Question: A 61 year old female with ESRD and HCV (stage 2 liver fibrosis) is being considered for kidney transplantation. The patient inquires about antiviral treatment prior to her kidney transplant, since it is relatively contraindicated post kidney transplant. It can cause renal allograft rejection. What regimen should you prescribe?
A. Peg-interferon 180 mcg/wk & Ribavirin 1200 mg/d
B. Peg-interferon 180 mcg/wk & half-dose Ribavirin
C. Peg-interferon 180 mcg/wk & no Ribavirin
D. do not attempt treatment with ESRD, it is futile
Answer: One of the negative predictors of sustained virologic response (SVR) is chronic renal insufficiency (CRI). Other negative predictors include black race, genotype 1, insulin resistance, and advanced fibrosis. Although this patient has renal disease, treatment can still be considered.
Peg-interferon doses need not be reduced at the outset of treatment, unless there is significant cell-line depression. In the case of ESRD, anemia could be present. Ribavirin, on the other hand, is contra-indicated in ESRD, as it can cause severe hemolytic anemia.
Therefore, if treatment is considered here, it should be be Peg-interferon monotherapy. There is robust evidence that monotherapy is inferior to dual therapy with Ribavirin, so her SVR rate will be low. Nevertheless, if this is her only chance to clear the virus, an attempt is worthwhile. For a nice review of HCV antiviral treatment in the CRI setting, click on the link below: