Updated KDIGO Recommendations for Hepatitis C in CKD

The Kidney Disease: Improving Global Outcomes (KDIGO) 2018 Clinical Practice Guideline Update provides 66 recommendations for the diagnosis, evaluation, prevention, and treatment of hepatitis C virus (HCV) in chronic kidney disease (CKD). The update of the 2008 guideline reflects major advances since the introduction of direct-acting antivirals (DAAs). In the latest online report from the Annals of Internal Medicine, Craig Gordon, MD, MS, of Tufts Medical Center in Boston, and colleagues offer a synopsis of 32 key recommendations.

A multidisciplinary work group formulated the scope of the guideline update. Chapters include The Detection and Evaluation of HCV in CKD; Treatment of HCV Infection in Patients with CKD; Prevention of HCV Transmission in Hemodialysis Units; Management of HCV-infected Patients Before and After Kidney Transplantation; and Diagnosis and Management of Kidney Diseases Associated with HCV Infection.

The 2018 guideline recommends screening patients for HCV infection at important junctures, including evaluation for CKD or kidney transplantation, initiation of hemodialysis, peritoneal dialysis, or home hemodialysis, or transfer to a new dialysis facility. Clinicians should order nucleic acid testing alone or an immunoassay followed by nucleic acid testing if immunoassay is positive.

Treatment recommendations for CKD and dialysis patients center on the selection of the antiviral regimen. The guidelines recommend:

• all CKD patients infected with HCV be evaluated for antiviral therapy.
• use of an interferon-free regimen.
• the choice of specific regimen be based on HCV genotype (and subtype), viral load, prior treatment history, drug-drug interactions, glomerular filtration rate (GFR), stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities.
• patients with GFR ≥30 mL/min/1.73 m² (CKD G1–G3b) be treated with any licensed direct-acting antiviral (DAA)-based regimen.
• Patients with GFR <30 mL/min/1.73 m² (CKD G4–G5D) should be treated with a ribavirin-free DAA-based regimen.

For kidney transplant recipients, the guidelines recommend:

• all kidney transplant recipients infected with HCV be evaluated for treatment.
• treatment with a DAA-based regimen.
• the choice of regimen be based on HCV genotype (and subtype), viral load, prior treatment history, drug-drug interactions, GFR, stage of hepatic fibrosis, liver transplant candidacy, and comorbidities.
• avoiding treatment with interferon.
• pre-treatment assessment for drug-drug interactions between the DAA-based regimen and other concomitant medications including immunosuppressive drugs in kidney transplant recipients.
• calcineurin inhibitor levels be monitored during and after DAA treatment.

With respect to the timing of HCV treatment in kidney transplant candidates, the guideline recommends collaborating with the transplant center. Kidney transplant candidates with HCV who are willing to accept a kidney from an HCV-infected donor may have a shorter waitlist time if they forgo HCV treatment until after transplantation. Candidates with compensated cirrhosis from HCV, however, should consider pretransplant treatment to reduce fibrosis. All candidates for DAA therapy should undergo pretesting for hepatitis B infection.

Potential living kidney donors with HCV infection should receive DAA treatment and, upon achieving a sustained virologic response, be re-evaluated to ensure that they are still appropriate kidney donors.

Finally, patients with HCV-associated glomerular disease should be treated for HCV with DAA, and in specific cases (ie, cryoglobulinemic flare, nephrotic syndrome, or rapidly progressive kidney failure) immunosuppressive therapy with or without plasma-exchange.

“We are optimistic that the current KDIGO guideline will increase attention on the intersection between HCV and CKD and spur future investigation into new directions to improve the care of this patient population,” the work group concluded.

Reference

Gordon CE, Berenguer MC, Doss W, et al. Prevention, diagnosis, evaluation, and treatment of hepatitis C virus infection in chronic kidney disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2018 Clinical Practice Guideline [published online September 23, 2019]. Ann Intern Med. doi:10.7326/M19-1539