Can patients with HBV or HCV glomerulopathies eventually undergo kidney transplantation?
As discussed earlier, both types of glomerulopathies that occur with HCV and HBV are directly related to active viral replication.
In the case of HBV, it results from immune complexes, whereas in the case of HCV, it is associated with the development of cryoglobulinemia. If transplantation is considered in these cases, one of the first questions to ask is: “What is the status of the liver involvement from these viruses?”
The answer to this question is crucial in order to define whether the patient needs a combined liver–kidney transplant or a kidney transplant only. The presence of cirrhosis on biopsy would automatically mandate that a combined transplant be performed.
Without a liver biopsy it is not always possible to estimate whether or not cirrhosis is present. Evaluation of liver function studies, clotting parameters, and the presence or absence of portal hypertension are all useful in the clinical assessment for the presence of cirrhosis.
If the patient has stable liver function and no evidence of cirrhosis, then a kidney transplant alone can be considered. The second question to answer is: “How active is the viral disease?” It would be counterproductive to perform a transplant on a patient and provide intensive immunosuppression if there is uncontrolled viral proliferation. The risks of exacerbating viral activity can lead to either post-transplant immune complex kidney disease or post-transplant liver disease. One of the most common causes of death in patients with HCV after transplantation is liver disease. There is an increased risk of hepatoma in patients with active HCV or HBV, and routine monitoring of alpha fetoprotein levels is required during follow-up.
In the case of HCV, as long as there is no sign of cirrhosis, a new strategy in the use of DAAs is not to treat the patient while they are on the waiting list, and sign them up to receive an HCV positive donor kidney. Then after the transplant they are started on DAA therapy. The waiting list for an HCV-positive organ donor is significantly shorter than waiting for a routine cadaver donor.
