From the Guidelines
The most appropriate management for this 62-year-old woman with end-stage kidney disease and active hepatitis C infection is to discuss hepatitis C virus treatment and timing (option D). The patient has evidence of active hepatitis C infection with a positive antibody test and a high viral load of 2.8 million IU/mL, which requires treatment before transplantation. Her hepatitis B serologies indicate past infection with immunity (positive core antibody and surface antibody, negative surface antigen), so she does not need hepatitis B treatment. Direct-acting antiviral agents for hepatitis C have high cure rates and are generally well-tolerated in patients with kidney disease, as recommended by the KDIGO 2022 clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease 1. Treatment before transplantation is often preferred to prevent post-transplant complications like fibrosing cholestatic hepatitis and to avoid potential drug interactions with immunosuppressants. However, in some cases with long transplant waiting times, treatment might be deferred until after transplantation. This decision requires careful discussion with the patient about the risks and benefits of pre- versus post-transplant treatment, considering her specific clinical situation, expected waiting time for a kidney, and the center's protocols for transplanting patients with hepatitis C, as also suggested by the EASL recommendations on treatment of hepatitis C 1. Some key considerations include the choice of specific regimen based on prior treatment history, drug–drug interactions, GFR, stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities, with regimens such as Sofosbuvir / Daclatasvir, Glecaprevir / Pibrentasvir, and Grazoprevir / Elbasvir being recommended for patients with end-stage kidney disease 1. Ultimately, the decision on the timing of hepatitis C treatment should be individualized and based on a thorough discussion of the potential benefits and risks.
From the FDA Drug Label
5 WARNINGS AND PRECAUTIONS
- 1 Risk of Hepatitis B Virus Reactivation in Patients Coinfected with HCV and HBV Hepatitis B virus (HBV) reactivation has been reported in HCV/HBV coinfected patients who were undergoing or had completed treatment with HCV direct acting antivirals, and who were not receiving HBV antiviral therapy. Test all patients for evidence of current or prior HBV infection by measuring HBsAg and anti-HBc before initiating HCV treatment with ledipasvir and sofosbuvir In patients with serologic evidence of HBV infection, monitor for clinical and laboratory signs of hepatitis flare or HBV reactivation during HCV treatment with ledipasvir and sofosbuvir and during post-treatment follow-up.
The patient is Hepatitis B core antibody positive and Hepatitis B surface antibody positive, indicating a resolved HBV infection, and Hepatitis C antibody positive with a high viral load. Given the patient's serologic evidence of HBV infection, the most appropriate management would be to discuss hepatitis C virus treatment and timing, considering the risk of HBV reactivation. The correct option is to Discuss hepatitis C virus treatment and timing 2.
From the Research
Patient Evaluation and Management
The patient is a 62-year-old woman with end-stage kidney disease, undergoing evaluation for kidney transplantation. She has a peritoneal dialysis catheter in place and is being managed for hypertension with multiple medications. Laboratory studies reveal positive hepatitis B core antibody, positive hepatitis B surface antibody, negative hepatitis B surface antigen, positive hepatitis C antibody, and a hepatitis C viral load of 2.8 million IU/mL.
Hepatitis C Management
Given the patient's hepatitis C status, management of this condition is crucial, especially considering her candidacy for kidney transplantation. The goal is to achieve sustained virologic response (SVR) to reduce the risk of hepatitis C-related complications and improve transplantation outcomes.
Treatment Options
- Direct-Acting Antivirals (DAAs): Studies 3, 4, 5 highlight the efficacy and safety of DAAs in treating hepatitis C, offering high SVR rates with shorter treatment durations and fewer side effects compared to traditional interferon-based therapies.
- Specific Regimens: For patients with hepatitis C genotype 1, sofosbuvir + pegylated interferon + ribavirin or simeprevir + pegylated interferon + ribavirin are recommended 6. However, for genotype 2, which might be relevant depending on the patient's genotype (not specified), sofosbuvir + ribavirin or newer combinations like Sofosbuvir plus Velpatasvir and Glecaprevir plus Pibrentasvir have shown high efficacy and safety 5.
- Considerations for Kidney Transplantation Candidates: While the provided studies do not directly address the management of hepatitis C in kidney transplantation candidates, the principle of achieving SVR before transplantation, if possible, is generally recommended to prevent post-transplant complications.
Most Appropriate Management
Considering the patient's need for kidney transplantation and the presence of hepatitis C, discussing hepatitis C virus treatment and its timing is crucial. The most appropriate management would involve evaluating the best treatment regimen based on the patient's hepatitis C genotype, the stage of her kidney disease, and her overall health status. Given the options provided: