HCV-Associated Glomerulonephritis

CKD Managementmedium

A 50-year-old female with chronic hepatitis C presents with nephrotic range proteinuria and a recent kidney biopsy shows membranoproliferative glomerulonephritis (MPGN). What is the recommended treatment approach for her kidney disease?

  1. A.Initiate direct-acting antivirals (DAAs)Correct
  2. B.Start high-dose steroids
  3. C.Begin plasmapheresis
  4. D.Prescribe ACE inhibitors alone

Explanation

HCV-associated MPGN is usually an immune-complex glomerulonephritis, frequently associated with mixed cryoglobulinemia. The fundamental treatment is eradication of HCV with a direct-acting antiviral regimen, because viral clearance removes the antigenic stimulus driving immune-complex formation and can improve hematuria, proteinuria, and kidney function. KDIGO recommends antiviral therapy for all patients with HCV-associated glomerulonephritis. In patients with stable kidney function and no nephrotic syndrome, DAAs should be given before immunosuppression. In a patient with nephrotic syndrome, however, the decision to add immunosuppression must be individualized. Nephrotic-range proteinuria alone does not automatically require immunosuppression; DAAs may still produce renal remission. Rituximab, usually with or without glucocorticoids, should be considered when nephrotic syndrome is complicated by severe hypoalbuminemia, anasarca, thrombosis, progressive kidney dysfunction, or other major cryoglobulinemic manifestations. Patients with an acute cryoglobulinemic flare or rapidly progressive GN require DAAs plus immunosuppressive therapy, preferably rituximab, with plasma exchange considered in severe or life-threatening disease.

Why each option

A.
DAAs address the underlying HCV infection, potentially reversing renal damage.
B.
Steroids are not the first-line treatment for HCV-associated MPGN.
C.
Plasmapheresis is not typically used for HCV-associated MPGN.
D.
ACE inhibitors alone do not address the underlying viral cause.

Reference: KDIGO 2022 Clinical Practice Guideline, Chapter 5

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