Friday, December 15th 9AM EST: HCV Update
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ISN-KDIGO Webinar with Paul Martin (speaker) & Bertram Kasiske (moderator)
It rapidly became apparent after diagnostic testing for HCV was introduced that patients on maintenance hemodialysis (MHD) had a high prevalence of HCV infection and furthermore that HCV acquisition was occurring in the outpatient dialysis setting. Despite screening of blood products, HCV infection has remained highly prevalent in the MHD population. In a multinational study in the period 1996-2002, the prevalence of HCV in US HD patients was 7.4%. A recent update from the period 2012-2015 indicates that the prevalence of HCV in US MHD patients is 6.9%. This suggests that with a US dialysis population of approximately 450,000 patients that there may be 30,000 HCV infected patients on maintenance hemodialysis.
Despite effective strategies to limit spread of HCV among MHD patients, HCV acquisition confirmed by phylogenetic analysis still occurs and typically reflects lack of attention to basic infection prevention measures such as not sharing medication vials between patients and hand hygiene. CDC have been informed about 36 cases of acute HCV in MHD patients in 2014-2015 and have issued an alert stressing the need to adhere to precautions to prevent HCV spread in HD units.
In the general population efforts to identify HCV infected patients have typically focused on individuals with acknowledged risk factors for HCV infection including blood transfusion prior to 1991 and intravenous drug use (IVDU). Included in this high risk group were also dialysis patients reflecting the high prevalence of HCV in this population. However more recently recommendations for testing has included the so-called baby boomer population born between 1945 and 1965 as this “birth cohort” again due to a high prevalence of HCV infection as a consequence of prior IVDU.
In the CKD population HCV testing is recommended as part of the evaluation of CKD, at entry to renal replacement therapy and every 6 months in patients on maintenance hemodialysis ( KDIGO in press).
For an HCV infected CKD patient there are a number of important consequences of infection including an increased risk of death. Cirrhosis and hepatocellular cancer have been implicated in this excess mortality. Another important consequence of HCV infection for a patient with CKD is the effect on potential candidacy for kidney transplantation. HCV infection has been shown to diminish graft and recipient survival following kidney transplant. HCV infected kidney transplant candidates with cirrhosis or focal hepatocellular cancer may not be eligible for isolated kidney transplant and may require consideration for combined liver/kidney transplant, a far more extensive procedure. There is also increasing evidence that HCV infection is not only implicated in causing renal disease often mediated by cryoglobulinemia but also may accelerate the course of CKD in general.