Is there a role for treating hepatitis C in a patient who is being evaluated for kidney transplantation? That is, will the posttransplantation immune suppression aggravate the hepatitis C such that treatment should be considered before the procedure, if possible, in a person whose liver biopsy is suggestive of treatable disease?

Response from  Adrian M. Di Bisceglie, MD, FACP 
Professor of Internal Medicine, Chief of Hepatology, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, Missouri

The issue of hepatitis C in patients receiving dialysis or being considered for renal transplantation remains problematic. Chronic hepatitis C virus infection is relatively common (as high as 20%) in this population.^[1] The effect of hepatitis C on the outcome of transplantation is also somewhat uncertain, but it has been associated with poorer clinical outcomes. Indeed, some institutions consider advanced liver disease due to hepatitis C a contraindication to renal transplantation, and liver biopsy is routinely done to assess the degree of hepatic fibrosis.

Treatment with interferon-based therapies in the setting of chronic renal failure has not been very successful. Studies done in this setting have usually been confined to very small numbers of subjects, and rates of sustained virologic response have been quite low (usually < 20%).^[2] In addition, the use of ribavirin is contraindicated in patients with renal failure. Because ribavirin is excreted by the kidney, it tends to accumulate in patients with renal failure and even modest or low doses may cause profound hemolytic anemia.^[3] Thus, the clinician is left with the option of using pegylated interferon alone, which has only limited efficacy. Finally, the use of interferon after renal transplantation has been associated with a significantly increased risk of rejection of the renal graft.

In summary, antiviral therapy with interferon and ribavirin is not routinely used in patients on dialysis or after renal transplantation. However, interferon (preferably, pegylated interferon) could be considered selectively, on a patient-by-patient basis.