Hepatitis C in chronic kidney disease: predialysis patients present more severe histological liver injury than hemodialysis patients?

Pan-genotypic direct-acting antivirals for patients with hepatitis C virus infection and chronic kidney disease stage 4 or 5

Hepatitis C virus (HCV) infection is a major health problem with significant clinical and economic burdens in patients with chronic kidney disease (CKD) stage 4 or 5. Current guidelines recommend pan-genotypic direct-acting antivirals (DAAs) to be the first-line treatment of choice for HCV. This review summarizes the updated knowledge regarding the epidemiology, natural history, public health perspectives of HCV in patients with CKD stage 4 or 5, including those on maintenance dialysis, and the performance of pan-genotypic DAAs in these patients. The prevalence and incidence of HCV are much higher in patients with CKD stage 4 or 5 than in the general population. The prognosis is compromised if HCV patients are left untreated regardless of kidney transplantation (KT). Following treatment-induced HCV eradication, patient can improve the health-related outcomes by maintaining a long-term aviremic state. The sustained virologic response (SVR12) rates and safety profiles of pan-genotypic DAAs against HCV are excellent irrespective of KT. No dose adjustment of pan-genotypic DAAs is required across CKD stages. Assessing drug-drug interactions (DDIs) before HCV treatment is vital to secure on-treatment safety. The use of prophylactic or preemptive pan-genotypic DAAs in HCV-negative recipients who receive HCV-positive kidneys has shown promise in shortening KT waiting time, achieving excellent on-treatment efficacy and safety, and maintaining post-KT patient and graft survival. HCV elimination is highly feasible through multifaceted interventions, including mass screening, treatment scale-up, universal precautions, and post-SVR12 reinfection surveillance.

The Management of Viral Hepatitis in CKD Patients: An Unresolved Problem

Chronic kidney disease (CKD) patients in dialysis (HD) show peculiar, atypical features of clinical presentation and diseases (cardiovascular, metabolic, hematologic). This is also true for viral hepatitis infections, for which CKD patients represent an important risk group. In the past, hepatitis B virus (HBV) was the major cause of viral hepatitis in end-stage renal disease (ESRD). However, the introduction of a rigorous infection-control strategy, routine screening of patients and staff for hepatitis B serologic markers, vaccination of susceptible patients and staff, use of separate rooms and dedicated machines for HD of HbsAg-positive patients have all led to a decline in the spread of HBV infection in dialysis. Despite the prevalence of the antibody-hepatitis C virus (HCV), there has been a marked decrease in HD patients; after the introduction of routine screening for HCV and the use of erythropoietin, its occurrence ranges from 5% to 25% in the United States, with a prevalence of 6.8% in Europe. In CKD and in HD patients, the presence of HBV and HCV is an independent and significant risk factor for death and this risk may be at least partially attributed to chronic liver disease with its attendant complications. Liver disease can progress with modest hepatic inflammation and prominent fibrosis; the natural history of viral hepatitis in these patients is dependent on the immune dysfunction typical of kidney disease. Despite recent advances in antiviral therapy, there are still many uncertainties in regards to the efficacy and long-term outcomes of treatment with antiviral agents.

Liver biopsy in patients on hemodialysis with hepatitis C virus infection: An important tool

Hepatitis C virus (HCV) infection is commonest blood borne infection amongst hemodialysis patients. Still, there is paucity of data on liver biopsy in these patients. Our center is doing regular liver biopsy in these patients and thus thought of sharing our experience. In this retrospective study, all patients with HCV infection on hemodialysis were subjected to liver biopsy. Serum bilirubin, liver enzyme, HCV-PCR, genotype and viral load measurement were done in all. Biopsy specimen was stained with H and E, Periodic Acid Schiff, Gomori Stain, Masson Trichrome and Perls Stain. International Working Group scoring system of Ishak et al. was used for Grading and Staging. Of the 270 liver biopsies, mean age of patients was 34.05 ± 10.28 years and 233 (85.3%) were males. Mean duration of hemodialysis was 10.9 ± 7.4 months while of known HCV infection was 5.2 ± 4.0 months. Genotype 3 was commonest followed by 1. All had normal bilirubin and 64 (23.1%) had normal ALT. In 37 (13.3%) patients anti-HCV was not detectable. Mean histology grade was 4.03 ± 1.65 (1-10) and stage was 0.75 ± 0.98 (0-3). Only one patient had cirrhosis on histology. Associated hemosiderosis was seen 10 patients. Only minor complications were observed with no mortality. In conclusion, our study shows that in one-fourth patients with active liver disease, liver enzymes are persistently normal in patients on hemodialysis. Further, carefully performed liver biopsy is reasonably safe procedure though some patients do have non-fatal complications. Liver biopsy helps in assessing disease activity, which otherwise cannot be assessed. Histological grade and stage in these patients is usually mild and cirrhosis is rare. Till such time other non-invasive test is validated, liver biopsy will remain an important test in these patients.

Hepatitis C is less aggressive in hemodialysis patients than in nonuremic patients

BACKGROUND AND OBJECTIVES

The severity of liver disease among hepatitis C patients on hemodialysis is controversial. The aim of this study was to compare the clinical, biochemical, and liver histologic characteristics of hepatitis C virus (HCV) in hemodialysis patients and in those with normal renal function.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A case-control study was carried out with 36 HCV patients on hemodialysis and 37 HCV patients with normal renal function matched for gender, age at infection, and estimated time of infection.

RESULTS

HCV patients on hemodialysis had lower levels of alanine aminotransferase and lower viral load. Hepatic fibrosis was significantly higher in the patients with normal renal function (73%) than in hemodialysis patients (47.2%, P < 0.025); the same was observed for inflammatory activity (control group 59.5% versus hemodialysis patients 27.7%, P = 0.003). In addition, the risk of tissue inflammation was four times lower in hemodialysis patients (odds ratio = 0.23, P < 0.004), and severe inflammatory activity on biopsy was the only independent risk factor for fibrosis (P < 0.001).

CONCLUSIONS

The lower biochemical and inflammatory activities observed in hemodialysis patients suggest that hemodialysis and uremia may have a protective role against progression of the disease caused by HCV.

Hepatitis C in hemodialysis patients: current global magnitude, natural history, diagnostic difficulties, and preventive measures

Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality in hemodialysis (HD) patients. The reported prevalence of HCV among the HD population has varied greatly from 1.9 to 84.6% in different countries in recent years. The length of time on HD is generally believed to be associated with HCV acquisition in HD subjects. Nevertheless, several recent reports failed to recognize any significant role of blood transfusion. Although there are some considerations about the accuracy of serologic testing in detecting HCV in HD patients, the accumulated data in this review suggest the false-negativity rate to be not more than 1.66% (153/9,220). Therefore, substituting virologic for serologic testing in the routine diagnosis of HCV infection in HD patients seems unreasonable. Several phylogenetic analyzes of viral isolates suggested nosocomial patient-to-patient transmission of HCV among HD patients for which the main potential source is believed to be contaminated hands and articles. However, isolation of HCV-infected HD patients and use of dedicated machines are currently unjustified while strict adherence to universal precautions seems to be enough to control disease spread in HD units. The present article is an update on epidemiological and clinical features of HCV in HD population.

Analysis of differently expressed proteins and transcripts in gills of Penaeus vannamei after yellow head virus infection

In this proteomic analysis of gills from yellow head virus (YHV)-infected Penaeus vannamei, we identified 13 spots with up-regulated protein expression levels and five spots with down-regulated levels. LC-nanoESI-MS/MS indicated that the up-regulated proteins included enzymes in the glycolytic pathway, the tricarboxylic acid cycle and amino acid metabolism. The other up-regulated proteins were arginine kinase, imaginal disk growth factor (IDGF) and a Ras-like GTP binding protein. By contrast, expression levels were reduced for an SCP-calcium binding protein (SCP), actin-1, a valosin-containing protein, and Rab11. Time-course assays by real time RT-PCR revealed no significant increase in mRNA level of glycolytic enzymes and arginine kinase. However, a significant decrease in SCP mRNA was observed. The present results are consistent with previously published work and suggest that a decrease in SCP expression may play an important role in the shrimp response to viral infections in general.