Hepatitis C and management of end-stage renal disease.

The USA differs in at least two ways from European ESRD patient [7]. Remaining on dialysis for additional centres discussed elsewhere in this Supplement. These years in an attempt to eradicate the hepatitis C virus are two important issues concerning hepatitis C and may carry a greater mortality risk in the USA than management of end-stage renal disease ( ESRD). in Europe. Firstly, whereas some European centres perform active With these two points in mind, then, I would like screening of dialysis patients for hepatitis C [1], much to present a somewhat contrary view concerning manless routine screening is done in the USA. The Centers agement of the ESRD patient who is positive for for Disease Control (CDC ) feel that such screening is hepatitis C and does not have decompensated liver not necessary for dialysis units at the current time failure. [2,3]. This lack of routine screening means that we Today’s treatments for hepatitis C in ESRD patients cannot provide the same type of temporal comparisons are improving rapidly, but certainly leave much to be that have been reported for Spain and Brussels. These desired. For the non-ESRD patient, results look very reports demonstrate a marked decrease in the incidence good with combination therapy, using ribavirin and of hepatitis C for these countries. Staff at many dialysis interferon a. The haemolytic anaemia associated with units in the USA believe they already have a very low ribavirin in combination with interferon is worrisome incidence of hepatitis C in their units. This firmly held for patients who already have renal failure-induced belief would be more convincing if yearly (or twice- anaemia and a high incidence of coronary artery yearly) screening data supported it. I will present data disease [8,9]. from a large transplant centre to which 3796 ESRD Elimination (without relapse) of the hepatitis C virus dialysis patients (mostly from the south-eastern USA) among genotypes 1 a and b (which are the predominant were referred between January 1993 and August 1999. genotypes of infection found in the USA) is not Over seven per cent of these patients were positive for impressive with interferon a alone. It is likely that hepatitis C antibody, with an average referral time combination therapy eventually will be needed for after only 1.5 years on dialysis. The impression from effective hepatitis C therapy and it is essential that that sample and time period is that there has not been such combinations of drugs be evaluated for safety in the same success in reducing hepatitis in our dialysis the ESRD population. units as seen in Europe. It is even possible that the The length of time required for treatment appears incidence of hepatitis C is increasing in dialysis units to be >1 year, and the number of patients who are in the USA, but without routine screening this is able to complete treatment is amazingly low. Even that merely speculation. It is not clear, without screening, minority who are able to complete treatment and in if the prevalence of hepatitis C is increasing, decreasing whom detectable virus is eliminated seem to have an or not changing in dialysis units in the USA. impressive rate of recurrence after exposure to the Secondly, survival of patients on dialysis in the USA immunosuppressive agents needed for kidney transis worse than that seen in some European countries plantation [10]. Others have suggested that kidney [4,5]. Indeed, we seem to see more deaths from athero- transplantation can be accomplished without such high sclerotic vascular disease than is seen in Spain. There rates of recurrence of viraemia [11]. Thus, current have been a number of suggestions about the reasons treatment is seldom effective for the most common for higher mortality rates in the USA [6 ]. The reason genotypes of virus seen in the USA. It is costly, is for bringing it up in this discussion, however, is that seldom completed even by highly motivated patients higher mortality rates alter my views concerning the (study patients), has serious side effects and, even when urgency to perform transplants in ESRD patients. judged successful, is not certain to keep patients free Transplantation decreases the risk of death for an of virus after transplantation. Progress in treatment, however, appears to be rapid.