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Balk EM, Adam GP, Jadoul M, Martin P, Gordon CE. A Systematic Review of Direct-Acting Antivirals for Hepatitis C in Advanced CKD. Kidney Int Rep 2023; 8:240-253. [PMID: 36815114 PMCID: PMC9939364 DOI: 10.1016/j.ekir.2022.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Direct-acting antivirals (DAAs) have improved treatment of hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD). To facilitate the 2022 update of the Kidney Disease: Improving Global Outcomes (KDIGO) guideline for CKD patients with HCV, we systematically reviewed DAA regimens in patients with CKD stages G4 and G5 nondialysis (G4-G5ND), CKD stage G5 on dialysis (G5D), and kidney transplant recipients (KTRs). Methods We conducted a systematic review by searching PubMed, Embase, Cochrane, CINAHL, and ClinicalTrials.gov through February 1, 2022, and conferences from 2019 to 2021. Studies of HCV-infected patients with CKD G4-G5ND, G5D, and KTRs treated with specified DAA regimens were included. Outcomes included death at 6 months or later, sustained virologic response at 12 weeks (SVR12), serious adverse events (SAEs) attributed to DAA, and treatment discontinuation because of adverse events. Maximum likelihood meta-analyses were determined; certainty of evidence was assessed per GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Results We identified 106 eligible studies (22 reported on CKD G4-G5ND, 69 on CKD G5D, and 29 on KTRs). In each population, the majority of DAA regimens achieved SVR12 ≥ 93%. We found generally low quality of evidence of low risk of SAEs (mostly 0%, up to 2.9%) and low risk of discontinuation because of adverse events (mostly 0%-5%). Across 3 unadjusted observational studies in KTRs, the risk of death after DAA treatment was substantially lower than without treatment (summary odds ratio, 0.16; 95% CI, 0.04-0.61). Conclusion Combination DAA regimens are safe and highly effective in patients with advanced CKD, on dialysis, and with kidney transplants.
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Affiliation(s)
- Ethan M. Balk
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Gaelen P. Adam
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Craig E. Gordon
- Division of Nephrology, Department of Medicine, Tufts University School of Medicine, Boston, Massachussetts, USA
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George Michael T, Anwar CA, Ahmed OA, Sarhan I, Elshazly Y, Shaker MK, Eltabbakh M, Hashem W, Tawfic SR, Kamel SY, Kandil DM, Naguib GG, Khedr A, Ghanem EA, Dabbous H, Doss W, El-Sayed MH. Micro-elimination of hepatitis C in patients with chronic kidney disease: an Egyptian single-center study. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background and aims
Micro-elimination of hepatitis C in renal patients is crucial. This study aims to assess the efficacy and safety of directly acting antivirals in chronic kidney disease patients and the effect of treatment on kidney functions.
Results
This prospective cohort study included 77 chronic HCV-infected patients with chronic kidney disease. Patients were consented and treated for 12 weeks with either sofosbuvir and daclatasvir ± ribavirin if glomerular filtration rate was > 30 mL/min per 1.73m2 or ritonavir-boosted paritaprevir-ombitasvir-ribavirin if it was < 30 mL/min per 1.73m2. Patients were divided into two categories (responders versus non-responders). Predictors of response to treatment were statistically analyzed through logistic regression analysis. Sixty-two patients received ritonavir-boosted paritaprevir-ombitasvir-ribavirin, 3 received sofosbuvir and daclatasvir, and 12 received sofosbuvir and daclatasvir plus ribavirin. Most patients were on hemodialysis (n = 36) while 31 were stage 3 kidney disease. All patients completed their treatment course; ribavirin doses were adjusted or stopped in patients who developed anemia (40%). Seventy-two patients (93.5%) achieved sustained virological response 12 weeks following end-of-treatment. Five patients (6.5%) were non-responders, 4 of whom were on hemodialysis (p = 0.179). All non-responders were on ritonavir-boosted paritaprevir-ombitasvir-ribavirin. The mean serum creatinine level at weeks 4 and 8 of treatment demonstrated significant improvement compared to pretreatment values (p < 0.001) in patients on conservative therapy.
Conclusion
Treatment of chronic kidney disease patients for chronic hepatitis C with directly acting antivirals is safe, efficacious with high response rates and likely to improve renal functions if started early in the course of kidney disease.
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Sims OT, Truong DN, Wang K, Melton PA, Atim K. Time to HCV Treatment Disfavors Patients Living with HIV/HCV Co-infection: Findings from a Large Urban Tertiary Center. J Racial Ethn Health Disparities 2022; 9:1662-1669. [PMID: 34254269 PMCID: PMC8752646 DOI: 10.1007/s40615-021-01105-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/20/2021] [Accepted: 06/24/2021] [Indexed: 12/09/2022]
Abstract
This study aimed to assess time to hepatitis C (HCV) treatment (i.e., the time between the initial clinic visit for HCV evaluation and the HCV treatment start date), to compare clinical characteristics between patients who received HCV treatment ≥ and < 6 months, and to identify predictors of longer time to HCV treatment in patients living with HCV. This study conducted a retrospective secondary analysis of patients living with HCV mono-infection and HIV/HCV co-infection who received HCV treatment with DAAs (n=214) at a HIV Clinic. Binomial logistic regression was used to identify predictors of longer time to treatment (i.e., ≥ 6 months). The median time to HCV treatment was 211 days. Compared to patients who were treated < 6 months, a higher proportion of patients who were treated ≥ 6 months had HIV/HCV co-infection (31% vs. 49%, p=0.01) and chronic kidney disease (8% vs. 18%, p=0.03). In multivariate analysis, HIV/HCV co-infection was positively associated with a longer time to HCV treatment (adjusted odds ratio, aOR=2.0, p=0.03). Time to HCV treatment disparities between African American and White American did not emerge from the analysis, but time to HCV treatment disfavored patients living with HIV/HCV co-infection. Studies are needed to identify and eliminate factors that disfavor patients living with HIV/HCV co-infection.
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Affiliation(s)
- Omar T Sims
- Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
- Center for AIDS Research, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Integrative Center for Aging Research, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- African American Studies, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California San Francisco, 3137 University Hall, 1720 2nd Avenue South, Birmingham, AL, 35294-1260, USA.
| | - Duong N Truong
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Collat School of Business, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kaiying Wang
- Department of Mathematics and Statistics, College of Arts & Sciences, Georgia State University, Atlanta, GA, USA
| | - Pamela A Melton
- School of Social Work, Tulane University, New Orleans, LA, USA
| | - Kasey Atim
- School of Social Work, University of Alabama, Tuscaloosa, AL, USA
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Tiwari P, Bashir A, Verma A, Duseja A, De A. Adjuvant use of ribavirin with treatment of hepatitis C virus in kidney transplant recipients: A systematic review and meta-analysis of real-world data. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_10_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Fabrizi F, Cerutti R, Dixit V, Ridruejo E. Sofosbuvir-based regimens for HCV in stage 4-stage 5 chronic kidney disease. A systematic review with meta-analysis. Nefrologia 2021; 41:578-589. [PMID: 36165141 DOI: 10.1016/j.nefroe.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 01/18/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Hepatitis C is an important agent of liver damage in patients with chronic kidney disease and the advent of DAAs has dramatically changed the management of HCV positive patients, including those with advanced CKD. Sofosbuvir is the backbone of many anti-HCV regimens based on DAAs but it remains unclear whether it is appropriate for HCV-infected patients with stage 4-5 CKD. STUDY AIMS AND DESIGN We performed a systematic review of the literature with a meta-analysis of clinical studies in order to evaluate the efficacy and safety of SOF-based DAA regimens in patients with stage 4-5 CKD. The primary outcome was sustained viral response (as a measure of efficacy); the secondary outcomes were the frequency of SAEs and drop-outs due to AEs (as measures of tolerability). The random-effects model of DerSimonian and Laird was adopted, with heterogeneity and stratified analyses. RESULTS Thirty clinical studies (n=1537 unique patients) were retrieved. The pooled SVR12 and SAEs rate was 0.99 (95% confidence intervals, 0.97; 1.0, I2=99.8%) and 0.09 (95% CI, 0.05; 0.13, I2=84.3%), respectively. The pooled SVR12 rate in studies with high HCV RNA levels at baseline was lower, 0.87 (95% CI, 0.75; 1.0, I2=73.3%) (P<0.001). The pooled drop-out rate due to AEs was 0.02 (95% CI, -0.01; 0.04, I2=16.1%). Common serious adverse events were anemia (n=26, 38%) and reduced eGFR (n=14, 19%). SAEs were more common in studies adopting full-dose sofosbuvir (pooled rate of SAEs 0.15, 95% CI, 0.06; 0.25; I2=80.1%) and in those based on ribavirin (0.15, 95% CI, 0.07; 0.23, I2=95.8%). Six studies (n=69 patients) reported eGFR levels at baseline/post- antiviral therapy; no consistent changes were found. CONCLUSIONS SOF-based regimens appear safe and effective in patients with stage 4-5 CKD. Serum creatinine should be carefully monitored during therapy with SOF in patients with CKD. Randomized controlled studies in order to expand our knowledge on this point are under way.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Dialysis and Transplantation IRCCS Ca Granda Foundation and Maggiore Polyclynic Hospital, Milano, Italy.
| | - Roberta Cerutti
- Division of Nephrology, Dialysis and Transplantation IRCCS Ca Granda Foundation and Maggiore Polyclynic Hospital, Milano, Italy
| | - Vivek Dixit
- Division of Digestive Diseases, UCLA School of Medicine, CA, USA
| | - Ezequiel Ridruejo
- Hepatology Section, Department of Medicine, Centro de Educacion Medica e Investigaciones Clinicas Norberto Quirno "CEMIC", Ciudad Autonoma de Buoenos Aires, Argentina; Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Provincia de Buenos Aires, Argentina; Latin American Liver Research, Educational and Awareness Network (LALREAN), Pilar, Provincia de Buenos Aires, Argentina
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Fabrizi F, Cerutti R, Dixit V, Ridruejo E. Sofosbuvir-based regimens for HCV in stage 4-stage 5 chronic kidney disease. A systematic review with meta-analysis. Nefrologia 2021. [PMID: 34154846 DOI: 10.1016/j.nefro.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hepatitis C is an important agent of liver damage in patients with chronic kidney disease and the advent of DAAs has dramatically changed the management of HCV positive patients, including those with advanced CKD. Sofosbuvir is the backbone of many anti-HCV regimens based on DAAs but it remains unclear whether it is appropriate for HCV-infected patients with stage 4-5 CKD. STUDY AIMS AND DESIGN We performed a systematic review of the literature with a meta-analysis of clinical studies in order to evaluate the efficacy and safety of SOF-based DAA regimens in patients with stage 4-5 CKD. The primary outcome was sustained viral response (as a measure of efficacy); the secondary outcomes were the frequency of SAEs and drop-outs due to AEs (as measures of tolerability). The random-effects model of DerSimonian and Laird was adopted, with heterogeneity and stratified analyses. RESULTS Thirty clinical studies (n=1537 unique patients) were retrieved. The pooled SVR12 and SAEs rate was 0.99 (95% confidence intervals, 0.97; 1.0, I2=99.8%) and 0.09 (95% CI, 0.05; 0.13, I2=84.3%), respectively. The pooled SVR12 rate in studies with high HCV RNA levels at baseline was lower, 0.87 (95% CI, 0.75; 1.0, I2=73.3%) (P<0.001). The pooled drop-out rate due to AEs was 0.02 (95% CI, -0.01; 0.04, I2=16.1%). Common serious adverse events were anemia (n=26, 38%) and reduced eGFR (n=14, 19%). SAEs were more common in studies adopting full-dose sofosbuvir (pooled rate of SAEs 0.15, 95% CI, 0.06; 0.25; I2=80.1%) and in those based on ribavirin (0.15, 95% CI, 0.07; 0.23, I2=95.8%). Six studies (n=69 patients) reported eGFR levels at baseline/post- antiviral therapy; no consistent changes were found. CONCLUSIONS SOF-based regimens appear safe and effective in patients with stage 4-5 CKD. Serum creatinine should be carefully monitored during therapy with SOF in patients with CKD. Randomized controlled studies in order to expand our knowledge on this point are under way.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Dialysis and Transplantation IRCCS Ca Granda Foundation and Maggiore Polyclynic Hospital, Milano, Italy.
| | - Roberta Cerutti
- Division of Nephrology, Dialysis and Transplantation IRCCS Ca Granda Foundation and Maggiore Polyclynic Hospital, Milano, Italy
| | - Vivek Dixit
- Division of Digestive Diseases, UCLA School of Medicine, CA, USA
| | - Ezequiel Ridruejo
- Hepatology Section, Department of Medicine, Centro de Educacion Medica e Investigaciones Clinicas Norberto Quirno "CEMIC", Ciudad Autonoma de Buoenos Aires, Argentina; Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Provincia de Buenos Aires, Argentina; Latin American Liver Research, Educational and Awareness Network (LALREAN), Pilar, Provincia de Buenos Aires, Argentina
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An updated systematic review and meta-analysis on efficacy of Sofosbuvir in treating hepatitis C-infected patients with advanced chronic kidney disease. PLoS One 2021; 16:e0246594. [PMID: 33566846 PMCID: PMC7875415 DOI: 10.1371/journal.pone.0246594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/22/2021] [Indexed: 12/20/2022] Open
Abstract
Sofosbuvir seems to be a revolutionary treatment for Hepatitis C-infected patients with advanced chronic kidney disease (CKD) but existing evidence is not quite adequate. The aim of this study was to evaluate the efficacy and safety of Sofosbuvir-based therapy without Ribavirin for all hepatitis C virus genotypes among patients with advanced CKD. We conducted an updated systematic literature search from the beginning of 2013 up to June 2020. Sustained virologic response (SVR) rate at 12 and/or 24 weeks after the end of treatment, and adverse events in HCV-infected patients with advanced CKD were pooled using random effects models. We included 27 published articles in our meta-analyses, totaling 1,464 HCV-infected patients with advanced CKD. We found a substantial heterogeneity based on the I2 index (P = 0.00, I2 = 56.1%). The pooled SVR rates at 12 and 24 weeks after the end of Sofosbuvir-based treatment were 97% (95% Confidence Interval: 95-99) and 95% (89-99) respectively. The pooled SVR12 rates were 98% (96-100) and 94% (90-97) in patients under 60 and over 60 years old respectively. The pooled incidence of severe adverse events was 0.11 (0.04-0.19). The pooled SVR12 rate after completion of the half dose regimen was as high as the full dose treatment but it was associated with less adverse events (0.06 versus 0.14). The pooled SVR12 rate was 98% (91-100) in cirrhotic patients and 100% (98-100) in non-cirrhotic patients. The endorsement of Sofosbuvir-based regimen can improve the treatment of hepatitis C virus infection in patients with advanced CKD.
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Ajlan AA, Al-Gain R, Ahmed M, Abu-Riash T, Alquaiz M, Alkhail FA, Alashgar H, Alkhairallah T, Alkortas D, Al-Jedai A. Developing a multidisciplinary HCV direct-acting antivirals utilization management and assessment program. J Am Pharm Assoc (2003) 2020; 61:e159-e170. [PMID: 33309191 DOI: 10.1016/j.japh.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/17/2020] [Accepted: 11/13/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The introduction of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infections has revolutionized outcomes for patients with HCV. Cost-effective use of these antivirals in addition to ensuring patient adherence is of paramount importance. OBJECTIVES The goal of this article is to describe the processes by which a tertiary care, multisite institution managed the complexities involved in administering DAA treatment and managing the increased cost of therapy. Specifically, the objectives of this article are to describe the development of a multidisciplinary HCV management program and the role of pharmacists in this program, including formulary management strategies and monitoring of DAAs use in our institution, development of guidelines, electronic prescribing protocols and order sets, and specific outcomes based on a concurrent medication use evaluation. PRACTICE DESCRIPTION King Faisal Specialist Hospital and Research Centre is a tertiary care referral hospital. As a tertiary referral hospital, it offers primary and highly specialized inpatient and outpatient medical care. The process of selecting and developing institutional HCV management program is described. PRACTICE INNOVATION This article provides key details regarding how a multidisciplinary HCV program using DAAs can be implemented successfully at a tertiary care facility. Key facets of our innovation include establishing formulary guidelines, setting up eligibility criteria for patients, and establishing an HCV taskforce and multidisciplinary HCV program clinic. EVALUATION Medication use evaluations were regularly conducted to monitor sustained virologic response rates, adherence to guidelines, adverse reactions, and drug interactions. METHODS Formulary guidelines, setting up an eligibility criterion for patients, and an HCV taskforce and multidisciplinary HCV program clinic were established. RESULTS The involvement of pharmacists in a multidisciplinary HCV program in outpatient settings resulted in improved formulary decision making, reduction of costs, and improvement of adherence to institutional guidelines. PRACTICE IMPLICATIONS The role of a pharmacist in the management of patients with HCV with DAAs is important. Pharmacists play an integral part in medication management and overall reduction in health care expenditure. Many disease management programs can be complemented with pharmacists to improve patient care and reduce cost. CONCLUSION HCV treatment is challenging, and a multidisciplinary approach to treat HCV is critical. It is a rapidly evolving field; therefore, it requires dynamic formulary management and collaborative practice approaches to monitor pharmacotherapy carefully and efficiently. Clinical pharmacists play a pivotal role within the multidisciplinary team by providing support to both patients and health care providers with regard to the treatment of HCV.
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