Although chronic hepatitis C increases mortality and morbidity in hemodialysis patients, it also prolongs the waiting time for renal transplantation since SVR cannot be obtained. Patients with untreated chronic hepatitis C are also under risk for complications such as liver cirrhosis and hepatocellular carcinoma (4). Chronic hepatitis C patients who underwent hemodialysis before DAAs, pegylated interferon alpha 2a monotherapy was administered. The use of other pegylated interferon alpha 2b and ribavirin used in the treatment of chronic hepatitis C was not recommended since they are excreted from the body by renal pathway and they accumulate and lead to secondary toxic side effects in patients with chronic renal failure ( CRF ) when the dose is increased for higher efficacy. In patients with CRF, the use of ribavirin was found inconvenient, and it was recommended to combine it with interferon doses of 200–800 mg through close surveillance. Due to the difficult application of interferon and the side effects of these drugs, the treatment was sometimes discontinued. In particular, patients who are considered for renal transplantation should be given antiviral therapy to negate or reduce HCV RNA. This is because high levels of HCV RNA increase the risk of resection of the renal transplanted.
The relationship of cryoglobulinemia, membranoproliferative glomerulonephritis, membranous glomerulonephritis and focal segmental glomerulosclerosis with HCV infection is known. In these patient groups, HCV treatment may also reduce the existing kidney failure.
The use of new DAAs is promising in this challenging group of patients. In our study, 20 hemodialysis patients with chronic hepatitis C were evaluated. Treatment was discontinued in 2 patients due to thrombus formation in AV fistula in the first month of DAA treatment. There is no data in the literature that DAA increases the risk of thrombus. Seventeen out of 18 patients received OBV/PTV/r + DSV ± ribavirin treatment for 12 weeks. Because the remaining one patient had cirrhosis and genotype 1, 24-week treatment was given. ETR was found to be 100%. SVR12 was evaluated in 14 out of 18 patients and found to be 100%. One of the ten patients whose SVR24 was evaluated had a relapse. This is similar to SVR24 in the average population. In a study conducted by Pockros et al. on 20 patients with chronic hepatitis C and stage 4 and 5 CRF, OBV/PTV/r + DSV ± ribavirin treatment was reported to be effective (5). Beinhardt et al. investigated the efficacy of DAA in a total of 25 patients with chronic hepatitis C, 10 of whom were on dialysis, eight of whom were renal transplant recipients, and seven of whom were kidney and orthotropic liver transplant recipients concurrently. Although the number of patients in the groups was small in the study, it was emphasized that DAA treatment was effective and usable in renal transplant patients (6).
In hemodialysis patients, the use of DAAs which's clearance occurs utilizing renal should be avoided to prevent the accumulation of drugs or metabolites. The clearance of sofosbuvir metabolite, an NS5B polymerase inhibitor, is renal and is not recommended to be used in those with glomerular filtration rate < 30 mL/ min / 1,73 m2 (7–8). Although the clearance of simeprevir and daclatasvir is from the liver, there are some studies reporting toxicity in some patients with severe renal failure (9–10).
Ombitasvir, paritaprevir, ritonavir, and dasabuvir are metabolized through the liver. In phase I trials, it was found that there was no need for dose adjustment in mild, moderate and severe renal failure (11). Today, ombitasvir/paritaprevir/ritonavir (25/150/100 mg once a day) and dasabuvir (250 mg twice a day) treatment is found to be effective in hemodialysis patients with chronic hepatitis C.