Evaluation of Long-Term Outcomes of Direct Acting Antiviral Agents in Chronic Kidney Disease Subjects: A Single Center Cohort Study

BACKGROUND

The chronic kidney disease (CKD) population, including kidney transplant recipients (KTRs) and subjects on renal replacement therapy, is particularly vulnerable to unfavorable outcomes from chronic hepatitis C (CHC). Currently, there are oral direct-acting antiviral agents (DAAs) available to eradicate the virus with favorable short-term outcomes; however, their long-term effects are lacking. The aim of the study is to assess the long-term efficacy and safety of DAA therapy in the CKD population.

METHODS

An observational, cohort single-center study was performed. Fifty-nine CHC subjects with CKD, treated with DAAs between 2016 and 2018, were enrolled in the study. Safety and efficacy profiles were assessed, including sustained virologic response (SVR), occult hepatitis C infection (OCI) incidence, and liver fibrosis.

RESULTS

SVR was achieved in 96% of cases (n = 57). OCI was diagnosed only in one subject following SVR. Significant liver stiffness regression was observed 4 years after SVR compared to baseline values (Mdn = 6.1 kPa, IQR = 3.75 kPa; 4.9 kPa, IQR = 2.9 kPa), p < 0.001. The most common adverse events were anemia, weakness, and urinary tract infection.

CONCLUSION

DAAs provide a safe and effective cure for CHC in both CKD patients and KTRs with a favorable safety profile in the long-term follow-up.

Clinical utility of hepatitis C virus core antigen (HCVcAg) assay to identify active HCV infection in hemodialysis and renal transplant patients

BACKGROUND

The prevalence of HCV infection is high and it is a major cause of liver-related morbidity and mortality in hemodialysis and renal transplant patients. Diagnosis of hepatitis C virus (HCV) infection requires both HCV antibody screening and confirmatory nucleic acid testing (NAT). Hepatitis C virus core antigen (HCVcAg) is a reliable direct viral marker to identify active HCV infection.

AIM

To assess the clinical utility of HCV core antigen to identify active HCV infection in hemodialysis and renal transplant patients.

METHODS

A representative total of 231 plasma samples with a predominance of low viral load were included for HCVcAg testing and its performance characteristics were compared with the gold standard HCV RNA.

RESULTS

Comparison of HCVcAg with HCV RNA showed an excellent specificity of 99% (95% CI: 94.7 to 100%) and sensitivity of 80.62% (95% CI: 73.59 to 87.7%). Likewise, the PPV and NPV of HCVcAg were 99.1% (95% CI: 93.7% to 99.9%) and 80.2% (95% CI: 74% to 85.2%) respectively. The correlation between HCVcAg and HCV RNA was found to be good (R2 = 0.86, p<0.0001). Among common Indian HCV genotypes (1, 3 & 4), good correlation was observed between HCV RNA and HCVcAg (R2 = 0.81, p <0.0001).

CONCLUSIONS

It is the first Indian study to show that HCVcAg is a reliable, cost-effective direct marker to identify active HCV infection in hemodialysis and renal transplant patients. Implementation of HCVcAg testing could improve the accessibility to efficacious and affordable disease management in hemodialysis and renal transplant patients. In HCVcAg negative cases, sequential testing with anti-HCV antibody followed by HCV RNA could be a reliable and cost-effective approach.

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

Hepatitis C virus (HCV) is a common cause of increased morbidity and mortality in kidney transplant patients. It is associated with posttransplant glomerulonephritis, chronic allograft nephropathy, and New Onset Diabetes after Transplant (NODAT). In the past, HCV was difficult to treat due to the presence of interferon alpha-based therapies that were difficult to tolerate and were associated with adverse side-effects, such as the risk of rejection. With the advent of oral directly acting antiviral therapies, the landscape for HCV and transplantation has changed. These agents are highly effective and well tolerated with minimal side-effects. Sustained viral response rates in excess of 90% are achieved with most current treatment regimens active against all HCV genotypes. These new agents may show an improvement in graft and patient survival while essentially eliminating the risk of acute rejection from the use of prior interferon-based HCV therapies. These agents may also result in an improvement in organ allocation for HCV donor/HCV recipient transplantation. This review is meant to discuss the epidemiology of HCV, the new oral direct-acting antiviral agents (DAAs) and future opportunities for research in the field of HCV related transplantation.

Direct-acting antivirals for hepatitis C virus in patients on maintenance dialysis

The frequency of hepatitis C virus (HCV) infection remains high in patients with chronic kidney disease (CKD) and plays a detrimental role in mortality in this population. According to the latest survey, the adjusted hazard ratio for HCV-positive versus HCV-negative patients on long-term dialysis was 1.12 (95% CI, 1.05 to 1.20) and 1.10 (95% CI, 0.98 to 1.22) for all-cause and cardiovascular mortality, respectively. An impairment on quality of life has also been documented in HCV-infected patients undergoing regular dialysis. Most clinicians have been so far reluctant to treat hepatitis C in patients with advanced CKD, due to concerns regarding low efficacy and safety of interferon-based regimens. The advent of all-oral, direct-acting antivirals (DAAs) has revolutionized treatment paradigms for HCV, including patients with other comorbidities such as CKD. Two combinations of DAAs have been recently approved for the treatment of HCV in advanced CKD: elbasvir/grazoprevir (evaluated in 1 randomized controlled trial) and ombitasvir/paritaprevir/ritonavir/dasabuvir with or without ribavirin (examined in some observational, single-arm studies). These antiviral combinations have provided high safety and efficacy (SVR12 rates >90%) in HCV-infected patients with stage 4-5 CKD. Sofosbuvir, a nucleotide analogue inhibitor of the HCV NS5B polymerase, is the cornerstone of most anti-HCV current regimens but is not currently recommended for patients with severe renal insufficiency (eGFR <30 mL/min per 1.73 m2). However, several small-sized studies have been published on the safety and efficacy of sofosbuvir-based regimens for patients with hepatitis C on maintenance dialysis; overall, the viral response was satisfactory (SVR12 rates ranging between 58% and 100%) with a few drug-related drop-outs. Studies are in progress to assess whether ribavirin-free antiviral combinations with novel DAAs are a viable option for patients with severe renal impairment and chronic HCV infection.

Treatment of HCV in Renal Disease: Subtle Management Considerations in the Era of Direct-acting Antivirals

Chronic hepatitis C virus (HCV) infection is burdensome in patients with chronic kidney disease and contributes to substantial liver-related and all-cause morbidity and mortality. HCV infection itself may cause kidney dysfunction, as exemplified through mixed cryoglobulinemic vasculitis. HCV is more prevalent in patients with significant kidney disease compared to the general population, and recent reports have shown inadvertent HCV transmission in U.S. hemodialysis centers. Further, HCV has been demonstrated to accelerate kidney dysfunction and is associated with worse clinical outcomes in patients with kidney disease. As such, the HCV-infected population with concurrent kidney disease is an important patient subgroup that warrants focused medical care and attention. With the advent of direct-acting antivirals (DAAs), the successful treatment of HCV is now a medical reality for many patients. Nuances in regimen selection and timing need to be considered when treating those with kidney dysfunction, particularly for those considering kidney transplantation.

Interferon-Based Treatment of Hepatitis C Virus Infection Reduces All-Cause Mortality in Patients With End-Stage Renal Disease: An 8-Year Nationwide Cohort Study in Taiwan

The long-term survival of end-stage renal disease (ESRD) patients with hepatitis C virus (HCV) infection who received interferon treatment has not been extensively evaluated.The HCV cohort was the ESRD patients with de novo HCV infection from 2004 to 2011; they were classified into treated and untreated groups according to interferon therapy records. Patients aged <20 years and those with a history of hepatitis B, kidney transplantation, or cancer were excluded. The control cohort included ESRD patients without HCV infection matched 4:1 to the HCV cohort by age, sex, and year of ESRD registration. We followed up all study participants until kidney transplantation, death, or the end of 2011, whichever came first. We assessed risk of all-cause mortality by using the multivariate Cox proportional hazard model with time-dependent covariate.In the HCV cohort, 134 patients (6.01%) received interferon treatment. Compared with the uninfected control cohort, the treated group had a lower risk of death (hazard ratio 0.47, 95% confidence interval [CI] 0.22-0.99). The untreated group had a 2.62-fold higher risk (95% CI 1.24-5.55) of death compared with the treated group. For the HCV cohort without cirrhosis or hepatoma, the risk of death in the treated group was further markedly reduced (hazard ratio 0.17, 95% CI 0.04-0.68) compared with that in the control cohort.For ESRD patients with HCV infection, receiving interferon treatment is associated with a survival advantage. Such an advantage is more prominent in HCV patients without cirrhosis or hepatoma.

QUALITY OF LIFE IN HEMODIALYSIS PATIENTS

Purpose:

To explore the quality of life in hemodialysis patients.

Material and Methods:

The sample studied consisted of 320 patients undergoing hemodialysis in one-day dialysis center. Data were collected by the completion of a specially designed questionnaire which apart from the sociodemographic and clinical variables, it also included the scale Missoula-VITAS Quality of Life Index (MVQOLI) for assessing quality of life.

Results:

Of the 320 hemodialysis patients, 57,2% were men while 28,1% of the participants were 71-80 years old. The average total score of quality of life was found to be 17.43 (in a range 0-30). The total score of quality of life was found to be higher in participants <60 years (p= 0,009), of higher educational level (p=0.001), being very informed about the health problem (p=0,013), complied with therapeutic recommendations and the proposed diet (p=0,025 & p=0,012, respectively), having very good relations with the medical and nursing staff or other patients (p<0,001), not experiencing difficulties with social or family environment (p=0,001), had help at home (p <0,001) and in those who did not conceal their health problem from the social environment (p<0.001). Furthermore, it was found that the increasing duration of hemodialysis session entailed poorer quality of life (p<0,001). These results were largely confirmed by multiple linear regression.

Conclusions:

Sociodemographic and clinical characteristics seems to influence the quality of life in hemodialysis patients.

Therapy of hepatitis C by direct-acting anti-virals: the end of HCV in dialysis population?

The advent of direct-acting anti-viral (DAA) drugs is dramatically changing the treatment of hepatitis C virus (HCV) in patients with intact kidney function ('cure rates' >90% and infrequent adverse events). The information on efficacy and safety of DAAs for HCV therapy in patients with renal failure is limited. We have reviewed the available evidence regarding efficacy and safety of numerous DAAs (boceprevir, telaprevir, sofosbuvir, simeprevir, grazoprevir, elbasvir, ombitasvir, paritaprevir, ritonavir, dasabuvir, ledispavir, daclatasvir, asunaprevir, beclabuvir) in treating HCV-infected patients with renal impairment and/or end-stage renal disease. The major limitation of this review is the paucity of published data and its reliance on abstracts and product monographs. Preliminary data suggest that combination antiviral therapy (grazoprevir and elbasvir) is provided with great efficacy in patients with HCV genotype 1 and chronic kidney disease stage 4 or 5 including those on intermittent dialysis, SVR12, 99% (114/115), according to a per-protocol analysis. In another trial, patients with HCV genotype 1 and chronic kidney disease stage 4 or 5 were given the 3D regimen; an interim evaluation reported that all patients completing treatment to date had viral response (100%, 14/14) but data on sustained viral response are under evaluation. Treatments were generally well tolerated.

Current Management of Chronic Hepatitis B and C in Chronic Kidney Disease

The landscape of therapeutic options for hepatitis B and C has changed drastically over the course of 2 decades. There are now novel, effective, well-tolerated, oral antiviral agents being used to successfully control chronic hepatitis B (HBV) infections and cure chronic hepatitis C (HCV) infections. However, patients with CKD were rarely included in the Phase II and III randomized trials for these medications. This paucity of data and the high prevalence of comorbidities associated with CKD pose distinct challenges to physicians treating chronic hepatitis B virus and hepatitis C virus infections in the setting of kidney insufficiency/failure. Thus, this review will attempt to summarize the current data regarding novel antiviral therapies for HBV and HCV in the CKD population.

Single nucleotide polymorphisms near IL28B gene and response to treatment of chronic hepatitis C in hemodialysis patients

BACKGROUND

It has been shown that single nucleotide polymorphisms (SNPs) near the interleukin 28B (IL28B) gene were associated with sustained virological response following standard antivirological treatment of chronic hepatitis C.

OBJECTIVES

The aim of the study was to evaluate the association between SNPs near the IL28B gene and response to the treatment of chronic hepatitis C in hemodialysis patients.

PATIENTS AND METHODS

The study group included 24 hemodialysis patients with chronic hepatitis C routinely treated with pegylated interferon α-2 a. HCV genotype 1 was the cause of chronic hepatitis C in all study participants. Sustained virological response was determined by an assay with a sensitivity of 20 IU/mL, 6 months after completion of the antivirological treatment. The genotyping of the three most widely studied IL28B gene polymorphisms (rs12979860, rs8099917, and rs12980275) was performed in all study participants.

RESULTS

Sustained virological response was achieved in 50% of the treated patients. The treatment response was significantly associated with the CC genotype of rs12979860, TT genotype of rs8099917, and AA genotype of rs12980275 (p = 0.003, p = 0.009, and p = 0.012, respectively).

CONCLUSIONS

The three most widely studied SNPs near the IL28B gene were associated with sustained virological response following antivirological treatment of chronic hepatitis C in hemodialysis patients.

Health related quality of life in Iranian hemodialysis patients with viral hepatitis: changing epidemiology

BACKGROUND

There are surprisingly a few studies that evaluate the impact of chronic viral hepatitis, which is common in HD (hemodialysis) patients, on HRQOL (health related quality of life).

OBJECTIVES

We conducted a study to evaluate the impact of chronic viral hepatitis on HRQOL and to compare their HRQOL with non-infected HD patients via a HRQOL questionnaire.

PATIENTS AND METHODS

The Iranian adapted version of the Kidney Disease Quality of Life Short Form (KDQOL-SF) version 1.3 questionnaires were filled out by the HD patients. In all HD patients, serum HBsAg, HBS Abs, and HCV Abs [enzyme-linked immunosorbant assay (ELISA)] were routinely checked every six months. Patients were considered to have chronic HBV infection if HBsAg was positive for more than six months. In all HD patients, third generation assay was used to detect HCV infection. Furthermore, serum HCV-RNA (PCR) was examined in anti-HCV-positive patients for confirmation of HCV infection.

RESULTS

in this cross sectional study 4101 patients from 103 dialysis units in Iran between October 2010 and August 2011 were included. Prevalence of hepatitis B and hepatitis C infection was 2.1% and 1.3% respectively. Almost all KDQOL items for viral hepatitis patients had equivalent or better scores than those without viral hepatitis. In the logistic regression after adjustment for age, sex, educational level, marital status, dialysis vintage, HBs Ag positivity and HCV Ab positivity, only age (P < 0.001) and educational level (P = 0.015) had negative impact on quality of life.

CONCLUSIONS

Our data show that not only general health and physical activity were preserved but also health perception may be better among HD patients with viral hepatitis.

Interferon treatment for patients with chronic hepatitis C complicated with chronic renal failure receiving hemodialysis

BACKGROUND AND AIMS

The Japan Society for Dialysis Therapy established "Guidelines for the Treatment of Hepatitis C Virus Infection in Dialysis Patients." We evaluated the status of HCV infection and the treatment of hemodialysis patients in Gunma prefecture.

METHODS

Questionnaires concerning the infection rate, recognition of the guidelines, and treatment status were sent to all 64 hospitals/clinics that had hemodialysis systems in Gunma prefecture. The hepatitis C virus-infected hemodialysis patients who received pegylated interferon (peg-IFN) were analyzed at Gunma University Hospital.

RESULTS

The positive rate for hepatitis C virus antibody was 256/2582 hemodialysis patients (9.9%). The positive rate varied between institutions (range 0-40.0%; median 9.0%). All institutes recognized the establishment of the guidelines. Conventional or peg-IFN treatment was being given at 37.5% of the institutions. The other 62.5% institutions answered that they intended to provide the treatment in the future if collaboration with a hepatologist could be arranged. The most common answers regarding the indication for IFN treatment were as follows: few complications, under 60 years of age, more than 10 years of survival expected on hemodialysis. Eighteen patients received peg-IFN treatment. The sustained virological response rate of all patients was 33.3%, 0% in 1b/high viral titer, 50% in genotype 2, and 100% in genotype 2/low viral titer. The sustained virological response rate was worse in the patients with 1b/high viral load and diabetic nephropathy (P < 0.05).

CONCLUSIONS

Recognition of the publication of the guidelines was high. However, the number of patients treated with peg-IFN was still low. Further enlightenment and cooperation between hemodialysis teams and hepatologists are therefore needed.

Critical review of the use of erythropoietin in the treatment of anaemia during therapy for chronic hepatitis C

Combined pegylated interferon (PegIFN) and ribavirin represents the standard therapy for patients with chronic hepatitis C (CHC), which allows for sustained viral response (SVR) in up to 90% of patients depending on certain viral and host factors. Clinical studies have demonstrated the importance of adherence to therapy, that is, the ability of patients to tolerate and sustain a fully dosed therapy regimen. Adherence is markedly impaired by treatment-related adverse effects. In particular, haemolytic anaemia often requires dose reduction or termination of ribavirin treatment, which compromises treatment efficacy. Recent evidence points to a beneficial role of recombinant erythropoietin (EPO) in alleviating ribavirin-induced anaemia thereby improving quality of life, enabling higher ribavirin dosage and consequently improving SVR. However, no general consensus exists regarding the use of EPO for specific indications: its optimal dosing, treatment benefits and potential risks or cost efficiency. The Swiss Association for the Study of the Liver (SASL) has therefore organized an expert meeting to critically review and discuss the current evidence and to phrase recommendations for clinical practice. A consensus was reached recommending the use of EPO for patients infected with viral genotype 1 developing significant anaemia below 100 g/L haemoglobin and a haematocrit of <30% during standard therapy to improve quality of life and sustain optimal ribavirin dose. However, the evidence supporting its use in patients with pre-existing anaemia, non-1 viral genotypes, a former relapse or nonresponse, liver transplant recipients and cardiovascular or pulmonary disease is considered insufficient.

Treatment of hepatitis C virus infection in patients with end-stage renal disease

Hepatitis C virus (HCV) infection is a major health problem in patients with end-stage renal disease (ESRD). The incidence of acute HCV infection during maintenance dialysis is much higher than that in the general population because of the risk of nosocomial transmission. Following acute HCV infection, most patients develop chronic HCV infection, and a significant proportion develop chronic hepatitis, cirrhosis, and even hepatocellular carcinoma. Overall, chronic hepatitis C patients on hemodialysis bear an increased risk of liver-related morbidity and mortality, either during dialysis or after renal transplantation. Interferon (IFN) therapy is modestly effective for the treatment of HCV infection in ESRD patients. Conventional or pegylated IFN monotherapy has been used to treat acute hepatitis C in ESRD patients with excellent safety and efficacy. Regarding chronic hepatitis C, approximately one-third of patients can achieve a sustained virological response (SVR) after conventional or pegylated IFN monotherapy. The combination of low-dose ribavirin and conventional or pegylated IFN has further improved the SVR rate in treatment-naïve or retreated ESRD patients in clinical trials. Similar to the treatment of patients with normal renal function, baseline and on-treatment HCV virokinetics are useful to guide optimized therapy in ESRD patients. Of particular note, IFN-based therapy is not recommended at the post-renal transplantation stage because of the low SVR rate and risk of acute graft rejection. In conclusion, ESRD patients with HCV infection should be encouraged to receive antiviral therapy, and those who achieve an SVR usually have long-term, durable, virological, biochemical, and histological responses.

Hepatic disorders in chronic kidney disease

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are the most common and serious causes of liver damage in patients with chronic kidney disease (CKD). The natural histories of HBV and HCV infections in patients with CKD are not fully understood; however, recent evidence has emphasized the adverse effect of HBV and/or HCV infection on survival in this population. Chronic liver disease is the fourth most important cause of death after renal transplantation. The negative effect of HCV infection on survival among renal transplant recipients has been linked to liver dysfunction and extrahepatic complications, such as chronic glomerulonephritis, post-transplantation diabetes mellitus, chronic allograft nephropathy, and sepsis. The transmission of HCV by solid organ transplantation has been unequivocally demonstrated. Renal transplant recipients who receive kidneys from HCV-positive donors are at increased risk of death. Although several studies have shown that in patients with HCV infection and chronic renal failure renal transplantation is associated with better survival than is dialysis, recent clinical guidelines recommend that kidneys from HCV-infected donors should not be used in HCV-seropositive recipients without detectable HCV viremia. Monotherapy with conventional interferon has been suggested to be a useful treatment for hepatitis C infection in patients on dialysis. Although no evidence suggests that patients with CKD are more prone to suffer from hepatic toxic effects than individuals with normal kidney function, patients with CKD usually receive multiple medications; and drug interactions may, therefore, have a role in the pathogenesis of drug-induced liver disease in this population.