#JustReleased KDIGO 2018 Guideline for Management of Hepatit

KDIGO 2018 Guideline for Management of Hepatitis C in Chronic Kidney Disease

The Kidney Disease: Improving Global Outcomes (KDIGO) has recently released Clinical Practice Guideline for the prevention, diagnosis, evaluation, and treatment of Hepatitis C in chronic kidney disease (CKD). The guidance has been published in the journal Kidney International Supplements, the official journal of the International Society of Nephrology. It is an update to the prior guideline published in 2008 and is aimed at the management of patients with HCV and chronic kidney disease, including those who are on chronic dialysis therapy and individuals with a kidney transplant.
Specifically, the topic areas for which new recommendations are issued include detection and evaluation of HCV in CKD; treatment of HCV infection in patients with CKD; management of HCV-infected patients before and after kidney transplantation; prevention of HCV transmission in haemodialysis units; and diagnosis and management of kidney diseases associated with HCV infection. 

The guideline encompasses five “chapters” each having its own set of recommendations that are based on systematic reviews of relevant studies, and appraisal of the quality of the evidence and the strength of recommendations which follow the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Current CKD Nomenclature Used By KDIGO

CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. CKD is classified based on cause, GFR category (G1-G5), and albuminuria category (A1-A3), abbreviated as CGA.

Prognosis of CKD by GFR and albuminuria category

Some of the key recommendations are:-

1. Detection and evaluation of HCV in CKD
• Use an immunoassay followed by nucleic acid testing (NAT) if immunoassay is positive (1A)
• Screen all patients for HCV infection upon initiation of in-center hemodialysis or upon transfer from another dialysis facility or modality (1A)
• Use NAT alone or an immunoassay followed by NAT if immunoassay is positive (1A)
• Screen all patients for HCV infection at the time of evaluation for kidney transplantation (1A)
• Screen for HCV infection with immunoassay or NAT in in-center hemodialysis patients every 6 months (1B)
• In units with a new HCV infection, all patients to be tested for HCV infection and the frequency of subsequent HCV testing should be increased (1A)
• Hemodialysis patients with resolved HCV infection to undergo repeat testing every 6 months using NAT to detect possible re-infection (1B)
• Assess HCV-infected patients with CKD for liver fibrosis (1A)
• An initial noninvasive evaluation of liver fibrosis is recommended (1B)
• Assessment for portal hypertension in CKD patients with suspected advanced fibrosis (1A)
• All CKD patients with a history of HCV infection, whether NAT-positive or not, be followed up regularly to assess progression of kidney disease (1A)
• All CKD patients with a history of HCV infection, whether NAT-positive or not, be screened and, if appropriate, vaccinated against HAV and HBV, and screened for HIV (1A)

2. Treatment of HCV infection in patients with CKD
• An interferon-free regimen is recommended (1A)
• Choice of specific regimen be based on HCV genotype (and subtype), viral load, prior treatment history, drug-drug interactions, glomerular filtration rate (GFR), stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities (1A)
• Treat patient with GFR ± 30 ml/min per 1.73 m2 (CKD G1-G3b) with any licensed direct acting antiviral (DAA)-based regimen (1A)
• Patients with GFR < 30 ml/min per 1.73 m2 (CKD G4-G5D) should be treated with a ribavirin-free DAA-based regimen
• Pre-treatment assessment is recommended for drug-drug interactions between the DAA-based regimen and other concomitant medications including immunosuppressive drugs in kidney transplant recipients (1A)
• Calcineurin inhibitor levels be monitored during and after DAA treatment (1B)

Recommended DAA Rx regimens for patients with CKD G4-G5D and kidney transplant recipients, by HCV genotype

3. Preventing HCV transmission in hemodialysis units
Hemodialysis facilities should adhere to standard infection control procedures including hygienic precautions that effectively prevent transfer of blood and blood-contaminated fluids between patients to prevent transmission of blood-borne pathogens (1A)
• Do not use dedicated dialysis machines for HCV-infected patients (1D)
• Hemodialysis centers should examine and track all HCV test results to identify new cases of HCV infections in their patients (1B)
• Aggressive measures be taken to improve hand hygiene (and proper glove use), injection safety, and environmental cleaning and disinfection when a new case of HCV is identified that is likely to be dialysis-related (1A)

4. Management of HCV-infected patients before and after kidney transplantation
• Kidney transplantation is the best therapeutic option for patients with CKD G5 irrespective of presence of HCV infection (1A)
• HCV-infected patients with compensated cirrhosis (without portal hypertension) should undergo isolated kidney transplantation (1B)
• Refer HCV-infected patients with decompensated cirrhosis for combined liver kidney transplantation (1B) and defer HCV treatment until after transplantation (1D)
• All HCV-infected patients who are candidates for kidney transplantation to be considered for DAA therapy, either before or after transplantation (1A)
• If receiving a kidney from an HCV-positive donor improves the chances for transplantation, the HCV NAT-positive patient can undergo transplantation with an HCV-positive kidney and be treated for HCV infection after transplantation (2B)
• Transplantation of kidneys from HCV NAT-positive donors be directed to recipients with positive NAT (1A)
• Patients who develop new-onset proteinuria (either urine protein-to-creatinine ratio > 1 g/g or 24-hour urine protein > 1 g on 2 or more occasions) should have an allograft biopsy with immunofluorescence and electron microscopy included in the analysis (2D)
• Treat patients with post-transplant HCV-associated glomerulonephritis with a DAA regimen (1D)

5. Diagnosis and management of kidney diseases associated with HCV infection
• Treat patients with HCV-associated glomerular disease for HCV (1A)
• Patients with HCV-related glomerular disease showing stable kidney function and/or non-nephrotic proteinuria should be treated initially with DAA (1C)
• Patients with cryoglobulinemic flare, nephrotic syndrome, or rapidly progressive kidney failure be treated, in addition to DAA treatment, with immunosuppressive agents with or without plasma exchange (1C)
• Immunosuppressive therapy is recommended in patients with histologically active HCV-associated glomerular disease who do not respond to antiviral therapy, particularly those with cryoglobulinemic kidney disease (1B)







Kidney Disease, Improving Global Outcomes aims to improve the care and outcomes of kidney disease patients worldwide through promoting coordination, collaboration and integration of initiatives to develop and implement clinical practice guidelines.

Note: This list is a brief compilation of some of the key recommendations included in the Guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publications here: https://pxmd.co/ZgBdM 

About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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