Management of hepatitis B and C in special population

Table 1 Hepatitis B in chronic kidney disease

	HBV and CKD
Prevalence of CKD in HBV patients	8%
Pathogenesis	Direct cytopathic effect of the HBV on cells of the kidney; Glomerular deposition of immune complexes; Virus-induced specific immunological effector mechanisms (specific T lymphocyte or antibody); CHB induced cytokine toxicity on renal tissue
Risk factors	Smoking, diabetes mellitus, hypertension, cirrhosis.
Common type of renal injury	Membranous GN; Membranoproliferative GN; Polyarteritis nodosa; IgA nephropathy
Treatment indication	HBV DNA 2000 IU/mL with or without elevated ALT; Liver biopsy-chronic hepatitis with > F1 fibrosis; If planned for renal transplant, initiate NUCs 2 wk before transplant even if DNA ≤ 2000 IU/mL
Safe drugs	TAF (no dose adjustment till eGFR < 15 mL); ETV and TDF (If GFR > 50: ETV 0.5 mg/d or TDF 300 mg/d; GFR 30-49: ETV 0.5 mg alternate day or TDF 300 mg alternate day; GFR 10-29: ETV 0.5 mg once in 3 d and TDF 300 mg once in 3 d; on HD-ETV 0.5 mg or TDF 300 mg after every dialysis or every 7 d)
Prevention	Regular screening; Vaccination (double dose); Serology should be performed every year, and a booster dose should be given if antibody titers are below 10 mIU/mL.

HBV: Hepatitis B virus; CKD: Chronic kidney disease; CHB: Chronic hepatitis B; NUC: Nucleos(t)ide analogues; TDF: Tenofovir disoproxil fumarate; TAF: Tenofovir alafenamide fumarate; ETV: Entecavir; GFR: Glomerular filtration rate; GN: Glomerulonephritis; ALT: Alanine transaminase.

Table 2 Hepatitis C in chronic kidney disease

	HCV and CKD
Prevalence of HCV in CKD patients	10%-14%
Pathogenesis	Pronounced leucocyte infiltration of glomerular capillaries and the precipitation of immunoglobulins, immune complexes/cryoglobulins; Glomerular deposition of HCV protein
Risk factors	Age, male gender, lack of HCV treatment, concomitant HAV/HBV infection; Diabetes mellitus
Common types of renal injury	Membranous GN; Membranoproliferative GN; Essential mixed cryoglobulinemia (type II); IgA nephropathy; Polyarteritis nodosa
Treatment indication	Viremia
Safe drugs	Glecapravir + Pibrentasvir; Sofofbuvir + Velpatasvir; Sofosbuvir + Ledipasvir; Grazoprevir + Elbasvir
Prevention	Regular screening and strict infection control procedures; Effective dialysis machine decontamination

HCV: Hepatitis C virus; CKD: Chronic kidney disease; HAV: Hepatitis A virus; GN: Glomerulonephritis.

Table 3 Hepatitis B and Hepatitis C in pregnancy

	HBV	HCV
MTCT	90% if HBeAg+; 10% if HBeAg-; Directly proportional to viral load	6%; Higher risk with concomitant HIV infection, higher viral load, IV drug abuse; Higher risk with PROM and CVS
Treatment	TDF is safe; Can be initiated in third trimester	DAAs are not approved; Treat prior to pregnancy or 6 mo postpartum
Effect on pregnancy outcome	None	Preterm birth, ICP
Effect of pregnancy on virus	None	None
Effect of postpartum (immune restoration) on virus	Risk of HBV flares	Higher chance of viral clearance
Timing of transmission	Intrapartum > intrauterine	Intrapartum > intrauterine
C-section for all	Not indicated	Not indicated
Breastfeeding	Not contraindicated	Not contraindicated
Prevention	Active and passive immunization to child prevents 90% of transmission; Failure is nearly 15% if the viral load in mother is > log6	None
Confirming the perinatal transmission	Persistence of HBsAg in newborn for > 6 mo	Anti-HCV positive at 18 mo of age HCV RNA positive after 2 mo on 2 different samples
Confirming the protection	Anti-HBs titers at 9 mo	Negative Anti-HCV at 18 mo

HBV: Hepatitis B virus; HCV: Hepatitis C virus; HIV: Human immunodeficiency virus; IV: Intravenous; MTCT: Mother-to-child transmission; PROM: Prolonged rupture of membranes; CVS: Chorionic villous sampling; Ag: Antigen; ICP: Intrahepatic cholestasis of pregnancy; C-section: Cesarean section.