Université Paris Descartes; Hepatology Department, Cochin Hospital, APHP; INSERM U1223, UMS-20 and Center for Translational Science, Institut Pasteur, Paris, France.
Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
Nat Rev Nephrol. 2019 Feb;15(2):73-86. doi: 10.1038/s41581-018-0081-8.
Hepatitis C virus (HCV) infection is more prevalent and is associated with higher mortality in patients receiving dialysis and in kidney transplant recipients than in the general population. Kidney transplant recipients who are HCV-positive are also at higher risk of allograft and liver failure than are HCV-negative recipients. Moreover, HCV infection is associated with a higher incidence and faster progression of diabetes mellitus and chronic kidney disease (CKD), as well as a higher incidence of systemic (especially cardiovascular) complications. The finding that these complications of HCV infection are attenuated in patients who achieve a sustained virologic response (SVR) emphasizes the need to treat patients with CKD who are HCV-positive with oral antiviral therapies. Fortunately, the available evidence suggests that a SVR can be achieved in >95% of patients with late-stage CKD and in kidney transplant recipients. According to international guidelines, all patients with CKD and HCV infection should be considered for treatment with direct acting antivirals (DAAs), prioritizing those with symptomatic cryoglobulinaemic vasculitis, extensive liver fibrosis and stage 4-5 CKD. DAA treatment can be delayed until after transplantation in recipients whose waiting time is markedly reduced by accepting an HCV-positive organ. An emerging issue is the long-term renal safety of DAAs, which requires a re-appraisal. Overall, the elimination of HCV from patients with CKD now seems to be achievable, provided that DAA treatment is coupled with reinforced hygienic precautions to prevent reinfections in dialysis units.
丙型肝炎病毒（HCV）感染在接受透析和肾移植受者中的发生率高于普通人群，与死亡率更高相关。HCV 阳性的肾移植受者发生移植物和肝功能衰竭的风险也高于 HCV 阴性受者。此外，HCV 感染与糖尿病和慢性肾脏病（CKD）的发病率更高和进展更快以及全身性（尤其是心血管）并发症的发病率更高相关。在实现持续病毒学应答（SVR）的患者中，HCV 感染的这些并发症减轻的发现强调了需要用口服抗病毒疗法治疗 HCV 阳性的 CKD 患者。幸运的是，现有证据表明，晚期 CKD 患者和肾移植受者中超过 95%的患者可以实现 SVR。根据国际指南，所有 CKD 和 HCV 感染患者均应考虑用直接作用抗病毒药物（DAA）治疗，对有症状的冷球蛋白血症性血管炎、广泛的肝纤维化和 4-5 期 CKD 的患者应优先考虑。如果接受 HCV 阳性器官可以明显缩短等待时间，则可以在受者移植后延迟 DAA 治疗。一个新出现的问题是 DAA 的长期肾脏安全性，这需要重新评估。总体而言，只要 DAA 治疗与强化卫生预防措施相结合以防止透析单位中的再感染，就可以实现从 CKD 患者中消除 HCV。
