Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease

Publication Date: November 18, 2022
Last Updated: January 31, 2023

Chapter 1: Detection and evaluation of HCV in CKD

1.1: Screening patients with chronic kidney disease (CKD) for hepatitis C virus (HCV) infection

We recommend screening all patients for HCV infection at the time of initial evaluation of CKD. (1, C)
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We recommend using an immunoassay followed by nucleic acid testing (NAT) if immunoassay is positive. (1, A)
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We recommend screening all patients for HCV infection upon initiation of in-center hemodialysis or upon transfer from another dialysis facility or modality. (1, A)
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We recommend using NAT alone or an immunoassay followed by NAT if immunoassay is positive. (1, A)
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We suggest screening all patients for HCV infection upon initiation of peritoneal dialysis or home hemodialysis. (2, D)
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We recommend screening all patients for HCV infection at the time of evaluation for kidney transplantation. (1, A)
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1.2: Follow-up HCV screening of in-center hemodialysis patients

We recommend screening for HCV infection with immunoassay or NAT in in-center hemodialysis patients every 6 months. (1, B)
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Report any new HCV infection identified in a hemodialysis patient to the appropriate public health authority. (N, G)
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In units with a new HCV infection, we recommend that all patients be tested for HCV infection and that the frequency of subsequent HCV testing be increased. (1, A)
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We recommend that hemodialysis patients with resolved HCV infection undergo repeat testing every 6 months using NAT to detect possible re-infection. (1, B)
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We suggest that patients have serum alanine aminotransferase (ALT) level checked upon initiation of in-center hemodialysis or upon transfer from another facility. (2, B)
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We suggest that hemodialysis patients have ALT level checked monthly. (2, B)
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1.3: Liver testing in patients with CKD and HCV infection

We recommend assessing HCV-infected patients with CKD for liver fibrosis . (1, A)
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We recommend an initial noninvasive evaluation of liver fibrosis. (1, B)
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When the cause of liver disease is uncertain or noninvasive testing results are discordant, consider liver biopsy. (N, G)
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We recommend assessment for portal hypertension in CKD patients with suspected advanced fibrosis (F3–4). (1, A)
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1.4: Other testing of patients with HCV infection

We recommend assessing all patients for kidney disease at the time of HCV infection diagnosis. (1, A)
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Screen for kidney disease with urinalysis and estimated glomerular filtration rate (eGFR). (N, G)
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If there is no evidence of kidney disease at initial evaluation, patients who remain NAT-positive should undergo repeat screening for kidney disease. (N, G)
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We recommend that all CKD patients with a history of HCV infection, whether NAT-positive or not, be followed up regularly to assess for progression of kidney disease. (1, A)
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We recommend that all CKD patients with a history of HCV infection, whether NAT-positive or not, be screened and, if appropriate, vaccinated against hepatitis A virus (HAV) and hepatitis B virus (HBV), and screened for human immunodeficiency virus (HIV). (1, A)
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Chapter 2: Treatment of HCV infection in patients with CKD

We recommend that all patients with CKD (G1-G5), on dialysis (G5D), and kidney transplant recipients (G1T-G5T) with HCV be evaluated for direct-acting antiviral (DAA)-based therapy as outlined in Figure 1. (1, A)
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We recommend that the choice of specific regimen be based on prior treatment history, drug–drug interactions, GFR, stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities. (1, A)
If pangenotypic regimens are not available, HCV genotype (and subtype) should guide the choice of treatment (Figure 1).
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Treat kidney transplant candidates in collaboration with the transplant center to optimize timing of therapy. (N, G)
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We recommend pre-treatment assessment for drug–drug interactions between the DAA-based regimen and other concomitant medications including immunosuppressive drugs in kidney transplant recipients. (1, A)
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We recommend that calcineurin inhibitor levels be monitored during and after DAA treatment in kidney transplant recipients. (1, B)
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All patients with CKD (G1-G5), on dialysis (G5D), and kidney transplant recipients (G1T-G5T) with HCV should undergo testing for hepatitis B virus (HBV) infection prior to DAA therapy. (N, G)
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If hepatitis B surface antigen [HBsAg] is present, the patient should undergo assessment for HBV therapy. (N, G)
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If HBsAg is absent but markers of prior HBV infection (HBcAb-positive with or without HBsAb) are detected, exclude HBV reactivation with HBV DNA testing if levels of liver function tests rise during DAA therapy. (N, G)
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Figure 1. Direct-acting antiviral (DAA) regimens with evidence of effectiveness for various chronic kidney disease (CKD) populations

aThe figure includes only regimens that were evaluated by at least 2 studies in the specific CKD population and for which summary sustained virologic response at 12 weeks [wks] (SVR12) was >92%. Sofosbuvir monotherapy is excluded since current DAA regimens incorporate at least 2 agents. Other regimens may be appropriate for the above populations. Readers are encouraged to consult the Association for the Study of Liver Diseases (AASLD) or European Association for the Study of the Liver (EASL) guidelines for the latest information on various regimens. The suggested durations of treatment are those most commonly employed by the relevant studies. Studies commonly extended treatment for patients with cirrhosis, prior DAA failure, or for some genotypes. Readers should consult the AASLD or EASL guidelines, as needed, to determine optimal treatment duration. bThe order of hepatitis C virus (HCV) regimens does not indicate a ranking or preferential order of selection. The regimens are presented in order of the quality of evidence, then by HCV genotype, then alphabetically. The differences in quality of evidence primarily relate to the numbers of evaluated patients and small differences in methodological quality of the underlying studies. cEstimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. deGFR <30 ml/min per 1.73 m2, not dialysis-dependent. eRegimens in kidney transplant recipients (KTRs) should be selected to avoid drug–drug interactions, particularly with calcineurin inhibitors. fStrength of evidence for CKD G4T-G5T is very low for all regimens. gEvidence primarily for patients on hemodialysis. Very few patients were on peritoneal dialysis. G, refers to the GFR category with suffix D denoting patients on dialysis and ND denoting patients not on dialysis; PrO±D, ritonavir-boosted paritaprevir and ombitasvir with or without dasabuvir.

Figure 2. Summary of currently available direct-acting antiviral (DAA) treatment targets in hepatitis C virus (HCV) life cycle

Infection is initiated by (1): virus binding and internalization, followed by (2) cytoplasmic release and uncoating; (3) translation and polyprotein processing; (4) RNA replication; (5) packaging and assembling; and (6) virion maturation and release. Adapted with permission from Stanciu C, Muzica CM, Girleanu I, et al. An update on direct antiviral agents for the treatment of hepatitis C. Expert Opin Pharmacother 2021;22:1729–1741,88 reprinted by permission of the publisher (Taylor & Francis Ltd, http://www.tandfonline.com). NS3/4A, nonstructural protein proteases; NS5A, nonstructural phosphoprotein; NS5B, nonstructural protein RNA-dependent RNA polymerase

Chapter 3: Preventing HCV transmission in hemodialysis units

We recommend that hemodialysis facilities 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 (see Table 1). (1, A)
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We recommend regular observational audits of infection control procedures in hemodialysis units. (1, C)
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We recommend not using dedicated dialysis machines for HCV-infected patients. (1, D)
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We suggest not isolating HCV-infected hemodialysis patients. (2, C)
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We suggest that the dialyzers of HCV-infected patients can be reused if there is adherence to standard infection control procedures. (2, D)
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We recommend that hemodialysis centers examine and track all HCV test results to identify new cases of HCV infections in their patients. (1, B)
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We recommend that 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. (1, A)
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Strategies to prevent HCV transmission within hemodialysis units should prioritize adherence to standard infection control practices and should not primarily rely upon the treatment of HCV-infected patients. (N, G)
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Table 1. Infection control practices (“hygienic precautions”) particularly relevant for preventing HCV transmission

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  • Proper hand hygiene and glove changes, especially between patient contacts, before invasive procedures, and after contact with blood and potentially blood-contaminated surfaces/supplies
  • Proper injectable medication preparation practices following aseptic techniques and in an appropriate clean area, and proper injectable medication administration practice
  • Thorough cleaning and disinfection of surfaces at the dialysis station, especially high-touch surfaces
  • Adequate separation of clean supplies from contaminated materials and equipment

Table 3. Factors and lapses in infection control practices associated with transmission of HCV infection in dialysis units

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  • Preparation of injections in a contaminated environment (including at patient treatment station)
  • Reuse of single-dose medication vial for more than 1 patient
  • Use of mobile cart to transport supplies or medications to patients
  • Inadequate cleaning or disinfection of shared environmental surfaces between patients
  • Failure to separate clean and contaminated areas
  • Failure to change gloves and perform hand hygiene between tasks or patients
  • Hurried change-over processes
  • Low staff-to-patient ratio

Table 4. Hygienic precautions for hemodialysis (dialysis machines)

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Definitions
  • The ‘transducer protector’ is a filter (normally a hydrophobic 0.2-μm filter) that is fitted between the pressure-monitoring line of the extracorporeal circuit and the pressure-monitoring port of the dialysis machine. The filter allows air to pass freely to the pressure transducer that gives the reading displayed by the machine, but it resists the passage of fluid. This protects the patient from microbiologic contamination (as the pressure-monitoring system is not disinfected) and the machine from ingress of blood or dialysate. An external transducer protector is normally fitted to each pressure-monitoring line in the blood circuit. A back-up filter is located inside the machine. Changing the internal filter is a technical job.•A “single-pass machine” is a machine that pumps the dialysate through the dialyzer and then to waste. In general, such machines do not allow fluid to flow between the drain pathway and the fresh pathway except during disinfection. “Recirculating” machines produce batches of fluid that can be passed through the dialyzer several times.

Transducer protectors
  • External transducer protectors should be fitted to the pressure lines of the extracorporeal circuit.
  • Before commencing dialysis, staff should ensure that the connection between the transducer protectors and the pressure-monitoring ports is tight, as leaks can lead to wetting of the filter.
  • Transducer protectors should be replaced if the filter becomes wet, as the pressure reading may be affected. Using a syringe to clear the flooded line may damage the filter and increase the possibility of blood passing into the dialysis machine.•If wetting of the filter occurs after the patient has been connected, the line should be inspected carefully to see if any blood has passed through the filter. If any fluid is visible on the machine side, the machine should be taken out of service at the end of the session so that the internal filter can be changed and the housing disinfected.•Some blood tubing sets transmit pressure to the dialysis machine without a blood–air interface, thus eliminating the need for transducer protectors.

External cleaning
  • After each session, the exterior of the dialysis machine and all surfaces in the dialysis treatment station should be cleaned with a low-level disinfectant if not visibly contaminated. Pay particular attention to high-touch surfaces that are likely to come into contact with the patient (e.g., arm rests, blood pressure cuff) or staff members’ hands (e.g., machine control panel).•Disinfection of external machine surfaces should not commence until the patient has left the dialysis treatment station. A complete (unit-wide) patient-free interval between shifts might facilitate more thorough cleaning and disinfection of the unit.
  • If a blood spillage has occurred, the exterior should be disinfected with a commercially available tuberculocidal germicide or a solution containing at least 500 p.p.m. hypochlorite (a 1:100 dilution of 5% household bleach) if this is not detrimental to the surface of dialysis machines. Advice on suitable disinfectants, and the concentration and contact time required, should be provided by the manufacturer.
  • If blood or fluid is thought to have seeped into inaccessible parts of the dialysis machine (e.g., between modules or behind blood pump), the machine should be taken out of service until it can be dismantled and disinfected.

Disinfection of the internal fluid pathways
  • It is not necessary for the internal pathways of single-pass dialysis machines to be disinfected between patients, even in the event of a blood leak. Some facilities may still opt to disinfect the dialysate-to-dialyzer (Hansen) connectors before the next patient.
  • Machines with recirculating dialysate should always be put through an appropriate disinfection procedure between patients.

Table 5. Steps to initiate concurrently and undertake following identification of a new HCV infection in a hemodialysis patient

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  1. Report the infection to appropriate public health authority.
    1. Assess risk factors of the affected patient in conjunction with public health.
  2. Determine HCV infection status of all patients in the hemodialysis unit.
    1. Test all patients treated in the center for HCV infection (Chapter 1) unless they are already known to have active infection. Follow-up and testing of patients who were treated in the center and those subsequently transferred or discharged may be warranted.
  3. Conduct a thorough root cause analysis of the infection and address infection control lapses.
    1. Perform rigorous assessments of staff infection control practices to identify lapses. This should minimally include assessments of hand hygiene and glove change practices; injectable medication preparation, handling, and administration; and environmental cleaning and disinfection practices.
    2. Share findings with all staff members and take action to address lapses. Staff education and retraining may be necessary.
    3. Consider hiring a consultant with infection prevention expertise to provide recommendations for improvement of practices and work flow and/or to help implement actions to address identified lapses.
    4. Conduct regular audits to ensure improved adherence to recommended practice.
    5. Demonstrations of cleaning adequacy such as use of Glo Germ (Moab, UT) or luminol might be helpful for staff education.
  4. Communicate openly with patients.
    1. Inform all patients of the reason for additional HCV testing and the results of their HCV tests.
    2. If transmission within the center is suspected or confirmed, inform all patients of this. Patients should also be made aware of steps being taken to assess and improve practices.

Table 6. Strategies to support adherence to infection control recommendations in hemodialysis centers

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  • It is important for the designers of dialysis units to create an environment that makes infection control procedures easy to implement. Adequate hand-washing facilities must be provided, and the machines and shared space should make it easy for staff to visualize individual treatment stations. Certain jurisdictions specify the area around a hemodialysis machine.
  • The unit should ensure that there is sufficient time between shifts for effective decontamination of the exterior of the machine and other shared surfaces.
  • The unit should locate supplies of gloves at enough strategic points to ensure that staff has no difficulty obtaining gloves in an emergency.
  • When selecting new equipment, ease of disinfection should be considered.
  • There are indications from the literature that the rate of failure to implement hygienic precautions increases with understaffing. Understaffing has been associated with hepatitis C outbreaks. Certain jurisdictions specify a specific nurse-to-patient ratio (e.g., 1:4 in France). Formal healthcare training of all staff should be required (e.g., in the US, technicians provide most direct hemodialysis care but lack standardized training). Dialysis units that are changing staff-to-patient ratios, or introducing a cohort of new staff, should review the implications on infection control procedures and educational requirements.
  • Resource problems should be handled by carrying out a risk assessment and developing local procedures. For example, if blood is suspected to have penetrated the pressure-monitoring system of a machine but the unit has no on-site technical support and no spare machines, an extra transducer protector can be inserted between the blood line and the contaminated system so that the dialysis can continue until a technician can attend to the problem.
The following are useful CDC and WHO informational resources to improve hand hygiene, environmental cleaning and disinfection and injection safety:
  • http://www.cdc.gov/dialysis/PDFs/collaborative/Env_notes_Feb13.pdf
  • http://www.cdc.gov/dialysis/PDFs/collaborative/Env_checklist-508.pdf
  • http://www.cdc.gov/dialysis/PDFs/dialysis-Station-Disinfect-Tool-508.pdf
  • http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-Hygiene-Observations.pdf
  • http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-InjectionSafety-Checklist.pdf
  • http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-InjectionSafety-Observations.pdf
  • Hand Hygiene in Outpatient and Home-based Care and Long-term Care Facilities: http://apps.who.int/iris/bitstream/handle/10665/78060/9789241503372_eng.pdf (See Figure 9 of document and p. 44-49)

Table 7. Key hygienic precautions for hemodialysis staff (in addition to standard precautions)

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Definitions
  • A “dialysis station” is the space and equipment within a dialysis unit that is dedicated to an individual patient. This may take the form of a well-defined cubicle or room, but there is usually no material boundary separating dialysis stations from each other or from the shared areas of the dialysis unit.
  • A “potentially contaminated” surface is any item of equipment at the dialysis station that could have been contaminated with blood, or fluid containing blood, since it was last disinfected, even if there is no visual evidence of contamination.
  • Education
  • A program of continuing education covering the mechanisms and prevention of crossinfection should be established for staff caring for hemodialysis patients.
  • Staff should demonstrate infection control competency for the tasks they are assigned. Infection control competencies (e.g., use of aseptic technique) should be assessed upon hire and at least yearly thereafter.
  • Appropriate information on infection control should also be given to nonclinical staff, patients, caregivers, and visitors. Patients should be encouraged to speak up when they observe an infection control practice that is concerning to them.

Hand hygiene
  • Staff should wash their hands with soap or an antiseptic hand-wash and water, before and after contact with a patient or any equipment at the dialysis station. An alcohol-based hand rub may be used instead when their hands are not visibly contaminated.
  • In addition to hand washing, staff should wear disposable gloves when caring for a patient or touching any potentially contaminated surfaces at the dialysis station. Gloves should always be removed when leaving the dialysis station.
  • Patients should also clean their hands with soap and water, or use an alcohol-based hand rub or sanitizer, when arriving at and leaving the dialysis station.

Injection Safety
  • Medication preparation should be done in a designated clean area.
  • All vials should be entered with a new needle and a new syringe, which should be discarded at point of use.
  • Medications should be administered aseptically, after wearing a disposable glove and disinfecting the injection port with an antiseptic.
  • Hand hygiene must be performed before and after administration of injection.
  • All single-dose vials must be discarded and multidose vials, if used, should not be stored or handled in the immediate patient care area.

Equipment management (for management of the dialysis machine, see Table 4)
  • Single-use items required in the dialysis process should be disposed of after use on 1 patient.
  • Nondisposable items should be disinfected after use on 1 patient. Items that cannot be disinfected easily (e.g., adhesive tape and tourniquets) should be dedicated to a single patient and discarded after use.
  • The risks associated with use of physiologic monitoring equipment (e.g., blood pressure monitors, weight scales, and access flow monitors) for groups of patients should be assessed and minimized. Blood pressure cuffs should be dedicated to a single patient or made from a light-colored, wipe-clean fabric.
  • Medications and other supplies should not be moved between patients (e.g., on carts or by other means). Medications provided in multiple-use vials, and those requiring dilution using a multiple-use diluent vial, should be prepared in a dedicated central area and taken separately to each patient. Items that have been taken to the dialysis station should not be returned to the preparation area.
  • After each session, all potentially contaminated surfaces at the dialysis station should be wiped clean with a low-level disinfectant if not visibly contaminated. Surfaces that are visibly contaminated with blood or fluid should be disinfected with a commercially available tuberculocidal germicide or a solution containing at least 500 p.p.m. hypochlorite (a 1:100 dilution of 5% household bleach).

Waste and specimen management
  • Needles should be disposed of in closed, unbreakable containers, which should not be overfilled. A “no-touch” technique should be used to drop the needle into the container, as it is likely to have a contaminated surface. If this is difficult due to the design of the container, staff should complete patient care before disposing of needles.
  • All blood and other biologic specimen handling should occur away from dedicated clean areas, medications, and clean supplies.
  • The used extracorporeal circuit should be sealed as effectively as possible before transporting it from the dialysis station in a fluid-tight waste bag or leak-proof container for disposal. Avoid draining or manipulating the used circuit. If it is necessary to drain the circuit to comply with local regulatory requirements, or to remove any components for reprocessing, this should be done in a dedicated area away from the treatment and preparation areas.

Chapter 4: Management of HCV-infected patients before and after kidney transplantation

4.1: Evaluation and management of kidney transplant candidates regarding HCV infection

We recommend kidney transplantation as the best therapeutic option for patients with CKD G5 irrespective of presence of HCV infection. (1, A)
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We suggest that all kidney transplant candidates with HCV be evaluated for severity of liver disease and presence of portal hypertension prior to acceptance for kidney transplantation. (2, D)
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We recommend that patients with HCV, compensated cirrhosis, and no portal hypertension undergo isolated kidney transplantation and that patients with decompensated cirrhosis or clinically significant portal hypertension (i.e., hepatic venous pressure gradient ≥10 mm Hg or evidence of portal hypertension on imaging or exam) undergo a simultaneous liver–kidney transplantation. (1, B)
Treatment of those with mild-to-moderate portal hypertension should be determined on a case-by-case basis.
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We recommend referring patients with HCV and decompensated cirrhosis for combined liver–kidney transplantation (1, B)
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Timing of HCV treatment in relation to kidney transplantation (before vs. after) should be based on donor type (living vs. deceased donor), wait-list times by donor type, center-specific policies governing the use of kidneys from HCV-infected deceased donors, and severity of liver fibrosis. (N, G)
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We recommend that all kidney transplant candidates with HCV be considered for DAA therapy, either before or after transplantation. (1, A)
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We suggest that HCV-infected kidney transplant candidates with a living kidney donor be considered for treatment before or shortly after transplantation depending on the anticipated timing of transplantation. (2, B)
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4.2: Use of kidneys from HCV-infected donors

We recommend that all kidney donors be screened for HCV infection with both immunoassay and NAT (if NAT is available). (1, A)
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After assessment of liver fibrosis, HCV-infected potential living kidney donors who do not have cirrhosis should undergo HCV treatment before donation if the recipient is HCV-uninfected; they can be accepted for donation if they achieve sustained virologic response (SVR) and remain otherwise eligible to be a donor. (N, G)
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We recommend that kidneys from HCV-infected donors be considered regardless of HCV status of potential kidney transplant recipients. (1, C)
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When transplanting kidneys from HCV-infected donors into HCV-uninfected recipients, transplant centers must ensure that patients receive education and are engaged in discussion with sufficient information to provide informed consent. Patients should be informed of the risks and benefits of transplantation with an HCV-infected kidney, including the need for DAA treatment. (N, G)
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When transplanting kidneys from HCV-infected donors into HCV-uninfected recipients, transplant centers should confirm availability of DAAs for initiation in the early post-transplant period. (N, G)
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4.3: Use of maintenance immunosuppressive regimens

We recommend that kidney transplant recipients being treated with DAAs be evaluated for the need for dose adjustments of concomitant immunosuppressants. (1, C)
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4.4: Management of HCV-related complications in kidney transplant recipients

We suggest that patients previously infected with HCV who achieved SVR before transplantation undergo testing by NAT 3 months after transplantation or if liver dysfunction occurs. (2, D)
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Kidney transplant recipients with cirrhosis should have the same liver disease follow-up as non-transplant patients, as outlined in the American Association for the Study of Liver Diseases (AASLD) guidelines. (N, G)
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HCV-infected kidney transplant recipients should be tested at least every 6 months for proteinuria. (N, G)
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We suggest that patients who develop new-onset proteinuria (either urine protein-creatinine ratio > 1 g/g or 24-hour urine protein > 1 g on 2 or more occasions) have an allograft biopsy with immunofluorescence and electron microscopy included in the analysis. (2, D)
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We recommend treatment with a DAA regimen in patients with post-transplant HCV-associated glomerulonephritis. (1, D)
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Figure 3. Proposed management strategy in a hepatitis C virus (HCV)–infected kidney transplant candidate

∗Clinically significant portal hypertension is defined as hepatic venous pressure gradient ≥10 mm Hg or evidence of portal hypertension on imaging or exam, e.g., ascites, esophageal varices, collaterals on imaging. F0, no scarring or fibrosis; SKLT, simultaneous kidney–liver transplantation.

Chapter 5: Diagnosis and management of kidney diseases associated with HCV infection

HCV-infected patients with a typical presentation of immune-complex proliferative glomerulonephritis can be managed without a confirmatory kidney biopsy. However, a biopsy may be indicated in certain clinical circumstances (Figure 4). (N, G)
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We recommend that patients with HCV-associated glomerulonephritis receive antiviral therapy. (1, A)
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We recommend that patients with HCV-associated glomerulonephritis, stable kidney function, and without nephrotic syndrome be treated with DAAs prior to other treatments. (1, C)
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We recommend that patients with cryoglobulinemic flare or rapidly progressive glomerulonephritis be treated with both DAAs and immunosuppressive agents with or without plasma exchange. (1, C)
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The decision whether to use immunosuppressive agents in patients with nephrotic syndrome should be individualized. (N, G)
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We recommend immunosuppressive therapy in patients with histologically active HCV-associated glomerulonephritis who do not respond to antiviral therapy, particularly those with cryoglobulinemic kidney disease. (1, B)
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We recommend rituximab as the first-line immunosuppressive treatment. (1, C)
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Figure 4. Indications for biopsy in patients with hepatitis C virus (HCV) and severe glomerulonephritis

Algorithm above assumes that patient with HCV and with HCV and chronic kidney disease (CKD) is already receiving direct-acting antiviral (DAA) treatment. Systemic signs of cryoglobulinemia include skin lesions such as purpura, arthralgias, and weakness. eGFR, estimated glomerular filtration rate; RPGN, rapidly progressive glomerulonephritis; SVR, sustained virologic response.

Recommendation Grading

Overview

Title

Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease

Authoring Organization

Publication Month/Year

November 18, 2022

Last Updated Month/Year

May 23, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives


The Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease represents a focused update of the 2018 guideline. This guideline is intended to assist the practitioner caring for patients with hepatitis C virus (HCV) and kidney disease, including those who are on dialysis therapy, and kidney transplant candidates and recipients. Topic areas for which recommendations are updated include: Chapter 2: Treatment of HCV infection in patients with CKD; Chapter 4: Management of HCV-infected patients before and after kidney transplantation; and Chapter 5: Diagnosis and management of kidney diseases associated with HCV infection. Previous chapters on the detection and evaluation of HCV in CKD (Chapter 1) and prevention of HCV transmission in hemodialysis units (Chapter 3) have been deemed current, and their content has therefore remained unchanged. Development of this guideline followed an explicit process of evidence review and appraisal. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Limitations of the evidence are discussed, with areas of future research also presented.

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D006526 - Hepatitis C, D019698 - Hepatitis C, Chronic, D012080 - Chronic Kidney Disease-Mineral and Bone Disorder, D007668 - Kidney

Keywords

chronic kidney disease, hepatitis C, CKD, hepatitis C virus, HCV