Spotlight on HCV guidance

In the past month, three groups discussed new recommendations on hepatitis C virus (HCV) screening and treatment in the general population and in patients with chronic kidney disease (CKD).

First, on Aug. 27, the U.S. Preventive Services Task Force (USPSTF) released a draft recommendation statement on screening for HCV infection. If finalized, the B-grade statement would recommend screening all adults ages 18 to 79 years at least once, including pregnant adults. Clinicians may want to consider screening patients younger than age 18 years and older than age 79 years who are at high risk for the infection, the draft recommendation stated.

The recommendation incorporates new evidence and would replace the 2013 USPSTF statement on this issue, also a B-grade statement, which recommended screening adults at high risk for HCV infection, as well as one-time screening for adults born between 1945 and 1965. Since 2013, the prevalence of HCV infection has increased in younger patients and remains relatively high in older adults, while the treatment of HCV continues to evolve, the USPSTF noted. “As a result, the USPSTF concluded that broadening the age for HCV screening beyond its previous recommendation will identify infected patients at earlier stages of disease who could greatly benefit from effective treatment before developing complications,” the Task Force wrote.

The Kidney Disease: Improving Global Outcomes (KDIGO) work group's 2018 clinical practice guideline was summarized Sept. 24 by Annals of Internal Medicine. The guideline is an extensive update of the group's 2008 guideline on HCV infection in CKD, as “the approach to HCV management has evolved dramatically in the past 10 years,” the authors wrote.

The updated guideline includes 66 recommendations for the prevention, diagnosis, evaluation, and treatment of HCV infection in patients with CKD. It recommends screening all patients for HCV infection at the time of initial evaluation of CKD by using an immunoassay and, if positive, nucleic acid testing. Infected patients should be evaluated for antiviral therapy, and an interferon-free regimen is recommended.

The choice of specific regimen should be based on HCV genotype (and subtype), viral load, treatment history, drug-drug interactions, glomerular filtration rate (GFR), stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities. Patients with a GFR of 30 mL/min/1.73 m² or greater (CKD G1-G3b) may be treated with any licensed direct-acting antiviral (DAA)-based regimen, whereas those with a GFR below 30 mL/min/1.73 m² (CKD G4-G5D) should be treated with a ribavirin-free DAA-based regimen, the guideline said.

Finally, on Sept. 4, the American Society for Clinical Pathology added five new practices to question or avoid as part of the Choosing Wisely campaign, one of which was performing repeat HCV antibody testing in patients with a previous positive HCV test. A positive HCV antibody test remains positive for life, therefore, repeat HCV antibody testing adds cost but no benefit and should not be performed, according to the guidance. Instead, the group recommended ordering HCV viral load testing to assess patients who have had a remote and resolved HCV infection in whom reinfection is suspected.