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      Manejo de la infección por el VHC en la enfermedad renal crónica Translated title: Management of HCV infection in chronic kidney disease

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          Abstract

          La prevalencia de la infección crónica por el virus de la hepatitis C (VHC) en pacientes con enfermedad renal crónica es mayor que en la población general. En hemodiálisis, se estima una prevalencia del 13%, con una amplia variabilidad geográfica y entre las unidades de un mismo país. La biopsia hepática es una herramienta útil para decidir el inicio de la terapia antiviral y excluir causas concomitantes de disfunción hepática, como la hepatopatía grasa no alcohólica, cuya incidencia está en auge, y la hemosiderosis, que pueden afectar a la progresión de la enfermedad y condicionar la respuesta al tratamiento antiviral; además, la vía transyugular se puede utilizar para medir el gradiente de presión venoso hepático y confirmar la existencia de hipertensión portal. La hepatitis crónica por el VHC ha demostrado reducir la supervivencia en hemodiálisis y en el trasplante renal, así como la supervivencia del injerto. Constituye la cuarta causa de mortalidad y la principal causa de disfunción hepática postrasplante renal. El VHC se comporta como un factor de riesgo independiente para la aparición de proteinuria, aumenta el riesgo de desarrollar diabetes, una glomerulonefritis de novo o una nefropatía crónica del injerto, de empeorar la enfermedad hepática y de provocar un mayor número de infecciones. También se ha descrito un incremento de la frecuencia de hepatitis colestásica fibrosante que, junto a la evolución acelerada a cirrosis, puede elevar significativamente la morbimortalidad y conllevar la necesidad de un trasplante hepático. Además, la inmunosupresión en el trasplante renal predispone a la reactivación del VHC. Sin embargo, como la farmacocinética del interferón y la ribavirina está alterada en la insuficiencia renal y su uso tiene efectos adversos sobre la función y la supervivencia del injerto, la terapia combinada se limita a los individuos no trasplantados con un filtrado glomerular estimado mayor de 50 ml/min y en diálisis suele emplearse el interferón en monoterapia. El hecho de que una cuarta parte de los pacientes VHC-positivos evaluados para trasplante renal tenga fibrosis en puente o cirrosis en la biopsia hepática puede renovar el planteamiento del tratamiento pretrasplante renal.

          Translated abstract

          The prevalence of chronic infection with the hepatitis C virus (HCV) in patients with chronic kidney disease is higher than in the general population. The estimated prevalence is 13% in haemodialysis, with wide variations geographically and between units in the same country. A liver biopsy is a useful tool for deciding whether to start antiviral therapy and to exclude concomitant causes of liver dysfunction. Examples of this include nonalcoholic fatty liver disease, whose incidence is on the rise, and haemosiderosis, which may affect the progression of the disease and determine the response to antiviral therapy. In addition, the transjugular approach can be used to measure the hepatic venous pressure gradient and confirm the existence of portal hypertension. Chronic hepatitis due to HCV has been shown to reduce survival in haemodialysis, renal transplantation and graft survival. It is the fourth leading cause of death and the leading cause of post-renal transplantation liver dysfunction. HCV behaves as an independent risk factor for the occurrence of proteinuria; it increases the risk of developing diabetes mellitus, de novo glomerulonephritis and chronic allograft nephropathy; it leads to a deterioration in liver disease and causes a greater number of infections. An increased frequency of fibrosing cholestatic hepatitis has also been described which, together with the rapid evolution to cirrhosis, can significantly increase morbidity and mortality and lead to the need for liver transplantation. In addition, immunosuppression in renal transplantation predisposes a reactivation of HCV. However, as the pharmacokinetics of interferon and ribavirin is impaired in kidney failure and their use has adverse effects on function and graft survival, a combination therapy must be limited to non-transplanted individuals with an estimated glomerular filtration rate greater than 50ml/min, and with the interferon being used as monotherapy in dialysis. The fact that a quarter of HCV-positive patients evaluated for a renal transplant have bridging fibrosis or cirrhosis in the liver biopsy may renew renal pre-transplant treatment planning.

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          Most cited references 189

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          Diagnosis, management, and treatment of hepatitis C: an update.

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            Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups.

            Our aim was to assess the natural history of liver fibrosis progression in hepatitis C and the factors associated with this progression. We recruited 2235 patients from the Observatoire de l'Hépatite C (OBSVIRC) population, the Cohorte Hépatite C Pitié-Salpétrière (DOSVIRC) population, and the original METAVIR population. All the patients had a biopsy sample compatible with chronic hepatitis C as assessed by the METAVIR scoring system (grades the stage of fibrosis on a five-point scale, F0 = no fibrosis, F4 = cirrhosis, and histological activity on a four-point scale, A0 = no activity, A3 = severe activity). No patient had received interferon treatment before the liver biopsy sample was obtained. We assessed the effect of nine factors on fibrosis progression: age at biopsy; estimated duration of infection; sex; age at infection; alcohol consumption; hepatitis C virus C (HCV) genotype; HCV viraemia; cause of infection; and histological activity grade. We defined fibrosis progression per year as the ratio between fibrosis stage in METAVIR units and the duration of infection (1 unit = one stage, 4 units = cirrhosis). The median rate of fibrosis progression per year was 0.133 fibrosis unit (95% CI 0.125-0.143), which was similar to the estimates from previous studies (0.146 to 0.154). Three independent factors were associated with an increased rate of fibrosis progression: age at infection older than 40 years, daily alcohol consumption of 50 g or more, and male sex. There was no association between fibrosis progression and HCV genotype. The median estimated duration of infection for progression to cirrhosis was 30 years (28-32), ranging from 13 years in men infected after the age of 40 to 42 years in women who did not drink alcohol and were infected before the age of 40. Without treatment, 377 (33%) patients had an expected median time to cirrhosis of less than 20 years, and 356 (31%) will never progress to cirrhosis or will not progress for at least 50 years. The host factors of ageing, alcohol consumption, and male sex have a stronger association with fibrosis progression than virological factors in HCV infection.
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              Acute viral hepatitis increases liver stiffness values measured by transient elastography.

              Liver tissue alterations other than fibrosis may have an impact on liver stiffness measurement. In this study we evaluated 18 patients without a previous clinical history of liver disease, consecutively admitted for acute viral hepatitis. In each patient, aminotransferase determination and liver stiffness measurement were performed on the same study day, at 3 different points: (1) peak increase in aminotransferase; (2) aminotransferase 50% or less of the peak; (3) aminotransferase levels
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Journal
                nefrologia
                Nefrología (Madrid)
                Nefrología (Madr.)
                Sociedad Española de Nefrología (Cantabria, Santander, Spain )
                0211-6995
                1989-2284
                2011
                : 31
                : 3
                : 260-267
                Affiliations
                Alcázar de San Juan orgnameComplejo Hospitalario La Mancha-Centro orgdiv1Servicio de Nefrología
                Alcázar de San Juan orgnameComplejo Hospitalario La Mancha-Centro orgdiv1Servicio de Aparato Digestivo
                Article
                S0211-69952011000300005

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 115, Pages: 8
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