Successful treatment of chronic hepatitis C virus genotype 1b infection of a patient with compensated cirrhosis after renal transplantation using daclatasvir-asunaprevir combination therapy: a case report and literature review

Background: Hepatitis C virus (HCV) infection a major disorder that is not only a liver-related disease but also a cardiovascular complication in renal transplant recipient. Interferon-based therapy is a contraindication after transplantation because interferon is possibly induced to graft rejection. Only limited anecdotal evidence exists on the antiviral efficacy and tolerability of HCV direct acting antivirals (DAAs) in patients with chronic kidney disease (CKD), including renal transplant recipients. Then, we report a successful treatment case of chronic hepatitis C virus genotype 1b infection in a patient with compensated cirrhosis after renal transplantation using daclatasvirasunaprevir combination therapy and reviewed the literature. Case presentation: A 64-year-old female renal transplantation (RT) recipient complicated with compensated cirrhosis due to hepatitis C virus (HCV) genotype 1b infection was treated with interferon (INF)–ribavirin-free combinations of DAAs such as daclatasvir plus asunaprevir. She was medicated with daclatasvir 60 mg once a day and asunaprevir 100 mg twice a day for 24 weeks. Her initial HCV RNA was log10 6.2 IU/ml, and HCV RNA was not detected from 10 weeks. She achieved a sustained virological response at 24 weeks (SVR24). During this therapy, her serum creatinine and tacrolimus trough level were slightly elevated, but those abnormalities were returned to the basal level by decreasing the dose of extended-release tacrolimus. No other adverse event requiring discontinuation of the treatment occurred. Conclusions: Almost all DAA treatments of HCV infection in renal transplant recipients have been sofosbuvir-based antiviral treatment, but we considered that daclatasvir-asunaprevir combination therapy is suitable to renal-impaired recipient because sofosbuvir is contraindicated in patients whose estimated GFR is <30 ml/min/1.73 m, and both of daclatasvir and asunaprevir are mainly primarily metabolized by the liver. We showed excellent effect daclatasvirasunaprevir combination therapy to a renal transplant recipient with chronic HCV infection and reviewed the literature. * Correspondence: [email protected]; [email protected] Department of Internal Medicine, Fujita Memorial Hospital, 5-7, Houei, Fukui 910-0004, Japan © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fig. 1 Abdominal CT findings. Marked splenomegaly was observed, and a small amount of ascites were present on the surface of the liver. No liver atrophy or tumors were found Miyazaki and Miyagi Renal Replacement Therapy (2016) 2:61 Page 2 of 6 Background Chronic hepatitis C virus (HCV) infection progresses to hepatic dysfunction, cirrhosis, and hepatocellular carcinoma, and the target of the therapy is elimination of the virus [1]. Since Omata et al. [2] reported the effectiveness of interferon (IFN) in 1991, it has been the standard therapy for chronic HCV infection until the appearance of direct acting antivirals (DAAs) [3]. However, the use of IFN is prohibited in renal transplantation (RT) patients because IFN could induce acute rejection. Kidney Disease Improving Global Outcomes (KDIGO) recommends IFN therapy for recipients with HCV infection before RT [4]. Therefore, there has been no choice of treatment in post-transplant patients with chronic HCV infection. Here, we report the successful treatment of a patient with oral IFNand ribavirin-free DAAs (daclatasvir plus asunaprevir) for compensated cirrhosis due to HCV genotype 1b infection after RT. These new DAAs may change the natural history of HCV infection after RT. However, there is as yet no evidence to support the use of DAAs in the RT setting because the understanding of DAA metabolism and drug–drug interaction is insufficient. In addition, there have been no large studies of DAA treatment in this patient group [5].