Management Of HCV In CKD Patients

Management Of HCV
In CKD Patient
Dr.
Ayman Sabri Abd El Badie
Nephrology specialist
New Mansoura General Hospital
(NMGH)
ISN Ambassador Educational Program Meniet El Nasr Hospital Thursday, 19 January, 2017

Introduction
Hepatitis C virus (HCV) is
a small single-stranded
RNA virus with a lipid
envelope (E) containing
glycoproteins (E1 and
E2) and a core with a
genome consisting of
9600 nucleotides.
ISN Ambassador Educational Program Meniet El Nasr Hospital Thrsday, 19 January, 2017ary, 2017

ISN Ambassador Educational Program Meniet El Nasr Hospital Thursday, 19 January, 2017ary, 2017

The genetic sequence of HCV is characterized by
a high rate of spontaneous mutations, with
major implications for escape from the human
immune system and the development of an
effective vaccine.

HCV isolates are classified into six
distinct genotypes depending on
sequence homology.

EPIDEMIOLOGY
The WHO estimates that HCV infection affects
130 to 170 million people worldwide.
Egypt has the highest HCV prevalence rate in the
world, estimated nationally about 15 % of the
adult population.
ISN Ambassador Educational Program Meniet El Nasr Hospital Thursday, 19
January, 2017ary, 2017

Prevalence of HCV

HCV related renal disease
MPGN
Membranous
PAN
Others
- FSGS
-IgA nephropathy
-Postinfectious glomerulonephritis
-Immunotactoid glomerulopathy
- Fibrillary glomerulonephritis.
HCV related renal disease

Management
It is suggested that the decision to treat be
based on the potential benefits and risks of
therapy, including life expectancy, candidacy
for kidney transplantation, and
comorbidities.

Benefits of treatment
• Prevention of HCV complication as HCC ,
Lymphoma
• Reduced morbidity :
- Liver disease.
- Extra hepatic manifestation.
- Lymph proliferative disease.
- Cardiovascular complication.
• Improved survival on hemodialysis.
• preparation for transplantation.
• Elimination of disease dissemination.

INF  ± Ribavirin

Direct acting Anti Viral Drugs

Direct acting Anti Viral Drugs
Trade
name
Generic
Name
SovaldiSofosbuvir
HarvoniLedipasvir / sofosbuvir
OlysioSimeprevir
DaklinzaDaclatasvir
QuerevoParitaprevir /ritonavir / ombitasvir

Mechanism of action

The Monthly DNG Meeting Meynet El Nasr Hospital Friday, 22 April, 2016

eGFR
Native Kidney Transplanted Kidney
> 30 ml/min/1.73 m2
Querevo + Ribavirin 1000mg daily
if < 75 kg & 1200mg if >75kg
Harvoni + Ribavirin 1000mg daily
if < 75 kg & 1200mg if >75kg
Harvoni + Ribavirin 1000mg daily
if < 75 kg & 1200mg if >75kg
Daklinza 60 mg + Sovaldi 400mg +
Ribavirin daily fixed dose 600mg
Olysio 150mg + Sovaldi 400mg + Ribavirin if cirrhosis 1000mg daily
if < 75 kg & 1200mg if >75kg
12 weeks
12 weeks OR
24 weeks in presence of cirrhosis
24 weeks
Selected
protocol
Alternative
protocol 1
Alternative
protocol 2
ttt duration
with Riba.
ttt duration
without Riba.

eGFR
On conservative ttt or dialysis Transplanted Kidney
< 30 ml/min/1.73 m2
No cirrhosis Compensate Decompensate No cirrhosis Compensate Decompensate
Selected
protocol
Alternative
protocol 1
ttt duration
with Riba.
ttt duration
without
Riba.
Querevo + Ribavirin
200mg daily -
200mg thrice/week-
4h before dialysis
Daklinza 60 mg + Sovaldi 400mg + Ribavirin 200mg
daily - 200mg thrice/week
Olysio 150mg +
sovaldi 200mg
12 weeks 12 weeks
12 weeks 12 weeks24 weeks 24 weeks

Important Consideration
• eGFR by MDRD equation .

•Compensated cirrhosis …. >F3 by fibroscan or
equivalent chemical model.
•Decompensate cirrhosis ….. child paugh score
class B-7 or higher.
•Ribavirin dose …. withdrawal if not tolerated or
Hb level drops by 2 gm/dl despite ESA.

• HBV co-infection
Patients should be treated with the same
protocols as HCV mono-infected patients. If
HBV replicates at a significant rate,
concurrent HBV nucleoside/nucleotide
analogue therapy is indicated.

• HIV co-infection
Patients co-infected with HCV and HIV have higher
HCVRNA levels, higher rate of HCV persistence and
faster progression to cirrhosis and end stage liver
disease. The same IFN-free HCV treatment
recommendations for HIV/HCV co-infected persons
as for those with HCV-only infection.

• Drug drug interaction :
Don’t forget to modify doses of cyclosporin, tacrolimus,
sirolimus & everlimus according to blood level in
transplanted patients.
The interaction in between sofosbuvir and amiodarone
was the earliest life threatening complication,
hallmarked by bradycardia and cardiac arrest.
Querevo protocol … restricted to transplanted patient.
So, used only by transplant expert.

Risk of treatment

Failed treatment
Re-treatment of patients that do not achieve a SVR or
recur after treatment. The choice of retreatment
protocol depends on the failed initial protocol as
follows:
- Those with failed Interferon + Ribavirin protocol
should be treated according to the same
recommendations for treatment-naive patients.

- Olysio based Protocol for failure with any of Harvoni
based Protocol or Daklinza based protocol.
- Harvoni based Protocol or Daklinza based protocol for
failure with any Olysio based Protocol .
- Harvoni based Protocol or Daklinza based protocol or
Olysio base for failure with any Qurevo based
Protocol .

Adjunctive therapy

RPGN Sever Neuropathy
widespread cutaneous
vasculitis with ulceration
Sever active disease
Performed cryoglobulin B cell production Tissue injury
Anti viral
Plasma exchange Rituximab Steroid

Before or After Transplantation

While pre-transplant HCV eradication was highly
desirable in the interferon era, owing to the risk of
graft loss if the dug was administered after
transplantation, this policy became questionable
with the availability of safe DAAs. This provides
considerable relief if transplantation becomes an
urgent necessity, including that from deceased
donors. However, when it can wait, we strongly
recommend treating patients on the waiting list to
avoid the HCV-associated many-fold increased risk of
thrombotic microangiopathy and acute transplant
glomerulopathy in the early post-transplant period.

Management Of HCV In CKD Patients

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