Treatment of hepatitis B in patients with chronic kidney disease Chrysoula L. Pipili 1 , George V. Papatheodoridis 2 and Evangelos C. Cholongitas 3 1 Department of Nephrology, Aretaieion University Hospital, Athens, Greece; 2 2nd Department of Internal Medicine, Athens University Medical School, Hippokration General Hospital of Athens, Athens, Greece and 3 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece Although the prevalence of chronic hepatitis B virus (HBV) infection in patients with chronic kidney disease remains low in developed countries, clinicians should be aware of the rationale for treatment in this setting. This patient population presents particular features and various complicating conditions requiring special treatment strategies. Interferon, the standard treatment for HBV infection, has been poorly tolerated by patients with chronic kidney disease, has presented relatively low efficacy, and has posed renal transplant recipients under the risk of acute rejection. The advent of effective nucleos(t)ide analogs (NAs) has offered the opportunity to minimize the consequences of HBV infection in HBV-positive patients with chronic kidney disease. Combination with immunosuppressive agents might be considered in cases of rapid renal function deterioration and/or severe proteinuria. Among the newer NAs, entecavir may be preferred, because of its high potency, high genetic barrier to resistance, and favorable renal safety profile. However, entecavir presented low efficacy in case of lamivudine or telbivudine resistance, and thus tenofovir may be a better option in that setting. All HBsAg-positive candidates should be treated with NAs before renal transplantation in order to maintain undetectable HBV DNA, reduce liver fibrosis, and prevent hepatic decompensation after renal transplantation. This review summarizes updated issues related to treatment of chronic HBV infection in all categories of population with chronic kidney disease (those exhibiting HBV-associated glomerular disease, those treated with hemodialysis, as well as renal transplant candidates, donors, and recipients). Kidney International (2013) 84, 880–885; doi:10.1038/ki.2013.249; published online 19 June 2013 KEYWORDS: chronic kidney disease; hemodialysis; hepatitis B; transplantation Chronic infection with hepatitis B virus (HBV) in patients with chronic kidney disease represents a distinct and challenging clinical entity. The special characteristics of this patient group (immunosuppressive effect of renal failure, polypharmacy, susceptibility for nosocomial transmission, immunosuppressive therapy after renal transplantation) and the related changes in clinical course of liver disease often have long-term implications on morbidity and mortality and affect the patients’ management. 1 To date, the information about the use of antiviral therapy in patients with chronic kidney disease is scarce, as such patients were not included in the phase II or III randomized trials. Thus, several clinical questions about the optimal management of these patients remain unanswered. This review focuses on the current clinical knowledge for the treatment of chronic HBV patients with chronic kidney disease, including cases before end-stage renal disease, on maintenance hemodialysis, and in the renal transplantation setting. GENERAL TREATMENT RECOMMENDATIONS Treatment options for renal patients with chronic HBV infection are complex, being dictated by the overall clinical picture and best conducted by multidisciplinary approach and thorough renal monitoring. Very limited data—mostly case series—are available to guide therapy in this patient setting. Antiviral treatment is indicated in hepatitis B surface antigen (HBsAg)–positive patients with evidence of active liver disease based on aminotransferases and serum HBV DNA levels with or even without a liver biopsy. Serum HBV DNA levels of 2000–20,000IU/ml have been proposed as the threshold to start treatment, whereas it remains to be investigated whether the upper limit of normal for amino- transferases needs to be adjusted downward among patients on hemodialysis. 2 Although the ideal antiviral treatment would result in HBsAg seroconversion and HBV DNA clearance, the real goal in patients with chronic kidney disease is viral replication suppression (particularly in candidates for renal transplantation) and thus the prevention of viral complications (such as cirrhosis and hepatocellular carcinoma) and proteinuria remission with preservation of renal function. mini review http://www.kidney-international.org & 2013 International Society of Nephrology Correspondence: Evangelos C. Cholongitas, 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, 49, Konstantinopoleos Street, 54642, Thessaloniki, Greece. E-mail: [email protected] Received 20 January 2013; revised 17 April 2013; accepted 25 April 2013; published online 19 June 2013 880 Kidney International (2013) 84, 880–885
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