Direct-acting antiviral agents, hepatitis C and dialysis: an update


Hepatitis C virus infection is still common among patients with chronic kidney disease, particularly within Dialysis Units all over the world. Although the full extent of HCV transmission in dialysis units is unknown, outbreaks of HCV infection continue to occur all over the world. Evidence has been accumulated in the last decade suggesting that HCV plays consistent activity at hepatic and extra-hepatic level. A recent systematic review of the medical literature with a meta-analysis of clinical studies retrieved 15 longitudinal studies (n=2,299,134 patients); we found a significant relationship between anti-HCV positive serologic status and higher frequency of CKD; the summary estimate for adjusted hazard risk with HCV across the surveys, 1.54 (95% CI, 1.26; 1.87) (P<0.0001). The advent of direct-acting antiviral agents has revolutionized the therapy of HCV, including patients with advanced chronic kidney disease. Two regimens based on DAAs have been recently approved for the antiviral therapy of HCV in patients with CKD stage 4/5: elbasvir/grazoprevir and glecaprevir/pibrentasvir. Such regimens have been provided with high efficacy and safety, according to the results given by C-SURFER and EXPEDITION-4, respectively. Sofosbuvir, a non-structural 5B polymerase inhibitor, is the backbone of many anti-HCV drug regimens, and has significant renal excretion. As a result, the use of sofosbuvir is not recommended in patients with an eGFR <30 mL/min/1.73m2. In summary, recent studies have shown that several combinations of DAAs are currently available for CKD patients, including those with CKD stage 4/5. These drugs have reported high efficacy and satisfactory tolerability, regardless of HCV genotype or renal impairment. We need to improve the screening for HCV and the access to DAAs in patients with CKD stage 4/5.


Keywords: Chronic kidney disease; Dialysis; Direct-acting antiviral agents; Hepatitis C; Sustained virological response

Sorry, this entry is only available in Italian.


L’infezione cronica da virus dell’epatite C (HCV) è un problema sanitario globale: si calcola che circa 71 milioni di persone siano infette in tutto il pianeta [1]. HCV è tuttora frequente nei pazienti nefropatici, inclusi in pazienti con malattia renale cronica in fase pre-dialitica (Tabella 1) e dialitica [ 211]. Esiste ormai una solida evidenza scientifica riguardo il ruolo deleterio svolto dall’infezione da virus HCV sulla sopravvivenza dei pazienti infetti; HCV sembra produrre danno epatico ed extraepatico. Il danno epatico è legato all’epatite cronica con le sue manifestazioni quali cirrosi epatica, carcinoma epatocellulare e scompenso. Nell’ultima decade si sono rese evidenti le manifestazioni extraepatiche di HCV: il virus favorisce, tra l’altro, l’insorgenza di diabete mellito, aumenta la mortalità cardiovascolare, e promuove lo sviluppo della malattia renale cronica [12]. HCV è considerato la causa più frequente di malattia epatica nei pazienti con malattia renale cronica. A loro volta, le epatopatie sono importante causa di aumentata mortalità e morbilità nei pazienti con CKD, specialmente nei dializzati e nei portatori di trapianto renale [12].


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