Why should Hepatitis C (HCV) screening be done in patients with Chronic Kidney Disease (CKD)?

Hepatitis C Screening in Chronic Kidney Disease Patients

All patients with chronic kidney disease (CKD) should be screened for Hepatitis C virus (HCV) infection at the time of initial CKD diagnosis due to the increased risk of morbidity, mortality, and accelerated kidney disease progression associated with HCV infection. 1

Rationale for HCV Screening in CKD Patients

Epidemiological Considerations

• HCV prevalence is higher in CKD patients compared to the general population
• Global prevalence of approximately 10% in hemodialysis patients, ranging from 4% in Belgium to 20% in Middle Eastern countries 2
• Approximately 5% prevalence at hemodialysis initiation 2

Impact on Patient Outcomes

HCV infection in CKD patients is associated with:

• Increased mortality risk: 35% higher all-cause mortality (adjusted relative risk 1.35) 3
• Liver-related mortality: 3.8 times higher risk 3
• Cardiovascular mortality: 26% increased risk 3
• Accelerated CKD progression 1, 4
• Reduced quality of life and higher hospitalization rates 2
• Poorer outcomes after kidney transplantation 4, 5

HCV-Related Kidney Manifestations

HCV infection can directly cause or worsen kidney disease through:

• Cryoglobulinemic glomerulonephritis (most common HCV-related renal manifestation) 4
• Membranoproliferative glomerulonephritis (2-fold higher risk) 2, 4
• Other glomerular diseases: membranous nephropathy, focal segmental glomerulosclerosis, IgA nephropathy 4
• Immune complex deposition in renal tissue 2
• Increased risk of CKD development and progression 1, 5

Screening Recommendations by CKD Stage and Setting

All CKD Patients

• Screen at initial CKD diagnosis (Grade 1C recommendation) 1
• Use immunoassay followed by nucleic acid testing (NAT) if immunoassay positive (Grade 1A) 1

Dialysis Patients

• In-center hemodialysis: Screen at initiation or transfer from another facility (Grade 1A) 1

  • Use NAT alone or immunoassay followed by NAT if positive (Grade 1A) 1
  • Continue screening every 6 months (Grade 1B) 1
  • Monthly ALT monitoring (Grade 2B) 1, 2

• Peritoneal dialysis/home hemodialysis: Screen at initiation (Grade 2D) 1

Kidney Transplant Candidates

• Screen all patients at time of transplant evaluation (Grade 1A) 1

Management After Positive HCV Screening

1. Assess liver fibrosis (Grade 1A) 1

   • Initial noninvasive evaluation (Grade 1B) 1
   • Consider liver biopsy when cause is uncertain or noninvasive results are discordant 1
   • Assess for portal hypertension if advanced fibrosis suspected (F3-F4) (Grade 1A) 1

2. Evaluate for DAA-based therapy for all CKD patients with HCV (Grade 1A) 1

   • Treatment selection based on:
     • Prior treatment history
     • Drug-drug interactions
     • GFR
     • Stage of hepatic fibrosis
     • Kidney/liver transplant candidacy
     • Comorbidities

3. Regular monitoring for kidney disease progression (Grade 1A) 1

   • All CKD patients with history of HCV infection should be followed regularly

4. Additional screening

   • Screen and vaccinate against hepatitis A and B viruses (Grade 1A) 1
   • Screen for HIV (Grade 1A) 1

Benefits of HCV Treatment in CKD

• Improved renal function: Studies show improvement in GFR (from 40.5 to 45 ml/min) and reduction in proteinuria (from 1.18 to 0.79 g/24h) after DAA treatment 6
• 100% SVR rates reported in some studies of non-dialysis CKD patients 6
• Potential to slow CKD progression 5
• Improved transplant outcomes 5

Reporting and Infection Control

• Report any new HCV infection in hemodialysis patients to appropriate public health authorities 1, 2
• In units with new HCV infection, test all patients and increase frequency of subsequent testing (Grade 1A) 1
• Implement strict infection control practices to prevent transmission 2

Common Pitfalls to Avoid

• Overlooking HCV screening in early CKD stages
• Missing repeat screening in high-risk patients (especially hemodialysis)
• Delaying treatment in kidney transplant candidates
• Failing to monitor for kidney disease progression in HCV-infected patients
• Neglecting to screen for other viral hepatitis infections (HAV, HBV) and HIV

HCV screening and management in CKD patients is essential for improving both liver and kidney outcomes, reducing mortality, and optimizing transplant success.