Cryoglobulinemia-Induced Kidney Injury Secondary to Refractory Hepatitis C

Document Type

Conference Proceeding

Publication Date

10-25-2023

Publication Title

Am J Gastroenterol

Abstract

Introduction: Despite hepatitis C (HCV) antiviral therapy treatment, not all patients achieve sustained virologic response (SVR) and some can go on to develop chronic HCV and cirrhosis. Chronic HCV has many implications, one of which is an association with glomerular disease. We present a case of refractory HCV manifesting with cryoglobulinemia related kidney injury resulting in listing for simultaneous liver kidney transplant (SLK). Case Description/Methods: A 62 year old woman with Hepatitis C treated with 12 weeks of sofosbuvir / velpatasvir without SVR complicated by HCV and alcoholic cirrhosis with esophageal varies and recurrent ascites presents for nausea, vomiting and fatigue with worsening ascites. She undergoes recurrent paracenteses with negative cultures however cell counts are concerning for spontaneous bacterial peritonitis (SBP) so she is started on ceftriaxone and switched to prophylaxis. Infectious and imaging workup are unremarkable. Course complicated by acute kidney injury initially thought to be hepatorenal syndrome so she is started on albumin, midodrine and octreotide. However with minimal renal improvement, she is started on dialysis. Her renal function continues to decline and she later develops a reticular rash in her lower extremities concerning for vasculitis. Renal biopsy is performed and shows mixed cryoglobulinemic glomerulonephritis. Cryoglobulins are found in the serum and complement levels are also low. Skin biopsy is also performed and is negative for cryoglobulin. Post biopsies, she is restarted on sofosbuvir / velpatasvir daily for 24 weeks with plan to continue dialysis until she completes course of this treatment with repeat HCV RNA levels periodically. In the interim she is listed for SLK however is not deemed candidate until HCV retreated. Discussion: HCV RNA and HCV IgG antigen-antibody complexes are concentrated in cryoprecipitate and are an immunologic stimulus to the kidney. By eradicating HCV, a stimulus for renal insult is theoretically removed. Though this patient received treatment for HCV in the past, by not achieving SVR she continues to have a persistent nidus for kidney insult and thus warrants retreatment. Sofosbuvir-containing regimens are one of the primary treatment regimen for HCV infection and are renally cleared. Dialysis can clear these compounds so they should be administered post dialysis. Despite HCV viral clearance aiming to improve renal involvement, unfortunately this may not lead to clinical remission.

Volume

118

Issue

10

First Page

S2326

Find It @ Sladen

Share

COinS