Does a patient with Hepatitis C (Hep C) infection require a renal diet due to Impaired renal function?

From the Guidelines

A patient with hepatitis C and kidney disease should follow a renal diet while receiving appropriate hepatitis C treatment, prioritizing protein intake of 0.8 g/kg body weight/d as suggested by the KDIGO 2024 clinical practice guideline 1. The renal diet typically involves limiting sodium, potassium, phosphorus, and sometimes protein intake. Specifically, they should aim for 2-3 grams of sodium daily, moderate potassium (avoiding foods like bananas, oranges, and potatoes), reduced phosphorus (limiting dairy, nuts, and processed foods), and protein intake based on their kidney function. For hepatitis C treatment, direct-acting antivirals like Epclusa (sofosbuvir/velpatasvir), Mavyret (glecaprevir/pibrentasvir), or Zepatier (elbasvir/grazoprevir) are typically used, with the specific choice depending on the patient's viral genotype, kidney function, and medication interactions, as outlined in the EASL recommendations on treatment of hepatitis C 2016 1 and the KDIGO guideline for the evaluation and management of chronic kidney disease 1. Treatment usually lasts 8-12 weeks. It's crucial that patients maintain adequate hydration while avoiding fluid overload, take medications as prescribed, and have regular monitoring of both liver and kidney function. This dual approach addresses both conditions simultaneously, as untreated hepatitis C can worsen kidney disease, while proper dietary management helps preserve remaining kidney function. Key considerations include:

• Limiting protein intake to 0.8 g/kg body weight/d in adults with CKD G3–G5 1
• Avoiding high protein intake (>1.3 g/kg body weight/d) in adults with CKD at risk of progression 1
• Considering a very low–protein diet (0.3–0.4 g/kg body weight/d) supplemented with essential amino acids or ketoacid analogs in adults with CKD who are willing and able, and who are at risk of kidney failure 1

From the FDA Drug Label

1. 6 Clinical Trials in Adults with Severe Renal Impairment, Including those Requiring Dialysis Trial 0154 was an open-label clinical trial that evaluated 12 weeks of treatment with ledipasvir and sofosbuvir tablets (90 mg/400 mg) in 18 treatment-naïve and treatment-experienced (subjects with prior exposure to an HCV NS5B polymerase inhibitor were excluded) genotype 1 HCV-infected adults with severe renal impairment not requiring dialysis. At baseline, two subjects (11%) had cirrhosis and the mean eGFR was 24.9 mL/min (range: 9.0 to 39. 6). The SVR rate was 100% (18/18).

The FDA drug label does not directly answer whether a Hep C patient who is positive needs a renal diet. However, it does provide information on the treatment of HCV-infected adults with severe renal impairment.

• Key points:
  • The study included adults with severe renal impairment, not requiring dialysis.
  • The mean eGFR was 24.9 mL/min.
  • The SVR rate was 100% (18/18). Since the label does not explicitly address the need for a renal diet in Hep C patients, no conclusion can be drawn 2.

From the Research

Hepatitis C and Renal Disease

• Hepatitis C infection is associated with a wide range of extra-hepatic manifestations, including kidney disease 3.
• There is a strong association between hepatitis C and chronic kidney disease, with hepatitis C infection being a risk factor for proteinuria and/or impaired renal function 4.
• Hepatitis C infection can cause various types of renal diseases, including type I membranoproliferative glomerulonephritis (MPGN) associated with type II cryoglobulinemia, non-cryoglobulinemic MPGN, and membranous glomerulonephritis 4.

Treatment of Hepatitis C in Patients with Renal Disease

• The treatment of hepatitis C in patients with end-stage renal disease is a clinical challenge due to low response rates, high dropout rates, and poor tolerability of conventional or pegylated interferon with or without ribavirin 3.
• New direct-acting antiviral agents may dramatically change the treatment approach in hepatitis C-infected patients with mild to moderate renal impairment, but their safety in individuals with severe renal impairment remains to be confirmed 3.
• Patients with HCV-related glomerulopathies should be treated with angiotensin-converting enzyme inhibitors in association with anti-HCV therapy, which relies on a combined antiviral therapy of standard or pegylated interferon-α and ribavirin 4.

Management of Hepatitis C in Patients with Chronic Kidney Disease

• Hepatitis C virus infection is highly prevalent among chronic kidney disease subjects under hemodialysis and in kidney transplantation recipients, being an important cause of morbidity and mortality in these patients 5.
• The decision to treat HCV in patients with chronic kidney disease should be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and comorbidities 6.
• All renal transplant candidates with HCV should be assessed for antiviral treatment given the increased risk of progressive liver disease with immunosuppressive therapy, the increased life expectancy compared to other HCV-positive patients on dialysis, and the inability to receive interferon after transplant 6.

Dietary Considerations for Hepatitis C Patients with Renal Disease

• There is no direct evidence to suggest that a specific renal diet is required for hepatitis C patients with renal disease, but patients with chronic kidney disease should follow a diet that is tailored to their individual needs to slow the progression of kidney disease 7.
• Patients with hepatitis C and renal disease should be managed by a multidisciplinary team, including a hepatologist, nephrologist, and dietitian, to ensure that their dietary needs are met and that they receive appropriate treatment for their hepatitis C infection and renal disease 7.