Natural Course Of Hcv In Hemodialysis And Rtr Patients
HCV infection in dialysis patients is usually asymptomatic in both the acute and chronic phases. HCV is a slowly progressive disease, with a course typically extending for several decades, but dialysis patients have a much shorter life expectancy. This makes it very difficult to establish the long-term consequences of HCV infection for patients on dialysis as well as for RTRs.
Patients under regular hemodialysis were found to have lower ALT/aspartate transaminase elevations, lower grading and staging in histology, and lower viral load than non-dialyzed individuals in both acute and chronic HCV infection . A number of factors have been suggested to explain these findings. Likely, immunosuppression, uremia, and dialysis itself may play a role in this controversial issue .
To summarize, it has been calculated that HCV increases mortality among dialysis patients with an RR of 1.251.57 .
In a certain portion of HCV-positive recipients, HCV-related glomerulonephritis may lead to graft injury and may decrease its function. Berthoux found significantly higher anti-HCV positivity in RTRs with membranous glomerulonephritis and MPGN than in the entire recipient group . HCV infection has also been linked to chronic allograft nephropathy and diabetes mellitus after RT .
How Often Should I Be Tested For Kidney Disease
Everyone with HIV should be tested for kidney disease at least once. This should be done when you first learn you have HIV. Ask your health care provider if you were ever tested for kidney disease if not, get tested. People with HIV who have additional risk factors for kidney disease will need to be tested at least once a year.
Hepatitis C And Kidney Damage
One frequent explanation for why hepatitis C disease affects the kidneys is the association between the hepatitis C virus and its tendency to incite inflammation in our blood vessels . This inflammation will frequently involve the kidney and has the potential to set off inflammatory reactions in the kidney’s filter.
In other words, in most cases, it’s not a direct infection of hepatitis C that hurts kidney function, but the body’s response to hepatitis C that does the damage. Kidney function can then become “collateral damage” of a battle that rages between the hepatitis C virus and our body’s immune system, with afflicted patients left with varying degrees of kidney disease.
You May Like: Does Hepatitis Make You Itch
Can People With Hepatitis C Receive A Kidney Transplant
Individuals living with hepatitis C can receive a kidney transplant, but a medical team will need to consider the risks and benefits of the procedure.
For example, if a person with hepatitis C has significant liver damage, it may be unsafe for them to undergo transplant surgery. However, if they can receive a liver and kidney transplant at the same time, this may make receiving a new kidney possible.
Clinical Manifestations And Natural History
Besides MPGN, other forms of glomerular disease have been associated with HCV infection, which include IgA nephropathy, postinfectious glomerulonephritis, membranous nephropathy, thrombotic microangiopathies, focal and segmental glomerulosclerosis , and fibrillary or immunotactoid glomerulopathy . The course of these HCV-associated nephropathies is characterized by remission and relapsing phases.
The long-term outcome of HCV-associated nephropathies remains ill-defined. In a recent retrospective cohort study involving over 470,000 adult veterans, patients with HCV infection were more likely to develop ESRD than HCV-seronegative patients . Moreover, in patients with an estimated glomerular filtration rate â¤30 ml/min per 1.73 m2, the presence of HCV was associated with a nearly threefold higher risk of ESRD. These findings were confirmed by a subsequent cross-sectional study showing that HCV-positive patients had a 40% higher likelihood for developing renal insufficiencyâdefined as serum creatinine levels â¥1.5 mg/dlâcompared with seronegative subjects . Beside the risk of renal disease progression, the overall prognosis for patients with HCV-related nephritis is poor because of a high incidence of co-infections and cardiovascular disease .
Read Also: Hepatitis C How Can You Get It
What Happens To Your Health When You Arent Treated For Hepatitis C
Although medication can cure hepatitis C, millions of people arent taking it. The problem: Left untreated, the virus can lead to serious health complications.
Theres a reason the hepatitis C virus is called the silent killer. All too often, people dont realize theyve been infected. Out of the estimated 2.4 million people in the United States who have hepatitis C, more than half dont know they have it, according to the U.S. Department of Health and Human Services.
Usually when someone gets infected with hepatitis C, they initially until the disease gets fairly advanced, says Hardeep Singh, MD, a gastroenterologist and hepatologist at St. Joseph Hospital in Orange, California. The median time it takes for symptoms…to develop is 30 years.”
While some people are able to clear the virus on their own, most arent, and more than 50 percent go on to develop long-term, or chronic, hepatitis C, says the Centers for Disease Control and Prevention . Over time, untreated hepatitis C can cause hardening and scarring of the liver, which can cause complications that eventually lead to liver failure.
Liver cirrhosis and liver failure usually cannot be reversed sometimes a liver transplant is the only treatment option once advanced liver damage occurs. With hepatitis C, your risk of liver cancer also rises.
Here are a few other conditions that can be caused by untreated hepatitis C.
Measures To Prevent Hbv Spread In Hemodialysis Units
There are three stages of preventive measures of HBV spread within hemodialysis units:
The standard precautions against the transmission of any blood-borne infection represent the basis of all preventive methods. Each of these precautions should be very strictly applied. A separate hemodialysis room, exclusively designated for HBV-positive patients, seems to be a controversial issue however, this has been recommended by the Centers for Disease Control and Prevention since 2001 . HBV particles are usually found in high titers in the blood of patients on hemodialysis, and as HBV has been proven potentially infectious for > 1 week, there is the real risk of transmission from small amounts of blood, or even from infected surfaces that may appear to be clean. In comparison, the HCV and HIV viruses are less infectious: HCV survives in the environment for a shorter time, and HIV cannot survive in the environment . The risk of HBV transmission after a needle stick injury is obviously given by the serological status of the source, specifically of its HBV-DNA level/viral load. Repeatedly, it has been found that the risk of HBV transmission is 6% if the source is HBeAg negative and > 30% if the source is HBeAg positive .
Recommended Reading: How Does One Contract Hepatitis B
Natural History Of Hbv Infection In Ckd And Rtr Patients
To understand the natural history of HBV infection in CKD or dialysis patients is a complicated issue. The natural course of the disease is characterized by morbidity and mortality due to disease, as well as by the incidence of well-defined complications, which may be attributed to the disease. Morbidity and mortality in chronic hepatitis B are given by the incidence of liver cirrhosis, by the risk of its vascular or metabolic decompensation, and by the incidence of HCC. Furthermore, the natural course denotes the course of untreated disease. It is not so easy to fulfill these requirements with CHB in either CKD or dialysis patients.
Only 3% of dialyzed patients are diagnosed with liver cirrhosis however, the death rate among them is 35% higher than in non-cirrhotic patients . Maisonneuve et al. found the risk of HCC significantly higher in dialysis patients when compared to the general population however, this was linked to the prevalence of HBV , which is also higher in the dialysis population than in the general population. Factors associated with rapid progression of HBV-related liver disease include co-infections , alcohol abuse, and immunosuppression. Immunosuppression was recognized as a negative factor, particularly after renal transplantation . The course of HBV-related liver disease seems to be more aggressive after RT than for patients on long-term dialysis. Due to either immunosuppression or low activity of cytotoxic T lymphocytes, HBV replication increases.
What Are The Symptoms Of Autoimmune Hepatitis
People with autoimmune hepatitis may have some of the following symptoms
- feeling tired
- pain over the liver, in the upper part of the abdomen
- yellowish color of the whites of the eyes and skin, called jaundice
- darkening of the color of urine
- lightening of the color of stools
- skin conditions, such as rash, psoriasis, vitiligo, or acne
When symptoms of autoimmune hepatitis are present, they can range from mild to severe.
Some people with autoimmune hepatitis have no symptoms. In such cases, doctors may find evidence of liver problems during routine blood tests that leads to a diagnosis of autoimmune hepatitis. People without symptoms at diagnosis may develop symptoms later.
Some people with autoimmune hepatitis dont have symptoms until they develop complications due to cirrhosis. These symptoms include
- feeling tired or weak
- bloating from a buildup of fluid in the abdomen, called ascites
- swelling of the lower legs, ankles, or feet, called edema
- itchy skin
Also Check: Can You Give Yourself Hepatitis B
Maintenance Immunosuppressive Therapy In Kidney Transplant Recipients With Hcv Infection
Kidney transplantation is a peculiar condition whereby the most appropriate immunosuppressant needs to be chosen to prevent rejection while minimizing viral replication. Experimental studies in rats and mice ) have shown that cyclosporine A , at clinically relevant blood concentrations, inhibited the intracellular replication of HCV, an effect independent of its immunosuppressive activity. These findings were not observed with the other calcineurin inhibitor tacrolimus. However, in the clinical setting, the peculiar antiviral effects of CsA remain controversial , possibly underling different sensitivity of HCV virus to CsA related to polymorphisms of nonstructural HCV proteins NS5A and NS5B . Similarly, preliminary results in HCV-infected nontransplanted patients with lupus nephritis showed that mycophenolic acid, the active metabolite of mycophenolate mofetil , inhibited HCV viral replication . This is in line with findings of the USRDS registry of better survival in recipients of HCV-positive kidney given MMF than those on other immunosuppressive therapy . In a prospective study, however, HCV viremia increased after MMF administration without significant change in the serum concentration of liver enzymes .
Together, these studies indicate that the ideal immunosuppressive therapy for transplant patients infected with HCV remains ill-defined and will be a challenge for research in the future.
Chronic Kidney Disease Linked To Hepatitis B
Hepatitis B virus infection is associated with an increased risk of chronic kidney disease , according to a new study.
The study included 299,913 adults free of CKD at baseline who underwent health screening examinations from January 2002 to December 2016 in South Korea. In a fully adjusted model, individuals who tested positive for hepatitis B surface antigen had a significant 11% increased risk of incident CKD compared with those who tested negative, Yun Soo Hong, MD, of the Johns Hopkins University Bloomberg School of Public Health in Baltimore, and colleagues reported in BMC Nephrology. The investigators defined incident CKD as development of an estimated glomerular filtration rate below 60 mL/min/1.73 m2 and/or proteinuria.
HBsAG positivity was associated with a significant 23% increased risk of incident proteinuria and a non-significant 11% decreased risk of an eGFR below 60 mL/min/1.73 m2.
The investigators adjusted for age, sex, screening center, baseline eGFR, smoking status, alcohol consumption, education level, physical activity level, and the presence of hypertension, diabetes, and fatty liver disease.
Of the 299,913 study participants, 11,209 tested positive for HBsAG. These patients were significantly older than those who tested negative and more likely to be male . The HBsAG positive group also had a significantly higher proportion of current smokers .
Also Check: How Do You Get Autoimmune Hepatitis
Natural History Of Hcv Infection
Hemodialysis patients are at particular high risk for bloodborne infections because of prolonged vascular access and potential for exposure to contaminated equipment. It has been estimated that, among patients on hemodialysis, the prevalence of HCV infection varies greatly, from less than 5% to nearly 60% according to different areas of the world . Regardless of the geographic location, however, the prevalence is consistently associated with patient age and the number of transfused blood products . Given the introduction of routine screening and heightened attention to prevention of spread, the prevalence of HCV infection has declined in many dialysis centers, and yet it remains unacceptably high, ranging from 8% to 10% even in the most industrialized countries . In European dialysis centers the incidence rate for new-onset HCV infection varies from 0.4% to 16.0% per year . Spontaneous disappearance of HCV RNA has been reported in 1% of untreated dialysis patients .
Effects On Kidney Donors With Hepatitis C
Evidence suggests that in the general population, people who donate a kidney can live a regular life with their one remaining kidney, although there is a long-term risk of slightly high blood pressure.
When doctors remove one kidney, the remaining kidney compensates by increasing its blood-filtering capacity. People should experience a return of total kidney function to about 70% within 10 or 11 days of donating a kidney. In general, kidney donation may reduce someones life expectancy by 0.51 year.
There is little research on how donating a kidney affects HCV-positive people. Often, HCV-positive kidney donors are deceased individuals who have requested that doctors use their organs in transplant procedures.
If an individual is HCV-positive and wishes to donate a kidney during their lifetime, they should discuss it with their doctor. As chronic HCV can damage the kidneys, it may not be advisable to donate one due to the risk of this complication developing later on.
Don’t Miss: What Is Hepatitis C Infection
Renal Dysfunction In Hepatitis B Cirrhosis
|Acute kidney injury||Rise in serum creatinine of â¥50% from baseline or a rise of serum creatinine by â¥26.4 mmol/l in < 48 h HRS type 1 is a specific form of acute kidney injury|
|Chronic kidney disease||Glomerular filtration rate of < 60 ml/min for > 3 mo calculated using MDRD6 formula HRS type 2 is a specific form of chronic kidney disease|
|Acute-on-chronic kidney disease||Rise in serum creatinine of â¥50% from baseline or a rise of serum creatinine by â¥26.4 mmol/l in < 48 h in a patient with cirrhosis whose glomerular filtration rate is < 60 ml/min for > 3 mo calculated using MDRD6 formula|
- HRS, hepatorenal syndrome MDRD6, modification of diet in renal disease formula calculated using six variables of serum creatinine, age, gender, albumin, blood urea nitrogen and whether the patient is African-American.
Management Of Hcv And Ckd
The goal of treatment is to achieve sustained virologic response . Optimal treatment for HCV-infected CKD patients should consider the HCV genotype, extent of liver damage, CKD stage, transplant candidacy, prior HCV treatment, patient comorbidities, and the benefits and risks of antiviral treatment itself.8
Interferon-based therapy was used sparingly in the past as it was limited by low efficacy as well as high toxicity. A meta-analysis of 10 clinical studies by Fabrizi et al studying interferon/ribavirin in HCV-infected patients receiving hemodialysis showed a summary SVR rate of 56% and discontinuation rate of 25%.21
The advent of direct-acting antivirals has dramatically changed the approach to HCV genotype and viral load. For example, SVR rates generally exceed 90% in most subpopulations with DAAs.22,23 These therapies target non-structural parts of the HCV genome and include NS3/4A protease inhibitors, nucleotide analog NS5B polymerase inhibitors, NS5A inhibitors, and multi-class combination antiviral medications. These newer therapies have been the focus of clinical research in recent years for their improved efficacy, compared to interferon-based therapies. Typically, multiple DAAs are used in combination, NS5A or NS5B inhibitor with a protease inhibitor, to target the different aspects of the HCV genome. Multi-class combination antiviral medications for HCV infection are summarized in Figure 2.
NameFigure 2: Multi-Class Combination Direct-Acting Antivirals:
Don’t Miss: How Does Someone Contract Hepatitis C
Treatment For Kidney Disease & Hep C
Treatment can be broken down into categories, including: healthy living , no alcohol, no smoking, exercise, and regular monitoring by your kidney and liver specialist. If you have hepatitis C, seek treatment for hep C.
Determining which hepatitis C treatment to use for a patient with kidney disease is carefully considered since there are some hepatitis C treatments with direct-acting antivirals that are not formulated to work well for those with renal disease. It is best to consult with your liver specialist and kidney specialist .
Antiviral Therapy In Ckd And Hemodialyzed Patients
The current recommendations for the initiation of antiviral therapy in CKD and dialysis patients are based upon similar factors as they are for the general population. The most important parameter in this regard seems to be the viral replication level . The critical level for therapy initiation has been proven to be 2,000 IU/ml. In some cases, the therapeutic decision should not be based on the HBV-DNA level alone. Additionally, the severity of liver disease should be considered, and the antiviral therapy should only be initiated if significant fibrosis or necroinflammatory activity is present . Therefore, antiviral therapy should be initiated in HBeAg-positive as well as in HBeAg-negative disease only if HBV-DNA 2,000 IU/ml therefore, HBV-DNA should be tested annually or in case of any unexplained ALT elevation . In HBeAg-negative disease, the replication may be present due to mutations in the BCP or pre-C regions of the HBV genome . These mutations block the secretion of HBeAg into the serum of the infected individuals.
The ideal objective of the treatment is the seroconversion to anti-HBs. This status is called closest to cure as at the molecular level, HBV infection is an incurable disease because cccDNA persists in the hepatocytes of every HBV-exposed person for their entire lives. The real aim of the treatment, which is achievable by the current treatment options, is the long-term suppression of HBV replication .
Recommended Reading: Purina Pro Plan Hepatic Cat