viral hepatitis B (HBV) or C (HCV) are at an increased risk of progression to kidney and liver failures. Therefore, prior to initiation of antiretroviral therapy, early diagnosis and initiation of appropriate treatment protocols are imperative for co-infected individuals. This study evaluated the prevalence of HBV and HCV, and extent of liver and renal dysfunction among 90 newly diagnosed HIV patients attending the Cape Coast Teaching Hospital HIV clinic.

RESULTS

Levels of alanine aminotransferase, aspartate-platelet ratio index and estimated glomerular filtration rate were used respectively to diagnose hepatotoxicity, liver fibrosis and chronic kidney disease (CKD). Association analyses were evaluated by Pearson's Chi-square test or Fisher's exact test and considered significant at p < 0.05. Using rapid diagnostic tests, 75.6% (n = 68) had HIV1 mono-infection, 24.4% (n = 22) had HIV1/HBV co-infection while 0.0% (n = 0) had HIV1/HCV co-infection. The prevalence of hepatotoxicity, liver fibrosis, and CKD were 7.8% (n = 7), 2.2% (n = 2), and 15.5% (n = 14) respectively. Similar proportions of HIV1/HBV and HIV1 were diagnosed with liver fibrosis (p = 0.431). In relation to hepatotoxicity Grade, a high proportion of HIV1/HBV were diagnosed with Grade 2 (p = 0.042). Also, severely reduced kidney function (CKD stage 4) was observed in only HIV1/HBV (n = 2, 9.1%, p = 0.053).

Anti-hepatitis C virus therapy in chronic kidney disease patients improves long-term renal and patient survivals

BACKGROUND

Hepatitis C virus (HCV) infection is a documented risk factor for chronic kidney disease (CKD) and progression to end-stage renal disease (ESRD). However, to date there are no reports on the long-term hard endpoints (ESRD and death) of anti-HCV therapy [interferon-based therapy (IBT) or new direct-acting antivirals] in CKD patients. Direct-acting antivirals are not available in Taiwan's single-payer national health insurance database currently released for research. Therefore, we hypothesized that a retrospective analysis of the long-term outcomes of IBT in CKD patients will serve as a proxy for direct-acting antivirals to increase our understanding of progression to ESRD following HCV infection.

AIM

To evaluate the long-term outcomes (ESRD and death) of anti-HCV therapy, especially IBT, in HCV-infected patients with stage 1-5 CKD.

METHODS

We analyzed 93894 Taiwanese adults diagnosed with CKD and without HBV infection. Of these, 4.9% were infected with HCV. Of the 4582 HCV-infected CKD patients, 482 (10.5%) received IBT (treated cohort). They were matched 1:4 with 1928 untreated HCV-infected CKD patients (untreated cohort) by propensity scores and year, which further matched 1:2 by propensity scores with 3856 CKD patients without HCV infection (uninfected cohort). All participants were followed until the occurrence of ESRD, death, or the end of 2012. The association between HCV infection, IBT use, and risks of ESRD and death was analyzed using competing risk analysis.

RESULTS

Taking the uninfected cohort as a reference, the adjusted hazard ratios for ESRD, after adjusting for competing mortality, were 0.34 (0.14-0.84, P = 0.019) and 1.28 (1.03-1.60, P = 0.029) in the treated and untreated cohorts, respectively. The treated cohort had a 29% (0.54-0.92, P = 0.011) decrease in mortality compared to the untreated cohort, in which the mortality was 31% (1.18-1.45, P < 0.001) higher than in the uninfected cohort. The reduced risks of ESRD (0.14, 0.03-0.58, P = 0.007) and death (0.57, 0.41-0.79, P = 0.001) were greatest in HCV-infected CKD patients who received at least 4 mo of IBT, which accounted for 74% of the treated cohort.

CONCLUSION

Adequate anti-HCV therapy in CKD patients improves long-term renal and patient survival.

Association between hepatitis B virus infection and chronic kidney disease: A cross-sectional study from 3 million population aged 20 to 49 years in rural China

Hepatitis B virus (HBV) infection can lead to different types of chronic kidney diseases (CKD) in clinical practice. However, HBV infection has been observed to have no significant association with CKD indicators in some epidemiological surveys. This research aims to estimate CKD prevalence in HBV infection population and clarify the relationship between HBV infection status and CKD.The participants aged 20 to 49 years were selected by multistage random sampling from January 1, 2010 to December 31, 2012 across 31 provinces and regions in rural China. The data was collected by standard questionnaire and physical check-up. Status of HBV infection was diagnosed as immune tolerant phase, hepatitis B envelope antigen -positive chronic HBV infection, inactive HBV carrier, hepatitis B envelope antigen -negative chronic HBV infection and resolved HBV infection based on serological markers, and the level of hepatic function, respectively.In total, 2,969,502 subjects were included in the study. In population aged 20 to 49 years in rural China, prevalence of HBV infection was 12.17%. Prevalence of proteinuria, hematuria, estimated glomerular filtration rate less than 60 mL/min/1.73m and CKD was 0.94%(95% CI = 0.91-0.97%) vs. 0.65%(95% CI = 0.64-0.66%), 1.92%(95% CI = 1.87-1.96%) vs. 1.19% (95% CI = 1.18-1.21%), 1.02%(95% CI = 0.99-1.06%) vs. 0.77% (95% CI = 0.76-0.78%), and 3.85%(95% CI = 3.78-3.91%) vs. 2.60%(95% CI = 2.58-2.62%) in population with HBV infection and without infection, respectively. Prevalence of CKD and indicators was higher in population in every status of HBV infection than in population without infection, respectively (all P < 0·0001). Every HBV infection status was a risk factor for CKD.CKD prevalence was higher in population in every status of HBV infection than without infection. HBV infection was a risk factor for CKD in population aged 20 to 49 years in rural China.

Hepatitis C virus antibodies in outpatients with chronic kidney disease

Aim of the study

To determine the seroprevalence of hepatitis C virus (HCV) in outpatients with chronic kidney disease (CKD) attending a nephrology clinic.

Material and methods

Prospective observational study on consecutive outpatients attending a nephrology clinic. Inclusion criteria were age > 18 years, CKD, informed consent. There were no exclusion criterias. Recorded variables were age, gender, CKD grade and etiology, anti-HCV antibodies (Ab). Patients with positive HCV Abs were tracked for HCV RNA detection. Study interval was from November 2015 to March 2016. The study has been approved by the Ethic committee of F.D. Roosevelt University Hospital. Funded by Restricted Grant of AbbVie Slovakia.

Results

One hundred and thirty-four patients were enrolled, with median age 70 years (19.7-91), 52% women. CKD grades: G1/2 – 52 patients (39%), G3a – 34 patients (25%), G3b – 32 patients (24%), G4 – 8 patients (6%), G5 – 8 patients (6%); CKD etiology: tubulointerstitial nephritis (TIN) – 53 patients (40%), nephrosclerosis (NS) – 30 patients (22%), diabetic nephropathy (DN) – 23 patients (17%), glomerulonephritis (GN) – 23 patients (17%), others – 5 patients (4%). Anti-HCV antibodies were detected in 8 patients (6%). There were no significant differences in CKD grades between HCV+ and HCV– patients; Heymann nephritis and GN were significantly more frequent in HCV– patients, as was male gender. Of 8 HCV Ab positive patients, 5 were available for HCV RNA testing (2 died after completion of the study, 1 was lost to follow-up); of them, 1 patient tested positive.

Conclusions

Prevalence of anti-HCV antibodies in CKD patients was 6%, which is 4 times higher than in the general population of Slovakia; HCV RNA was detected in 1 patient (12.5%) of anti-HCV positive patients. Based on this result, multicentric, a larger-scale study is considered to be warranted.

Noninvasive Fibrosis Assessment in Chronic Viral Hepatitis C associated with End Stage Renal Disease

INTRODUCTION

HCV is considered the most encountered viral infection that affect patients after hemodialysis sessions. Even though liver biopsy is considered the golden standard for hepatic diagnosis, additional methods have been used for assessing liver fibrosis. Transient elastography (TE) has evolved as a reference method in some European countries and allows the physician to carry out a fibrosis evaluation in a noninvasive, low-cost and rapid method. Our objective was to assess the efficacy of TE in staging patients with HCV liver disease associated with ESRD, thus choosing the correct moment to perform the procedure.

MATERIALS AND METHODS

We included 34 patients known with ESRD within the regional Nephrology Clinic of Olt County Hospital and also having positive hepatitis C viral liver marker. TE was performed before and hemodialysis and data was analyzed.

RESULTS

The patients where we have encountered significant changes were especially within the F0 and F1 stage with a decrease of fibrosis after hemodialysis. Thus, 7 patients which had no fibrosis (F0) went from 4,14±0,98kPa to 3,54±0,84 (p<0,05) and 12 patients from the F1 stage went from 6,22±0,39kPa to 5,47±0,58kPa. The other stages had no significant changes with F2 changing after hemodialysis from 8.03±0,62kPa to 7, 76±0,6kPa.

CONCLUSIONS

TE represents a valuable tool for stiffness assessment and should be taken into considerations as a major option for ESRD patients with liver disease. However, more patients should be enrolled to strengthen this theory and thus providing more reliable results.

Nationwide cohort study suggests that nucleos(t)ide analogue therapy decreases dialysis risk in Taiwanese chronic kidney disease patients acquiring hepatitis B virus infection

AIM

To investigate the risk of end-stage renal disease (ESRD) in hepatitis B virus (HBV)-infected patients with chronic kidney disease (CKD) with and without nucleos(t)ide analogue (NA) therapy.

METHODS

This nationwide cohort study included 103444 Taiwanese CKD adults without hepatitis C virus infection from the Taiwan Longitudinal Health Insurance Database 2005 between 1997 and 2012. We identified 2916 CKD patients who acquired HBV infection and did not receive NAs (untreated cohort), and they were propensity-matched 1:4 with 11664 uninfected counterparts. We also identified 442 CKD patients who acquired HBV infection and received NAs (treated cohort), and they were propensity-matched 1:3 with 1326 untreated counterparts. The association between HBV infection, NA use, and ESRD was analyzed using competing risk analysis.

RESULTS

Multivariable Cox regression analysis showed a 1.67-fold higher risk (P < 0.0001) of ESRD in the untreated cohort (16-year cumulative incidence, 10.1%) than in the matched uninfected cohort (16-year cumulative incidence, 6.6%), which was independent of cirrhosis or diabetes. The treated cohort (16-year cumulative incidence, 2.2%) had an 87% lower ESRD risk (P < 0.0001) compared with the matched untreated cohort (16-year cumulative incidence, 11.9%). The number needed to treat for one fewer ESRD after NA use at 12 years was 12. Multivariable stratified analyses verified these associations in all subgroups.

CONCLUSION

This study suggests that untreated HBV infection and NA therapy are associated with increased and decreased risk of ESRD, respectively, in CKD patients. Identification of HBV status and targeted monitoring for ESRD development are important in CKD patients living in HBV-endemic areas.

Assessment of Liver Fibrosis by Transient Elastography Should Be Done After Hemodialysis in End Stage Renal Disease Patients with Liver Disease

BACKGROUND AND AIMS

The patients with end stage renal disease (ESRD) are at greater risk of acquiring chronic hepatitis B or C and subsequently development of liver disease. The aim of the study was to assess liver fibrosis by transient elastography (TE) and look for factors associated with change in liver stiffness measurement (LSM) with one session of hemodialysis (HD).

METHODS

Consecutive ESRD patients on maintenance hemodialysis (MHD) with suspected liver disease were enrolled. They underwent LSM by TE before and after one session of HD. Bioelectric impedance analysis was done to evaluate the volume status at the time of TE.

RESULTS

Sixty-eight patients with mean age of 40 ± 14 years were included. There was a significant reduction in LSM after HD (18.5 [95% CI 14.8-23.1] vs. 11.2 [95% CI 8.8-13.7] kPa, p < 0.001), with a mean LSM reduction of 7.2 [95% CI 5.25-9.19] kPa. On stratification in two groups by net ultrafiltration during HD (> or < 2.5 liters [L]), change in LSM was substantially higher in patients when total fluid removed was > 2.5 L (8.6 [95% CI 5.7-11.5] vs. 5.1 [95% CI 2.9-7.5], p = 0.05). In 18 patients who underwent liver biopsy, LSM after HD performed better at detecting significant fibrosis, with area under receiver operating characteristics curve 0.71 [95% CI 0.46-0.97], versus 0.64 [95% CI 0.38-0.90], respectively. An LSM value of 12.2 kPa after HD was 71% sensitive and 74% specific for detection of significant fibrosis (≥ F2), while values less than 9 kPa ruled out significant fibrosis with a sensitivity and specificity of 37 and 100%, respectively.

CONCLUSION

LSM by TE decreases significantly after HD in patients with ESRD on long-term MHD. Hence, TE should be done after HD for accurate assessment of liver fibrosis.

Renal safety of tenofovir and/or entecavir in patients with chronic HBV monoinfection

Background

Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) are recommended as the first-line therapy for chronic hepatitis B (CHB) due to their genetic barrier to resistance and effectiveness of virological suppression. TDF and ETV may cause renal toxicity through various mechanisms such as renal tubular injury, apoptosis, and mitochondrial toxicity. The aims of the current review were to assess the potential renal toxicity associated with the use of TDF and ETV in patients infected with chronic hepatitis B virus (HBV) and to provide clinical perspectives on these two agents in the treatment of CHB.

Methods

A literature search of clinical studies published in PubMed and posted on ClinicalTrials.gov website was implemented to find studies evaluating the potential renal toxicity of TDF and ETV.

Results

Twenty-one studies were examined in this review. The TDF dose used in the studies was 245 or 300 mg/day and that of ETV was 0.5 or 1 mg/day. Based on the markers of renal function, patients treated with TDF were not more likely to show changes in renal function than those treated with ETV; however, the estimated glomerular filtration rates (eGFRs) of patients receiving TDF tended to be more clearly reduced than those of patients receiving ETV. The eGFRs of patients treated with TDF decreased in a time-dependent manner, whereas those of patients treated with ETV increased or decreased across various time points.

Conclusion

The data shown in this study suggest that use of TDF and ETV could be at least associated with reductions in renal function in patients with chronic HBV infection. However, various risk factors, such as pre-existing renal failure and comorbidities, are also associated with decreased renal function during the treatment of TDF and ETV. Thus, studies of management strategies for HBV-infected patients with these risk factors are necessary in the near future.

Association between hepatitis B virus and chronic kidney disease: a systematic review and meta-analysis

 Background. Hepatitis B virus infection and chronic kidney disease are prevalent and remain a major public health problem worldwide. It remains unclear how infection with hepatitis B virus impacts on the development and progression of chronic kidney disease.

AIM

To evaluate the effect of infection with HBV on the risk of chronic kidney disease in the general population.

MATERIAL AND METHODS

We conducted a systematic review of the published medical literature to determine if hepatitis B infection is associated with increased likelihood of chronic kidney disease. We used the random effects model of DerSimonian and Laird to generate a summary estimate of the relative risk for chronic kidney disease (defined by reduced glomerular filtration rate and/or detectable proteinuria) with hepatitis B virus across the published studies. Meta-regression and stratified analysis were also conducted.

RESULTS

We identified 16 studies (n = 394,664 patients) and separate meta-analyses were performed according to the outcome. The subset of longitudinal studies addressing ESRD (n = 2; n = 91,656) gave a pooled aHR 3.87 (95% CI, 1.48; 6.25, P < 0.0001) among HBV-infected patients and no heterogeneity was recorded. In meta-regression, we noted the impact of male (P = 0.006) and duration of follow- up (P = 0.007) upon the adjusted hazard ratio of incidence of chronic kidney disease (including end-stage renal disease). No relationship occurred between HBV positive status and prevalent chronic disease (n = 7, n = 109,889 unique patients); adjusted odds ratio, were 1.07 (95% CI, 0.89; 1.25) and 0.93 (95% CI, 0.76; 1.10), respectively.

CONCLUSIONS

HBV infection is possibly associated with a risk of developing reduced glomerular filtration rate in the general population; no link between HBV sero-positive status and frequency of chronic kidney disease or proteinuria was noted in cross-sectional surveys.

Renal Function in Nucleos(t)ide Analog-Treated Patients With Chronic Hepatitis B: A Systematic Literature Review and Network Meta-Analysis

INTRODUCTION

Renal safety is an important factor in selecting the most appropriate nucleos(t)ide analog (NA) treatment for patients with chronic hepatitis B (CHB). This systematic literature review and network meta-analysis aimed to assess renal function associated with telbivudine treatment compared to other NAs in patients with CHB.

METHODS

A systematic literature search via Medline, Medline In-Process, Embase, and the Cochrane library for publications of randomized controlled trials and observational studies was conducted. Network meta-analysis was performed to compare renal function with telbivudine treatment versus other NAs after 1 year of therapy.

RESULTS

Overall, 40 (six randomized controlled and 34 observational) studies were included for review. Telbivudine consistently showed an improvement in renal function as measured by an estimated glomerular filtration rate (eGFR) over various time points regardless of the method of measurement. Changes in eGFR (mL/min) from baseline and corresponding 95% credible intervals with various NAs were as follows: monotherapies (telbivudine: 7.78 [6.91, 8.65], entecavir: -1.07 [-4.80, 2.62], lamivudine: -6.08 [-13.35, 1.15], tenofovir: -9.53 [-14.31, -4.89]) and combination therapies (telbivudine + adefovir: 8.37 [-34.00, 50.34], telbivudine + tenofovir: 8.29 [-0.05, 16.64], entecavir + adefovir: 4.15 [-38.55, 46.37], telbivudine + lamivudine: 0.51 [-11.77, 12.96], and lamivudine + adefovir: -0.39 [-42.48, 41.21]). At 1 year, the change in eGFR from baseline was significantly higher with telbivudine compared to other NAs.

CONCLUSION

The systematic literature review and network meta-analysis provide evidence that telbivudine is associated with significant improvement in renal function in patients with CHB, either alone or in combination with other NAs.

FUNDING

Novartis Pharma AG.

Immune mediated crescentic MPGN secondary to HBV infection: A rare presentation for a common infection

Hepatitis B virus (HBV) infection presenting as crescentic glomerulonephritis in the absence of cryoglobulinemia is an extremely rare phenomenon. We report a case of a 44-year-old male with HBV infection, who underwent kidney biopsy for rapidly progressive renal failure and nephrotic range proteinuria. Histopathological evaluation of the kidney biopsy was consistent with immune complex mediated crescentic membranoproliferative glomerulonephritis (MPGN). The patient achieved complete renal and virological remission with steroids, plasmapheresis and antiviral therapy. This case report summarises the importance of early initiation of immunosuppression and plasmapheresis under antiviral coverage for improved clinical outcomes.

A Taiwanese Nationwide Cohort Study Shows Interferon-Based Therapy for Chronic Hepatitis C Reduces the Risk of Chronic Kidney Disease

Hepatitis C virus (HCV) infection is a risk factor for chronic kidney disease (CKD). However, it remains unclear whether interferon-based therapy (IBT) for HCV was associated with reduced risk of CKD.From the Taiwan National Health Insurance Research Database, we identified 919 patients who received 3 months or more of IBT as our treated cohort. This cohort was propensity score-matched 1:4 with 3676 controls who had never received IBT for HCV infection (untreated cohort). Cumulative incidences of and hazard ratios (HRs) for CKD were calculated after adjusting for competing mortality.In the matched HCV cohort, the risk of CKD was significantly lower in the treated cohort (7-year cumulative incidence, 2.6%; 95% confidence interval [CI], 0.7%-6.9%) than in the untreated cohort (4%; 95% CI, 3.5%-5.2%) (P < 0.001), with an adjusted HR of 0.42 (95% CI, 0.20-0.92; P = 0.03). The results also held in the overall HCV cohort. The number needed to treat for 1 fewer CKD at 7 years was 58. The reduced risk of CKD was greatest (0.35; 0.14-0.87; P = 0.024) in HCV-infected patients who received 6 months or more of IBT. Multivariable stratified analysis verified that greater risk reduction of CKD was present in HCV-infected patients with hyperlipidemia, diabetes, hypertension, and those without coronary heart disease.In conclusion, IBT, especially for 6 or more months, is associated with reduced risk of CKD in HCV-infected patients. Hyperlipidemia, diabetes, hypertension, and coronary heart disease can modify this association.

13-year nationwide cohort study of chronic kidney disease risk among treatment-naïve patients with chronic hepatitis B in Taiwan

Background

Chronic hepatitis B virus (HBV) infection and chronic kidney disease (CKD) have high prevalences in Taiwan and worldwide. However, the association of untreated chronic hepatitis B virus (HBV) infection with chronic kidney disease (CKD) remains unclear.

Methods

This cohort study used claims data in the Taiwan National Health Insurance Research Database in 1996–2010, in which all diseases were classified by ICD-9-CM codes. We identified 17796 adults who had chronic HBV infection and did not take nucleos(t)ide analogues from 1998 to 2010 and also randomly selected 71184 matched controls without HBV in the same dataset. Cumulative incidences and adjusted hazard ratio (aHR) of incident CKD were evaluated through the end of 2010 after adjusting for competing mortality.

Results

The risk of CKD was significantly higher in the HBV cohort (13-year cumulative incidence, 6.2 %; 95 % confidence interval [CI], 5.4–7.1 %) than in the non-HBV cohort (2.7 %; 95 % CI, 2.5–3.0 %) (p < 0.001), and the aHR was 2.58 (95 % CI, 1.95-3.42; p < 0.001). Multivariable stratified analysis further verified significant associations of CKD with HBV in men of any age (aHR, 2.98; 95 % CI, 2.32–3.83, p < 0.001 for men aged <50 years; aHR, 1.58; 95 % CI, 1.31–1.91, p < 0.001 for men aged ≧50 years) and women under the age of 50 (aHR, 2.99; 95 % CI, 2.04–4.42, p < 0.001), but no significant association in women aged 50 or over.

Conclusion

Untreated chronic HBV infection is associated with increased risk of CKD. Hence, high-risk HBV-infected subjects should have targeted monitoring for the development of CKD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-015-0106-5) contains supplementary material, which is available to authorized users.

A nationwide cohort study suggests chronic hepatitis B virus infection increases the risk of end-stage renal disease among patients in Taiwan

The association of chronic hepatitis B virus (HBV) infection with end-stage renal disease (ESRD) is unclear. To help clarify this we conducted a nationwide cohort study to measure the association by analyzing the claims data from the Taiwan National Health Insurance Research Database with ICD-9 codes used to identify diseases. We identified 17,758 adults who had chronic HBV infection and had not taken nucleos(t)ide analogs from 1999 to 2010 and randomly selected 71,032 matched controls without HBV in the same data set. The risk of ESRD was compared between these two cohorts. Cumulative incidences and hazard ratios were calculated after adjusting for competing mortality. The risk of ESRD was significantly higher in the HBV cohort (12-year cumulative incidence, 1.9%) than in the non-HBV cohort (0.49%) with a significant adjusted hazard ratio of 3.85. Multivariable stratified analysis further verified significant associations of ESRD with HBV in men of any age and women under the age of 60 years, but no significant association in women aged ⩾60 years. Thus, a large national cohort study indicates that untreated chronic HBV infection is associated with increased risk of ESRD. Hence, high-risk HBV-infected patients should have targeted monitoring for the development of ESRD.

Characteristics of co-infections by HCV and HBV among Brazilian patients infected by HIV-1 and/or HTLV-1

Background

The human retroviruses HIV-1 and HTLV-1 share the routes of infection with hepatitis viruses B and C. Co-infection by these agents are a common event, but we have scarce knowledge on co-infection by two or more of these agents.

Objective

To evaluate the characteristics and risk factors for co-infections by HBV and HCV in patients infected by HIV-1 or/and HTLV-1, in Salvador, Brazil.

Methods

In a case–control study we evaluated patients followed in the AIDS and HTLV clinics of Federal University of Bahia Hospital. Clinical and epidemiological characteristics were reviewed, and patients were tested for the presence of serological markers of HBV and HCV infections. HCV-infected patients were tested by PCR to evaluate the presence of viremia.

Results

A total of 200 HIV-1, 213 HTLV-1-infected, and 38 HIV-HTLV-co-infected individuals were included. HIV-infected patients were more likely to have had more sexual partners in the lifetime than other patients’ groups. HIV-HTLV-co-infected subjects were predominantly male. Patients infected by HTLV or co-infected had a significantly higher frequency of previous syphilis or gonorrhea, while HIV infection was mainly associated with HPV infection. Co-infection was significantly associated to intravenous drug use (IVDU). HBV and/or HCV markers were more frequently found among co-infected patients. HBV markers were more frequently detected among HIV-infected patients, while HCV was clearly associated with IVDU across all groups. AgHBs was strongly associated with co-infection by HIV-HTLV (OR = 22.03, 95% CI: 2.69–469.7), as well as confirmed HCV infection (p = 0.001). Concomitant HCV and HBV infection was also associated with retroviral co-infection. Patients infected by HTLV-1 had a lower chance of detectable HCV viremia (OR = 0.04, 95% CI: 0.002–0.85).

Conclusions

Infection by HCV and/or HBV is frequent among patients presenting retroviral infection, but risk factors and prevalence for each infection are distinct for each agent. Retroviral co-infection increases the risk of a positive AgHBs, but HTLV-1 infection seems to increase the likelihood of HCV spontaneous clearance.

Hepatitis C infection and chronic renal diseases

Hepatitis C virus (HCV) infection and chronic renal diseases can be linked in two different ways. Some forms of renal disease are precipitated by HCV infection, while patients with end-stage renal disease are at increased risk for acquiring HCV infection. Patients with chronic HCV infection and renal disease have a poor prognosis. Most studies on treatment of HCV and renal diseases have been uncontrolled trials with small number of subjects. So, there is a lack of evidence-based recommendations and guidelines on the management of this condition. In this review, we will attempt to provide the most recent insights on HCV infection both as a extrahepatic manifestations and as a complication of end-stage renal patients.

Keto acid-supplemented low-protein diet for treatment of adult patients with hepatitis B virus infection and chronic glomerulonephritis

Objectives

An open-label, randomized, controlled, single-centre clinical trial to evaluate the effects of low-protein intake, with or without keto acid supplementation, on nutritional status and proteinuria, in patients with hepatitis B virus (HBV) and early stage chronic glomerulonephritis.

Methods

Patients with chronic glomerulonephritis and HBV infection were randomized to receive a low-protein diet (0.6–0.8 g/kg ideal body weight [IBW] per day) either without (LP group) or with (sLP group) keto acid supplementation (0.1 g/kg IBW per day), for 12 months. Nutritional, clinical and safety parameters were recorded.

Results

The study included 17 patients (LP group n = 9; sLP group n = 8). Proteinuria and microalbuminuria were significantly lower in the sLP group at 6 and 12 months compared with baseline, and at 12 months compared with the LP group. There were no significant differences in serum creatinine level or estimated glomerular filtration rate. Nutritional parameters (serum albumin and prealbumin) were significantly improved at 12 months, compared with baseline, in the sLP group.

Conclusions

Restriction of dietary protein intake to 0.6–0.8 g/kg IBW per day appears to have an acceptable safety profile. Supplementation with keto acids is associated with decreased urine protein excretion.

Selecting a prognostic renal surrogate for patients with hepatocellular carcinoma undergoing transarterial chemoembolization

BACKGROUND AND AIM

Renal insufficiency (RI) often coexists with hepatocellular carcinoma (HCC) and predicts a poor outcome in patients receiving transarterial chemoembolization (TACE). The modification of diet in renal disease (MDRD) and chronic kidney disease epidemiology collaboration (CKD-EPI) equations are used to provide estimated glomerular filtration rate (eGFR). This study aimed to determine a prognsotic renal surrogate for outcome prediction in HCC patients receiving TACE.

METHODS

A total of 684 patients with HCC undergoing TACE were retrospectively analyzed. The prognostic ability between the MDRD and CKD-EPI equation was compared by the Akaike information criterion (AIC).

RESULTS

Patients were categorized by eGFR into > 60, 30-60 and < 30 mL/min per 1.73 m(2) (equivalent to CKD stages 1-2, 3, and 4-5, respectively) groups. The eGFR generated by the MDRD equation had a better predictive accuracy by having a lower AIC score (3234.5) compared to the CKD-EPI equation (3236.7). The adjusted risk ratio for patients with eGFR 30-60 mL/min per 1.73 m(2) by the MDRD was 1.313 (P = 0.041) compared with patients with eGFR > 60 mL/min per 1.73 m(2) in the multivariate Cox model. The eGFR defined by the MDRD equation consistently had better prognostic ability when patients were stratified by the Child-Turcotte-Pugh score of 5 and > 5 and Cancer of the Liver Italian Program score 0 to 1 and > 1.

CONCLUSIONS

The eGFR according the MDRD equation may provide better prognostic accuracy than the CKD-EPI equation independent of liver functional reserve and tumor staging, and is a more feasible renal surrogate for outcome prediction in CKD stage 1-3 HCC patients receiving TACE.

Cu/Zn superoxide dismutase (SOD1) induction is implicated in the antioxidative and antiviral activity of acetylsalicylic acid in HCV-expressing cells

We evaluated the participation of oxidative stress in the negative regulation of hepatitis C virus (HCV)-RNA induced by acetylsalicylic acid (ASA). We used the HCV subgenomic replicon cell system that stably expresses HCV-nonstructural proteins (Huh7 HCV replicon cells) and the parental cell line. Cells were exposed to 4 mM ASA at different times (12-72 h), and pyrrolidine dithiocarbamate (PDTC) was used as an antioxidant control. Reactive oxygen species (ROS) production, oxidized protein levels, cytosolic superoxide dismutase (Cu/Zn-SOD), and glutathione peroxidase (GPx) activity were measured to evaluate oxidative stress. In addition, viral RNA and prostaglandin (PGE(2)) levels were determined. We observed that ASA treatment decreased ROS production and oxidized protein levels in a time-dependent fashion in both parental and HCV replicon cells with a greater extent in the latter. Similar results were found with PDTC exposure. Average GPx activity was decreased, whereas a striking increase was observed in average cytosolic SOD activity at 48 and 72 h in both cells exposed to ASA, compared with untreated cells. HCV replicon cells showed higher levels of Cu/Zn-SOD expression (mRNA and protein) with ASA treatment (48 and 72 h), whereas NS5A protein levels showed decreased expression. In addition, we found that inhibition of SOD1 expression reversed the effect of ASA. Interestingly, PDTC downregulated HCV-RNA expression (55%) and PGE(2) (60%) levels, imitating ASA exposure. These results suggest that ASA treatment could reduce cellular oxidative stress markers and modify Cu/Zn-SOD expression, a phenomenon that may contribute to the mechanisms involved in HCV downregulation.

Oral fluid and hepatitis A, B and C: a literature review

BACKGROUND AND AIMS

Viral hepatitis is a significant global health problem that, depending upon the virus, affects individuals of the developing and/or developed world. In recent years, there has been renewed interest in whether oral fluids can be considered as a source of viral hepatitis transmission and whether oral fluid, in particular, whole saliva, may be a useful source for viral detection as part of the diagnosis and monitoring of viral hepatitis. The aim of this article was to review current data concerning the possible carriage of the hepatitis A, B and C viruses within saliva and gingival crevicular fluid. Such knowledge will indicate if (i) oral fluid is a possible source of infection and (ii) whether oral fluid can be used for diagnosis and monitoring of viral hepatitis.

DATA AND SOURCES

A literature search was conducted using PubMed (Medline), EMBASE/Excerpta medica, the Cochrane database and Scopus. The results were limited to published material after 2000. Relevant material was evaluated and reviewed.

CONCLUSION

There is some evidence that hepatitis viruses A, B and C are present in oral fluids, particularly whole saliva and gingival crevicular fluid and may thus be possible sources of viral detection in clinical diagnosis and monitoring. However, the data are inconsistent and warrant the need for well-planned longitudinal studies to explore the precise frequency of oral carriage of such viruses and to determine the virological and host factors that may influence the oral presence of hepatitis A, B and C viruses.

Treatment of hepatitis C-mediated glomerular disease

Chronic kidney disease (CKD) is becoming a major public health issue worldwide, mainly due to the increasing prevalence of hypertension, diabetes and aging population. Chronic hepatitis C virus (HCV) infection commonly involves the kidneys, can be a cause of CKD, and significantly impacts morbidity and mortality in these patients. Prompt recognition and knowledge of how to best manage these patients are essential in order to have a successful renal outcome. Patients with HCV and kidney involvement can often be managed with a specific combination of antiviral drugs, immunosuppressants, plasmapheresis, and newer monoclonal antibodies. However, no large randomized controlled trials have been conducted in this patient population, optimal management of HCV-mediated kidney diseases is not well defined, and treatment itself can be associated with significant toxicity in patients with CKD. This article reviews the recent literature, discusses the limitations of current therapies, as well as toxicity associated with treatment, and suggests future areas for research.